Is Your Dental Plan Two Decades Out of Date?

What's Covered at What Tier? All dental plans put every conceivable dental procedure into one of several "tiers." The tier dictates what percent of the allowed dental charge the plan will pay. Traditionally, there have been three tiers and Orthodontics. Here are procedures typically covered in each:

Tier 1 (Preventive) - Traditionally Pays 100%

Exams and x-rays

Cleanings

Fluoride treatments

Sealants & space maintainers for kids

Tier 2 (Basic) - Traditionally Pays 80%

Fillings: amalgam (silver), composite (white) & stainless

Simple and Surgical extractions

Periodontal (gum) surgery and maintenance

Endodontic (root canal) procedures

Prosthetic maintenance - repair of denturs and crowns

Tier 3 (Major) - Traditionally Pays 50%

Crowns

Bridges

Dentures

In recent years expensive procedures like gum surgery and root canals have been increasingly moved to Tier 3

Has your dental plan kept pace with the dental technology advances of the last 20+ years?

Probably not.

The typical dental plan of the '80s paid:

100 % of “preventive” procedures
80 % of “basic” procedures
50 % of “major” procedures [see sidebar for definitions]
The deductible was usually $25, waived for preventive but applied to basic and major procedures.
Maximum annual benefit was $1000/person/year

The plan was generally described as “100/80/50 to $1,000 with a $25 deductible.”

Twenty years later, the typical plan is “100/80/50 to $1,000 with a $50 deductible.”

Same plan? No. There are some internal plan changes that have cheapened the 1985 plan but which help keep its “feel.” Oral surgery, Endodontic procedures (root canals) and Periodontic procedures (gum surgery) are now often covered at 50 percent instead of the earlier 80 percent. But what your broker may not be telling you is that there are other plan provisions you could use that would bring your plan up to date.

Too Much Protection? Or Just the Wrong Kind?

One of the most innovative developments has to do with the $1,000 annual max -- a fixture of plans for more than 30 years.

Despite inflation, you probably don't need to increase your dental maximum from, say, $1,000 to $1,500. That will add 7% to the cost of the plan, yet only 5.2% of employees hit the $1,000 maximum in any given year.

Instead, more carriers are starting to give credits to employees who meet a couple of criteria:

They visit the dentist at least once this year.
Their total dental expenditures are less than $500.

If the employee meets those criteria, his maximum benefit will increase by $250 in the next year -- growing from $1,000 to $1,250. This repeats until a $2,000 annual max ia achieved.

Doesn't this make more sense than the traditional plan? This plan reflects reality. Most of us take good care of our teeth and most years we just have a couple of cleanings.

And then, wham! When we least expect it, we need a root canal and a crown, or we develop periodontal disease. With a root canal and crown, you're going to blow through your $1,000 max with no trouble.

But if you have a plan that carries over credit, you're way ahead of the game. If your root canal/crown hits in year 4 or 5, you've got $1,750 - $2,000 of benefit saved up, and you spend much less out of your pocket.

Periodontal Disease

There is a virtual epidemic of periodontal disease in America today, and many believe it's transmissible. In 2004 the American Dental Hygienists Association estimated that 75 percent of adult Americans had periodontal disease, perhaps 80 – 100 million American adults. And oral health and physical health have demonstrated connections. A woman with periodontal disease is seven times more likely to give birth to a low-birth-weight baby —$73,000 more expensive than a normal-weight baby — than is a disease-free woman.

Growing evidence suggests a link between gum disease and coronary heart disease and strokes. An adult male with gum disease is twice as likely to have a coronary than is a disease-free adult male.

People with gingivitis (gum disease) should have dental cleanings done four times a year, but alas, many plans only cover two cleanings.

Therefore, many people go without… their condition worsens and the result is expensive gum surgery.

If your plan allowed appropriate quarterly cleanings with diagnosed periodontal disease, your employees could avoid serious dental surgery and might even have lower health claims.

TMJ

Few dental plans cover non-surgical treatment of temporomandibular joint problems (TMJ). Yet 15 percent of Americans have a problem that can be helped by such treatment.

White Fllings for Posterior Teeth

80 percent of dentists use only white fillings, even in posterior teeth, but most plans only pay the cost of amalgam (silver) fillings, resulting in dissatisfied employees.

Oral Cancer

Oral Cancer now represents three percent of cancer deaths in the US — its prevalence exceeds both melanoma and cervical cancer. It can be detected in its earliest stages by a simple procedure called a brush biopsy, but few plans cover that procedure.

Crown and Bridge Replacement

Although statistics show that 53 percent of bridges are still in service after 30 years and 78 percent of crowns after 10 years, most plans are priced to replace crowns and bridges every five years. Most plans cover things that aren’t needed and don’t cover things that are. If your plan sounds like that, insist that your broker or consultant give you a complete dental plan design analysis. If you get a blank stare, find another broker… it’s too important to ignore.

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