A Guide for Benefits Managers

Transcription

1 Dental Plan Design Review A Guide for Benefits Managers

2 Overview You or your benefits representatives have probably performed a thorough top page analysis of your dental plan contract. However, many analyses don t pinpoint specific provisions that may have implications on plan costs, employee out-of-pocket expenses or satisfaction with the plan. So it is possible that your plan may contain provisions of which you may not be aware, or fully understand. The Dental Plan Design Review from MetLife was developed to help you and your colleagues gain a better understanding of certain provisions that may appear in your dental benefits plan. And, we hope that it will help you better understand some of your plan s strengths and weaknesses. It may also help you formulate some questions that you might want to ask your current carrier. It is important to note that this Dental Plan Design Review is only a starting point. There are many types of plan provisions that vary widely among benefit plan providers, and it s important to consider any one provision only in the context of your entire plan before making any judgments. You should also note that all plans (including MetLife s) contain exclusions, limitations and other terms that may affect coverage. This guide is not intended to imply that any of the provisions shown should be viewed negatively. Rather, it is being provided to you to help your understanding of some provisions that may appear in your dental benefits plan. In the event of a conflict between the policy and this guide, the policy will take precedence. If, after reviewing this guide, you should have any questions, please contact your MetLife representative, insurance broker or benefits consultant. Dental Plan Design Review

3 PROVISION TO LOOK FOR: Closed Lists of Services This is usually located in the plan s Exclusions and Limitations section. When a plan contains a closed list of services, only those services specifically listed in the plan contract are covered. If you see generic terms listed as covered categories of care, such as Endodontics or Periodontics, you may want to ask what services are routinely not considered for coverage. For example: Does Endodontics include Root Canal Retreatment? Does Periodontics include Guided Tissue Regeneration? When reviewing a plan using closed lists, employers should request a list of services not listed and therefore noncovered, and specifically outline in their enrollment materials those services not covered. 5% of total plan cost. A plan with a closed list may cost less than a plan with an open list but, for any service not covered, the patient may have to pay the cost. Plan satisfaction may be affected when employees have to pay the full cost of services. : Open Lists Plans that have an open list of services will generally consider any necessary dental service for reimbursement, unless the service is specifically stated as excluded or not covered (such as TMJ, Implants, etc.) under the plan. The plan will generally not state that it is an open list, but rather not indicate that it is a closed list. We believe that open lists provide plan participants with an easier benefits program to understand, which may result in higher plan satisfaction. Plan savings are estimated ranges based on a 00/80/50 PPO plan using standard MetLife contract provisions and Dental Plan Design Review 2

4 LANGUAGE TO LOOK FOR: Natural Functioning Tooth This is usually located in the plan s Definitions section, or in the section that describes replacement of missing teeth. Plans that provide replacement coverage only for naturally functioning teeth may reduce the amount of the available benefit by stating that teeth that do not have another tooth to bite against are not necessary to replace if removed while the patient is covered. It also may limit additional services to that tooth, such as root canals, crowns or other services. 2% of total plan cost. Plans that provide coverage only for naturally functioning teeth can cost less than plans that provide coverage for any natural tooth (a typical exception is wisdom teeth, which are not usually considered for replacement or other services). And, patients may have to pay the full cost of services for those teeth. This may result in lower plan satisfaction. You may want to consider a provision that does not exclude consideration of replacement of teeth or other services for any natural tooth (whether or not it is opposed by another tooth). You may also want to consider a provision that requires professional review to determine the appropriateness of the replacement or service. Plan savings are estimated ranges based on a 00/80/50 PPO plan using standard MetLife contract provisions and Dental Plan Design Review 3

5 PROVISION TO LOOK FOR: Cleaning (Adult) two per year including periodontal cleanings This will typically be located in the plan s Exclusions and Limitations section or the section that describes eligible benefits. Some contracts combine both regular adult cleanings and periodontal cleanings under the same two per year frequency limit. Since periodontal cleanings are not the same as regular cleanings, the two should not be looked at the same. 0.5 % of total plan cost. Including this provision may result in a lower plan cost than a plan that reimburses for more than two cleanings per year including periodontal cleanings. However, patients may have to pay the full cost for cleanings that are not covered. Plan satisfaction may be affected when employees have to pay the full cost of services. If periodontal cleanings are included as part of an overall frequency limit on cleanings, you may want to give consideration to what the appropriate limit should be, given that some plan participants will have to pay the full cost of any cleanings that exceed the two per year limit. Plan savings are estimated ranges based on a 00/80/50 PPO plan using standard MetLife contract provisions and Dental Plan Design Review 4

6 PROVISION TO LOOK FOR: Tooth extraction not covered for asymptomatic teeth coverage will be considered only if the tooth/ teeth are symptomatic (i.e., actively causing a problem) This provision will typically be found in the plan s Exclusions and Limitations section. Some plans will only consider coverage for the extraction of teeth if they are currently causing a problem. However, dentists may recommend that wisdom teeth be removed at a time when they are not causing a problem to the patient. 3% of total plan cost. Plans with this provision can cost less; however, patients may have to pay the full cost for services not covered, such as removal of wisdom teeth that are not causing a problem. Plan satisfaction may be affected when employees have to pay the full cost of services. You may wish to consider a provision that allows for the removal of impacted teeth without a qualification of discomfort. You may want to reduce the coverage to 50% rather than 80%. Plan savings are estimated ranges based on a 00/80/50 PPO plan using standard MetLife contract provisions and Dental Plan Design Review 5

7 PROVISION TO LOOK FOR: Amalgam and Resin Fillings replacement fillings not covered on same tooth (or surfaces) within 24 months This provision is typically found in the plan s Exclusions and Limitations section or the section that describes eligible benefits. This provision limits the number of fillings per tooth or surface to one per 24 months. While properly placed fillings typically last for years, occasionally replacements are necessary (due to new decay or atypical failure of the original filling). This also complicates the treatment of a tooth that has both active decay on one surface and a different area of decalcification on another surface. If the area of decay is restored and an attempt to remineralize the tooth fails within the 24-month period, follow up treatment on the tooth will not be covered % of total plan cost. Plans with this provision may cost less than a plan without this provision but by placing a limit, for benefit purposes, on the period between same-tooth fillings, the cost of the services is placed on the patient. Plan satisfaction may be affected when employees have to pay the full cost of services. You may wish to consider a provision that provides benefits for fillings as needed, with no time or number limits on replacements. Plan savings are estimated ranges based on a 00/80/50 PPO plan using standard MetLife contract provisions and Dental Plan Design Review 6

8 LANGUAGE TO LOOK FOR: Orthodontic Severity Index This is typically located in the plan s Definitions section, or in the section that describes Orthodontics. Plans that include an Orthodontic Severity Index provision may only consider benefits if the extent of tooth misalignment ( malocclusion ) meets or exceeds stated criteria. 2% of total plan cost. If the malocclusion does not meet the criteria, the orthodontic treatment will not be covered, placing the expense for the treatment upon the patient. Plan satisfaction may be affected when employees have to pay the full cost of services. You may want to consider a plan that does not use an Orthodontic Severity Index. Plan savings are estimated ranges based on a 00/80/50 PPO plan using standard MetLife contract provisions and Dental Plan Design Review 7

9 PROVISION TO LOOK FOR: Services that have combined frequency limits These provisions will typically be found in the plan s Exclusions and Limitations section or the section that describes eligible benefits. Plans that contain these types of provisions impose an overall limit on the number or frequency of a combination of similar procedures, rather than individual limits on each specific procedure. Two examples of combined frequency limits on separate types of services are: Scaling and root planning, periodontal maintenance and adult cleanings Periodontal surgery, osseous surgery, guided tissue regeneration (GTR) and grafts per quadrant 0.5 2% of total plan cost. Plans that contain combined frequency limit provisions can make it difficult to understand when any of the individual services are eligible for benefit consideration. This also may cause confusion when two necessary services are rendered at the same time and they should both be considered individually for reimbursement, but only one is reimbursed. Combined frequency limits may result in lower plan satisfaction when the cost of the services is placed on the plan participant. You may want to consider plan provisions that define frequency limits for all services separately. For example, rather than include a provision limiting the frequency, you may consider a provision that limits only duplicate surgeries on the same area (as opposed to all surgeries). Plan savings are estimated ranges based on a 00/80/50 PPO plan using standard MetLife contract provisions and Dental Plan Design Review 8

10 Conclusion Remember that the Dental Plan Design Review is meant only as a starting point in your review of your dental benefits plan. If you feel a more comprehensive review may benefit you and your employees, you may want to enlist the help of your benefits broker or consultant. Your MetLife representative is also a helpful resource in assessing the strengths and weaknesses of your dental benefits plan. Dental Plan Design Review 9

11 (0908) 2008 METLIFE, INC. L (exp009)(All States)(DC,PR) PEANUTS United Feature Syndicate, Inc. Metropolitan Life Insurance Company 200 Park Avenue New York, NY 066