Fight Cavities In Dental Coverage

HCFA analysts are predicting that total dental care expenditures will climb to $105 billion by 2011.

Some employers might look to reduce dental benefits costs by changing plan designs. The design changes could include increases in patients deductibles and other out-of-pocket costs, longer waiting periods, and broader exclusions.

Other employers might increase employees premium contributions, offer employees a choice between two levels of coverage, or stop offering dental coverage altogether.

But employers who fail to understand the ramifications of their decisions about dental plan costs could end up actually increasing their costs.

Although many employers think of dental procedures as elective, consider the following: an article that appeared in the June 2001 issue of the Journal of Dental Education reported that employers lose more than 20 million work days each year due to dental problems.

Other studies have revealed a relationship between dental disease and medical disease.

Some studies, for example, have shown that people diagnosed with moderate to severe periodontal disease are more likely than other people to develop coronary heart disease and are also more likely to suffer strokes.

Research has also shown a significant correlation between moderate to severe periodontal disease in pregnant women and the likelihood that their babies will be born with low birthweights.

In addition, employees with certain types of medical conditions, such as diabetes, may be more vulnerable to infections and gum disease. These patients may need more than a yearly examination and cleaning.

That is why good dental plans should understand risk assessment and emphasize the prevention and early recognition of dental health problems, along with intervention when treatment needs are still minimal.

Comparing Plans

Brokers, agents and consultants can help employers think about more than the cost of coverage by reading and explaining dental insurance policies to make sure that employers get the level of value that they and their employees need.

Although two dental plans may appear to be similar with regard to services covered, a closer examination of the provisions may reveal key differences.

One item to consider is whether there are benefit waiting periods before employees are eligible for services. Waiting periods can compromise an employees ability to receive benefits for necessary treatment in a timely fashion, thus causing long-term costs to increase.

Other items to consider when reviewing a contract are:

The out-of-network reimbursement basis. Is the amount paid based on "reasonable and customary" charges, or is the amount paid based upon what a network provider accepts? Do the reasonable and customary charges include charges from all providers or only network providers?

Allocation of services. Are endodontics, periodontics and oral surgery split among different service categories?

Orthodontia. Is there a severity index to determine coverage? Does a plan cover treatment only if treatment starts while a patient belongs to the plan?

Fillings. Is there a 24-month limitation? Is the limit per tooth or per surface?

General anesthesia. Is it limited only to surgery, or is coverage also allowed in other situations?

Closed-list limitations. Is there a closed list of covered dental services? If so, what services are not covered? Some typical "not-covered" services are periodontal grafts, sedative fillings and pulp caps.

Definitions. Check the definitions for some of the words used throughout the document to understand what terms like "naturally functioning tooth" means.

In addition, ask whether plan changes are supported by research. Does the change compromise a patients ability to obtain benefits for appropriate dental treatment?

Smart Ways To Save

There are many ways to reduce the costs of a dental plan without compromising the value of the plan.

Some basic options include increasing the deductible, lowering the employers level of coinsurance, and reallocating services between different categories within the plan, especially those that are high cost and low volume.

For example, "basic dental services" may include oral surgery, fillings, endodontics and periodontics, and "major dental services" may include bridge work, dentures and crowns.

Suppose an employer starts with annual deductibles for all services of $25 for individuals and $75 for families.

Changing the annual deductibles to $50 for individuals and $150 for families can save an employer 2% to 4% per year.

Reallocating especially expensive services, such as root canals, periodontal surgery and work on impacted wisdom teeth, to a third covered category can also help.

A plan could cover 100% of the cost of preventive services, 80% of the cost of basic restorative services, and only 50% of the cost of major prosthodontics services.

An employer could save by shifting some services into the major prosthodontics category, from the basic restorative category, or by moving to a plan that covers only 75% of the cost of basic restorative services. Shifting to a 100/75/50 plan from a 100/80/50 plan could save the employer between 3% to 4% per year.

Employers could also consider altering coinsurance rates for employees using out-of-network providers.

If a plan reimburses 100/80/50 for services in-network and out-of-network, changing to a plan that keeps in-network coinsurance the same but provides 100/50/50 coinsurance for out-of-network may cut dental benefits costs between 10% and 15%.

Although lowering coinsurance rates for out-of-network care can save money, employers need to confirm that this type of change meets regulatory requirements and that the plans provider network can support the employees needs.

Dr. Alan Vogel, DMD, MPH, is national dental director for MetLife, New York.

Reproduced from National Underwriter Edition, April 7, 2003. Copyright 2003 by The National Underwriter Company in the serial publication. All rights reserved. Copyright in this article as an independent work may be held by the author.