Reference: Excerpts from the booklet "What Everyone Should Know About Selecting and Using Dental Benefits," a consumer's guide to dental insurance and delta dental insurance, published in the public interest by the California Dental Association.

By Arthur Kezian
It's Important To Put Your Money Where Your Mouth Is

It is quite natural to think about dental insurance as a means to cover the costs of treatment for serious medical conditions or accidents. But there's another type of insurance that's equally important to your well-being -- delta dental insurance. Because dental disease is so common, being protected by Los Angeles dental insurance and using it wisely are essential safeguards for you and your family.

There's A World Of Difference Between Medical and Dental Disease

Unlike medical disease, which can be both unpredictable and catastrophic, most dental ailments are preventable. Preventive care, including regular checkups and cleanings, is the key to maintaining your oral health. With regular visits to the dentist, problems can be diagnosed early and treated without extensive testing or elaborate and expensive procedures. That keeps the costs of dental care much lower than those of medical care. In fact, total spending for dental care is decreasing. In 1970, it made up 6.3 percent of total healthcare expenditures. But in 1991, dental care's share of health care spending was only 4.9 percent.

And Between Medical and Dental Benefits

Los Angeles Medical insurance is designed primarily to cover the costs of diagnosing, treating and curing serious illnesses. This process may involve a primary care physician and multiple specialists, a variety of tests performed by doctors and laboratories, multiple procedures and masses of medications. Depending on the health, age and attitudes of people in the medical coverage group, costs can fluctuate widely.

Dental insurances works differently. Most delta dental insurance is designed to ensure that the patient receives regular preventive care. High quality dental care rarely requires the complex, multiple resources often required by medical care. A thorough examination by theand a set of x-rays are all it usually takes to diagnose a problem. By and large, dental care is provided by a general practitioner, although some cases may require the services of a dental specialist. Because most dental disease is preventable, dental benefits plans are structured to encourage patients to get the regular, routine care so vital to preventing and diagnosing the onset of serious disease. In fact, most dental benefits plans require patients to assume a greater portion of the costs for treatment of dental disease than for preventive procedures. By placing an emphasis on prevention, and by covering regular teeth cleaning and check-ups, Americans saved nearly $100 billion in dental care costs during the 1980's.

Dental Insurance Los Angeles Is Helping Keep America Healthy

The availability of dental insurance and delta dental insurance is the single greatest factor in helping you get the dental care you need. More than 48 percent of all Americans -- 113 million of us -- are covered by privately financed dental insurance plans. This compares with just 12 million people who had such coverage in 1970. As a result of increased access to regular care and the widespread use of preventive measures, the incidence of dental decay has dropped sharply. Half of today's school children never have had a cavity.

Different Plans For Different Needs -- Know the Differences

Consumers can choose from an assortment of dental benefits plans that accommodate a variety of needs and expectations. The following factors differentiate one plan from another:Los Angeles Dentist

• The type of third party responsible for funding and administration of the plan;
• The alternatives offered for selecting a Los Angeles Dentist;
• The structure used to compensate the Dentist for services provided; and
• The method by which benefits and payments are calculated.
• Understanding these differences is essential to making an informed decision when selecting a plan and using the benefits Delta Dental Insurance.

Third Parties

Regardless of the dental benefits plan, there are usually three parties involved: you, the patient; the dentist providing care; and a third party with whom you or your employer contracts for coverage. If your options include a plan funded by your employer, you may have an administrator responsible for processing and payment of claims. The primary responsibility of the third party is to provide the financial foundation for your dental benefits plan. There are three types of third parties.

Dental Service Corporations -

These not-for-profit organizations negotiate and administer contracts for dental care to individuals or specific groups of patients. Delta Dental Insurance Plans and Blue Cross/Blue Shield Plans are examples of this third party type.

Insurance Carriers -

These for-profit companies underwrite the financial risk of, and process payment claims for, dental services. Carriers contract with individuals or patient groups to offer a variety of dental benefits packages, often including both fee-for-service and managed car plans.

Self-Funded Insurers -

These companies use their own funds to underwrite the expense of providing dental care to their employees, Delta Dental Insurance. The company pays for the dental costs of its employees, usually with limitations on services and fixed-dollar allocations.

Choosing A Dentist

Dental benefits plans can be categorized by the options offered for selecting a dentist. Some plans allow you the freedom to choose your own dentist, while others, in exchange for lower rates, limit your choice. These two alternatives are called open and closed panel plans.

Open Panel -

This type of dental benefits plan allows covered patients to receive care from any Dentist and allows any dentist to participate. Any dentist may accept or refuse to treat patients enrolled in the plan. Open panel plans often are described as Freedom of Choice plans.

Closed Panel -

This type of plan allows covered patients to receive care only from dentist who have signed a contract of participation with the third party. The third party contracts with a certain percentage of dentist within a particular geographic area. There are two types of closed panel plans.

Preferred Provider Organization (PPO) -

This plan allows a particular group of patients to receive dental insurance from a defined panel of dentists. The participating dentist agrees to charge less than usual fees to this specific patient base, providing savings for the plan purchaser. If the patient chooses to see a dentist who is not designated as a "preferred provider," that patient may be required to pay a greater share of the fee-for-service.

Exclusive Provider Organization (EPO) -

This closed panel plan allows a particular group of patients to receive only from participating dentists. Although there may be some exceptions for emergency and out-of-area care, if a patient decides to see a dentist who is not listed on the EPO panel, charges for service will not be covered by the plan. Because participating dentist are required to offer substantial fee reductions, many dentists elect not to participate in EPO-type plans. Under some benefits plans, participating dentists may be salaried employees of the EPO. An EPO contracts with a limited number of practitioners within a geographic area. Access to necessary specialized care can be restricted. The EPO also may limit the amount of services that a patient can receive in a given calendar year.

Paying The Dentist

When choosing a benefits plan, it is important to know who pays what to whom. Dental plans can be categorized into three types based on the compensation and treatment provided.

Indemnity Plans -

This type of plan pays the dentist on a traditional fee-for-service basis. A monthly premium is paid by the patient and/or the employer to an insurance carrier, which directly reimburses the dentist for the services provided. Delta Dental Insurance companies usually pay between 50 percent and 80 percent of the dentist's fee for covered services; the remaining 20 percent to 50 percent is paid by the patient. These plans often have a pre-determined deductible, a dollar amount which varies from plan to plan, that the patient must pay before the insurance carrier will begin paying for care. Indemnity plans also can limit the amount of services covered within a given year and pay the dentist based on a variety of fee schedules.

Capitation Plans -

This type of plan provides comprehensive dental care to enrolled patients through designated provider dentists. A Dental Health Maintenance Organization (DHMO) is a common example of a capitation plan. The dentist is paid on a per capita (per head) basis rather than for actual treatment provided. Participating dentists receive a fixes monthly fee based on the number of patients assigned to the office. In addition to premiums, patient co-payments may be required for each visit.

Direct Reimbursement Plans -

Under this self-funded plan, an employer or company sponsor pays for dental care with its own funds, rather than paying premiums to an Insurance carrier or third party. The patient pays the dentist directly and, once furnished with a receipt showing payment and services received, the employer reimburses the employee a fixes percentage of the dental care costs. The plan may limit the amount of dollars an employee can spend on dental care within a given year, but often places no limit on services provided. Patients can select a dentist of their choice and, in conjunction with the dentist, can play an active role in planning the treatment most appropriate and affordable to ensure optimum oral health.

Calculating Payments

A clear understanding of the methods used to calculate benefits and payments will allow you to compare and evaluate the purchasing power of different plans. The following are four common payment schedules:

Capitation (per capita) -

This fee schedule is used by plans structured to provide a predefined level of benefits. Because dental care needs vary by individual, it is critical to have a thorough understanding of the level or range of services "defined" or covered by the plan. Under this fee schedule, the patient is responsible to pay for treatment not covered within the scope of the plan. In some cases, the allocated payment a dentist receives from the benefits plan, including patient co-payments, is less than the actual cost of providing care. Patients often settle for less-than-optimal treatment alternatives or postpone necessary services when their co-payments do not cover all possible options.

Table or Schedule of Allowances -

Plans using this form of benefits calculation establish a maximum dollar limit for each covered procedure, regardless of the fee charged by the dentist. If you select a plan that uses this type of table or schedule, ask how often the table is adjusted for inflation or for changes in accepted dental procedures. In these plans, the difference between the allowed charge and the dentist's fee is paid directly by the patient.

Patients should understand that contracted fee reductions listed in some plan allowance schedules can significantly diminish the level and quality of care delivered. Contracted rates are based on the size of the patient population and projections of the amount and type of treatment performed within a given time frame. Since cost control drives this payment approach, your ability to choose your Los Angeles Dentist or see a specialist may be limited.

Direct Reimbursement -

In this self-funded plan, the patient pays the doctor for services. The employer or plan sponsor reimburses the employee for a predetermined percentage of all costs. Under this fee schedule, the employee has an incentive to work with the dentist to plan healthy and economical solutions.

Usual, Customary and Reasonable (UCR) -

Most indemnity (traditional fee-for-service) plans use this payment schedule. It allows patients to select their own dentist. The UCR schedule pays benefits based on a fixed percentage of the lesser of the dentist's fee or the fee determined by the insurance carrier to be "usual," "customary" or "reasonable" for the service in the community in which the service was delivered. Wide fluctuations in UC fees between communities have made this payment system highly controversial. Because many insurance carriers set the UCR percentage too low in comparison to the area's usual professional fees, patients may wind up paying more out-of-pocket. Most payments are made directly to the dentist, but in some instances they are made to the beneficiary.

Dental Plans Do Have Their Limitations

Today's health insurance, including your dental plan, is designed to help you get the care you need at a reasonable cost. Because each person's oral health is different, costs can vary widely. To control dental treatment costs, most plans will limit the amount of care you can receive in a given year. This is done by placing a dollar "cap" or limit on the amount of benefits you can receive, or by restricting the number or type of services that are covered. Some plans may total exclude certain services or treatment to lower costs. Know specifically what services your plan covers and excludes.

There are, however, certain limitations and exclusions in most dental benefits plans that are designed to keep dentistry's costs from going up without penalizing the patient. All plans exclude experimental procedures and services not performed by or under the supervision of a dentist, but there may be some less obvious exclusions. Sometimes dental coverage and health insurance may overlap. Read and understand the conditions of your dental plan. Exclusions in your dental plan may be covered by your medical insurance.

The Dental Consumer Advisor encourages consumers to choose plans that impose dollar or service limitations, rather than those that exclude categories of service. By doing so, you can receive the care that's best for you and actively participate with the dentist in the development of treatment plans that give the most and highest quality care.

To help you stretch each dental benefit dollar, most plans provide patients and purchasers with special administrative services. Find out if your plan provides the following mechanisms to help you budget, analyze and dispute, if necessary, the costs of your dental care.

Predetermination of Costs -

Some plans encourage you or your dentist to submit a treatment proposal to the plan administrator before receiving treatment. After review, the plan administrator may determine: the patient's eligibility; the eligibility period; services covered; the patient's required co-payment; and the maximum limitation. Some plans require predetermination for treatment exceeding a specified dollar amount. This process is known as preauthorization, precertification, pretreatment review or prior authorization.

Although your dental benefits plan may not be bound to predetermined costs, this mechanism can help you and your dentist plan and budget a treatment plan appropriate to your oral health needs.

Annual Benefits Limitations -

To help contain costs, your plan may limit your benefits by number of procedures and/or dollar amount in a given year. In most cases, particularly if you've been getting regular preventive care, these limitations allow for adequate coverage. By knowing in advance what and how much your plan allows, you and your dentist can plan treatment that will minimize your out-of-pocket expenses while maximizing compensation offered by your benefits plan.

Peer Review for Dispute Resolution -

Many plans provide a peer review mechanism through which disputes between third parties, patients and dentists can be resolved, eliminating many costly court cases. Peer review is established to ensure fairness, individual case consideration and a thorough examination of records, treatment procedures and results. Most disputes can be resolved satisfactorily for all parties.

Premium adjustments and Reevaluations -

Patients and plan purchasers should insist on regular reviews of premium levels to ensure that UCR or Table of Allowances payment schedules are equitable. This analysis can help optimize your benefit levels, ensuring that every dollar you spend is used wisely.

Coordination of Benefits -

If you are covered under two dental benefits plans, notify the administrator or carrier of your primary plan about your dual coverage status. Plan benefits coordination can help protect your rights and maximize your entitled benefits. In some cases you may be assured full coverage where plan benefits overlap, and receive a benefit from one plan where the other plan lists an exclusion.