Dental Benefits 101
You will receive 1 unit(s) of continuing education credit upon successful completion of this course. The registration fee is only $41.00

Description:
This course provides basic information on the various types of dental benefit programs in the marketplace including cost containment measures used by these plans.

Author:
The American Dental Association Council on Dental Benefit Programs
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Learning Objectives:
Upon completion of this course, the participant should be able to:
  1. Understand the differences between paid premium and self-funded dental plans
  2. Compare and contrast the various types of managed care plans in the marketplace
  3. Recognize the various types of plan designs that may present at your office
  4. Understand the differences between Medicaid and Medicare dental coverage
  5. Discuss various cost containment measures utilized by dental benefit plans
  6. Identify the most common types of coordination of benefits
  7. Describe several of the many payment challenges faced by out-of-network dentists


Abstract:
The American Dental Association has recognized the need to educate dentists and dental offices on the proper terminology that is being used today in the world of dental benefits. With the onslaught of new consumer-directed employee benefit plans and patients presenting at dental offices with these types of plans, it is important to disseminate information that can make it easier for dental offices to know how to properly handle patients with these types of plans. The goal of this course is to educate dentists on the various types of dental plans in the marketplace and how these plans can affect their patients. This includes a discussion of the various cost containment measures used by dental plans to control costs. After completing this course, dentists should have a better understanding of the terminology and mechanics used in dental benefit programs including the payment challenges faced by non-participating dentists.

Outline:
  1. Relationships with Third-Parties
    1. Contractual
    2. Non-Contractual
    1. Failure to Recognize Assignment of Benefits
    2. Reduced Levels of Reimbursement
    3. Higher Deductibles and Lower Annual Maximums
    4. Failure to Receive Explanation of Benefits Statements
    5. Faster Payment for Out-of-Network Dentists Allowing Discounts
  2. Types of Dental Plans
    1. Preferred Provider Organizations (PPO)
    2. Dental Health Maintenance Organizations (DHMO)/Capitation Plans/Prepaid Plans
    3. Indemnity Plans
    4. Direct Reimbursement (DR®)
    5. Point of Service Plans
    6. Discount or Referral Plans
    7. Exclusive Provider Organizations (EPO)
    8. Table or Schedule of Allowances Plans
  3. Financing of Dental Plans
    1. Self-Funded Plans
    2. Paid Premium Plans
    3. Medicaid
    4. Medicare
    5. Medicare Advantage Plans
  4. Management of Dental Plans
    1. Insurance Companies
    2. Third-Party Administrators (TPA)
  5. Plan Designs
    1. Traditional
    2. Dollar-Based
    3. Preventive Only/Limited Benefit
    4. Cafeteria Plans/Section 125 Plans
    5. Health Savings Accounts (HSA)
    6. Health Reimbursement Arrangements (HRA)
    7. Flexible Spending Accounts (FSA)
  6. Typical Plan Benefits and Limitations
    1. Pre-existing Conditions
    2. UCR – Three Different Concepts, Not One
    3. Annual Maximums
    4. Managed Care Cost Containment Features
    1. Least Expensive Alternative Treatment Provisions (LEAT)
    2. Bundling of Dental Procedures
    3. Downcoding
    4. Predetermination
    5. Deductibles
    6. Coinsurance Provisions
  7. Coordination of Benefits (COB)
    1. Types of COB
      1. Traditional
      2. Non-Duplication of Benefits
      3. Maintenance of Benefits
      4. Carve Out of Benefits
      5. Integration of Benefits
    2. Dependents
    3. When Does Secondary Pay?
    4. ADA Guidelines on Coordination of Benefits for Group Dental Plans
  8. How to Receive Assistance
    1. Claims Appeals
    2. State Insurance Commissioner’s Office
    3. Department of Labor
    4. Patient’s Human Resources Department
    5. Your American Dental Association
References:
  1.  “What Every Dentist Should Know Before Signing a Dental Provider Contract”, American Dental Association
  2. ADA’s Understanding Your Dental Benefits, 2009, page 4.
  3. Accessed from http://www.cms.hhs.gov/MedicaidDentalCoverage/, September 23, 2009
  4. Accessed from http://www.cms.hhs.gov/MedicareDentalCoverage/, September 23, 2009
  5. Accessed from http://www.medicare.gov/choices/advantage.asp, January 11, 2010
  6. Accessed from http://www.irs.gov/govt/fslg/article/0,,id=112720,00.html#1, September 16, 2009
  7. Accessed from http://www.ustreas.gov/offices/public-affairs/hsa/faq_basics.shtml, September 29, 2009
  8. Accessed from http://en.wikipedia.org/wiki/Flexible_spending_account, September 23, 2009
  9. ADA News, ADA/NADP share views on bundling and downcoding, June 20, 2007




Published date 2010-2013







American Dental Association is an ADA CERP Recognized Provider.

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.