To continue from the earlier post on dental insurance plans…
1. Third Parties
Regardless of the dental benefits plan, there are usually three parties
involved: you, the patient; the dentist providing care; and a third party
with whom you or your employer contracts for coverage. If your options
include a plan funded by your employer, you may have an administrator
responsible for processing and payment of claims. The primary
responsibility of the third party is to provide the financial foundation
for your dental benefits plan. There are three types of third parties.
Dental Service Corporations.
These not-for-profit organizations negotiate and administer contracts for
dental care to individuals or specific groups of patients. Delta Dental
Plans and Blue Cross/Blue Shield Plans are examples of this third party
type.
Insurance Carriers. These for-profit companies underwrite the financial
risk of, and process payment claims for, dental services. Carriers
contract with individuals or patient groups to offer a variety of dental
benefits packages, often including both fee-for-service and managed car
plans.
Self-Funded Insurers. These companies use their own funds to underwrite
the expense of providing dental care to their employees. The company pays
for the dental costs of its employees, usually with limitations on
services and fixed-dollar allocations.
2. Choosing A Dentist
Dental benefits plans can be categorized by the options offered for
selecting a dentist. Some plans allow you the freedom to choose your own
dentist, while others, in exchange for lower rates, limit your choice.
These two alternatives are called open and closed panel plans.
Open Panel. This type of dental benefits plan allows covered patients to
receive care from any dentist and allows any dentist to participate. Any
dentist may accept or refuse to treat patients enrolled in the plan. Open
panel plans often are described as Freedom of Choice plans.
Closed Panel. This type of plan allows covered patients to receive care
only from dentist who have signed a contract of participation with the
third party. The third party contracts with a certain percentage of
dentist within a particular geographic area. There are two types of
closed panel plans.
Preferred Provider Organization (PPO) — 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 usual fees
to this specific patient base, providing savings for the plan purchaser.
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.
Exclusive Provider Organization (EPO) — This closed panel plan allows a
particular group of patients to receive dental care only from
participating dentists. Although there may be some exceptions for
emergency and out-of-area care, if a patient decides to see a dentist who
is not listed on the EPO panel, charges for service will not be covered
by the plan. Because participating dentist are required to offer
substantial fee reductions, many dentists elect not to participate in
EPO-type plans. Under some benefits plans, participating dentists may be
salaried employees of the EPO. An EPO contracts with a limited number of
practitioners within a geographic area. Access to necessary specialized
care can be restricted. The EPO also may limit the amount of services
that a patient can receive in a given calendar year.
To learn more about Dental Plan click on the link or browse the rest of
this site.
The above is taken from the booklet “What Everyone Should Know About
Selecting and Using Dental Benefits.” A Consumer’s Guide to Dental
Insurance, published in the public interest by the California Dental
Association.
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