Covered Dental Expenses

Virtually all dental problems fall into 10 professional treatment categories:

1. Diagnostic. Examination to determine the existence of oral disease or to evaluate the condition of the mouth. Included in this category would be such procedures as X-rays and routine oral examinations.
2. Preventive. Procedures to preserve and maintain dental health. Included in this category are topical fluoride applications, cleaning, space maintainers, and the like.
3. Restorative. Procedures for the repair and reconstruction of natural teeth, including the removal of dental decay and installation of fillings.
4. Endodontics. Treatment of dental-pulp disease and therapy within existing teeth. Root canal therapy is an example of this type of procedure.
5. Periodontics. Treatment of the gums and other supporting structures of the teeth, primarily for maintenance or improvement of the gums. Periodontal curettage and root planing are examples of periodontic procedures.
6. Oral Surgery. Tooth extraction and other surgery of the mouth and jaw.
7. Prosthodontics. Construction, replacement, and repair of missing teeth. Examples include onlays, crowns and bridges, which are fixed prostheses, and dentures and partials, which are removable prostheses.
8. Orthodontics. Correction of malocclusion and abnormal tooth position through repositioning of natural teeth.
9. Pedodontics. Treatment for children who do not have all their permanent teeth.
10. Implantology. Use of implants and related services (e.g., over-dentures, fixed prostheses attached to implants, etc.), to replace one or all missing teeth on an arch.

In addition to the recognition of treatment or services in most of these 10 areas, the typical dental plan also includes provision for palliative treatment (i.e., procedures to minimize pain, including anesthesia), emergency care, and consultation.

These 10 types of procedures usually are categorized into three, four, and sometime five general groupings for purposes of plan design. The first classification often includes both preventive and diagnostic expenses. The second general grouping includes all minor restorative procedures. The third broad grouping, often combined with the second, includes major restorative work (e.g., prosthodontics), endodontic and periodontic services, and oral surgery. A fourth separate classification covers orthodontic expenses. Although excluded under most plans, implantology services are usually covered under a separate fifth classification.

Pedodontic care generally falls into the first two groupings.

Providers of Dental Benefits | Dental Plan Design

Providers of dental benefits generally can be separated into three categories: insurance companies, Blue Cross and Blue Shield organizations, and others, including state dental association plans (e.g., Delta plans); self-insured, self-administered plans; and group practice or HMO-type plans. Insurance companies and Blue Cross/Blue Shield plans cover the largest share of the population. However, enrollment in self-administered, self-insured plans; plans employing third-party administrators; dental association plans; and HMOs is in an upsurge.

The types of dental benefit plans resemble today's medical plans. There are three basic design structures: the fee-for-service indemnity or reimbursement approach, the preferred provider (PPO) approach, and the dental health maintenance organization.

Insurance company-administered dental benefits and most self-insured, self-administered plan benefits are provided on either an indemnity or preferred provider basis. Under the indemnity approach, expenses incurred by eligible individuals are submitted to the administrator, typically an insurer, for payment. If the expense is covered, the appropriate payment is calculated according to the provisions of the plan. The indemnity plan payment generally is made directly to the covered employee, unless assigned by the employee to the treating dentist.

Preferred provider benefits are payable directly to the treating dentist, generally according to a contract, which fixes the reimbursement level between the dentist and the plan. In most instances, this payment actually may be lower than what would be charged to a direct-pay or indemnity patient.

The dental benefits of both dental service corporations and Blue Cross/Blue Shield plans are generally provided on a preferred provider basis. The major differences between indemnity and preferred provider benefits relate to the roles of the provider and the covered individual. Under either approach, the plan sponsor normally has substantial latitude in determining who and what is to be covered and at what level.

Under the group practice or HMO-type arrangement, a prescribed range of dental services is provided to eligible participants, often in return for a prepaid, fixed, and uniform payment. Services are provided by dentists practicing in group practice clinics or by those in individual practice but affiliated for purposes of providing plan benefits to eligible participants. Some individuals eligible under these arrangements are covered through collectively bargained self-insurance benefit trusts. In these instances, trust fund payments are used either to reimburse dentists operating in group practice clinics or to pay the prescribed fixed per capita fee. Group practice HMO-type arrangements, which often have cost, quality assurance, and administrative advantages but more limited provider selection, generally offer little latitude in plan design. As a result, the balance of this chapter, since it is largely devoted to the issue of plan design, may have limited application to these types of arrangements.