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Understanding Dental Insurance Plans |
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Indemnity Coverage Insured Fee-for-Service Plans Under the indemnity option, members are reimbursed up to a fixed limit for treatment rendered by their own dentist. Members select any licensed dentist and are reimbursed up to a fixed amount for services provided. Patients are responsible to their dentists for any differences between the plan's allowance and the dentist's charges. Members will experience lower fees if they stay in network. Healthplex will assist your group in determining the appropriate reimbursement level, deductible, and maximum. Managed Care The Preventive Incentive Managed Care Plans are often called "capitation plans" or "DHMOs"(Dental HMOs). Based on the principle that it is less costly to prevent dental disease than it is to treat dental disease, managed dental care significantly controls major dental expenses. Managed care provides more coverage at lower costs. Many services are covered in full, including diagnostic and preventive treatment and multi year rate guarantees can be offered. With managed care, services are provided through a network of dentists whose interest is to bring the patient to a state of good dental health as quickly as possible and to maintain this healthy condition. With Managed Care, you have the satisfaction of knowing you are receiving excellent, affordable dental care. Managed Care Plans involve adherence to Quality Assurance and Utilization Review Programs. This type of dental plan is an insured product. Dual Choice Our Most Powerful Combination of Plans Everybody wins when you create a dental program that includes a Managed Care Plan along with an Indemnity, Fee-for-Service Plan. Members are satisfied because they have freedom to select the plan that satisfies their cost and provider concerns. Managed Care offers comprehensive benefits within the Healthplex network of dentists with little or no out-of-pocket expenses, while the Fee-For-Service Plan offers members a full schedule of allowances that are available at any dental office. Groups are satisfied because premiums are more competitive, and multi-year rate guarantees can be offered. In a time of rising health care costs, the advantages of a Dual Choice Program are significant. Preferred Provider Organizations (PPO) Another insurance plan is the PPO which falls somewhere between an indemnity plan and a dental HMO. This plan allows a particular group of patients to receive dental care from a defined panel of dentists. The participating dentist agrees to charge less than his/her usual fees to a particular patient or group of patients. 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. This type of plan can provide deeply discounted rates, thereby providing substantial saving to the patient, as long as the patient stays in network. Unlike the more restrictive DHMO, however, the patient may choose to forfeit the savings to see an out-of network provider. Direct Reimbursement Plan A dental plan that is becoming a more popular choice is the direct reimbursement plan. This is a self-funded plan - not insurance - in which the employer pays for dental care with its own funds rather than paying premiums to an insurance company. The patient pays the full amount directly to the dentist and then submits a receipt for the services rendered to his/her employer. Then employer reimburses the patient for all or part of the cost depending of the specific plan design. Your company may reimburse 100% of some dental costs, and a smaller percent of other dental costs. There may or may not be deductibles and annual maximums based on the benefits provided in the particular plan. Administrative Services Only (ASO) This arrangement is when a third party charges a set fee to handle some or all of the administration of a self funded dental plan. Administrative services provided could include just about any insurance company service such as actuarial services, underwriting, claims processing, provision of a dental network, benefit description, etc. An ASO plan always excludes the assumption of risk and it is therefore NOT insurance. Click here for a full description of Healthplex's Administrative Services. Point of Service - POS Members can go in or out of the Managed Care Network. Members may choose a managed care provider for some services and a provider that is not in the managed care network for other services. Members will experience lower fees if they stay in network. Dental Discount Programs This type of plan is NOT insurance. With a dental discount program local dentists have agreed to accept reduced rates from plan members. There are no premiums, exclusions, waiting periods.
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