Scheduled Plans | Dental Plan Design

Scheduled plans are categorized by a listing of fixed allowances by procedure. For example, the plan might pay $50 for a cleaning and $400 for root canal therapy. In addition, the scheduled plan may include deductibles and coinsurance (i.e., percentage cost-sharing provisions). Where deductibles are included in scheduled plans, amounts usually are small or, in some cases, required on a lifetime basis only.

Coinsurance provisions are extremely rare in scheduled plans since the benefits of coinsurance can be achieved through the construction of the schedule (i.e., the level of reimbursement for each procedure in the schedule can be set for specific reimbursement objectives). For example, if it is preferable to reimburse a higher percentage of the cost of preventive procedures than of other procedures, the schedule can be constructed to accomplish this goal.

There are three major advantages to scheduled plans:

1. Cost control. Benefit levels are fixed and therefore less susceptible to inflationary increases.
2. Uniform payments. In certain instances, it may be important to provide the same benefit regardless of regional cost differences. Collectively bargained plans occasionally may take this approach to ensure the "equal treatment" of all members.
3. Ease of understanding. It is clear to both the plan participant and the dentist how much is to be paid for each procedure.

In addition, scheduled plans sometimes are favored for employee-relations reasons. As the schedule is updated, improvements can be communicated to employees. If the updating occurs on a regular basis, this will be a periodic reminder to employees of the plan and its merits.

There also are disadvantages to scheduled plans. First, benefit levels, as well as internal relationships, must be examined periodically and changed when necessary to maintain reimbursement objectives. Second, where participants are dispersed geographically, plan reimbursement levels will vary according to the cost of dental care in a particular area unless multiple schedules are utilized. Third, if scheduled benefits are established at levels that are near the maximum of the reasonable and customary range, dentists who normally charge at below prevailing levels may be influenced to adjust their charges.

Services under the typical dental HMO are also provided on a scheduled basis—in a fashion. Since the contract between the participating dentist and the HMO generally specifies the basis on which the provider will be paid by the HMO and also fixes the amount that can be charged to the participant, the schedule furnished to participants typically identifies the amount the participant is required to pay rather than the amount the plan pays.