Managed Care Dental Plans



Preferred Provider Organization (PPO) plans are plans in which the patient has to select a dentist from a list provided to him. These dentists have agreed to discount their fee by contract with the insurance company. Some PPO plans also allow patients treated by dentists outside their list, where the patient is penalized by excess co-payments and higher deductibles. PPO's are normally less expensive than indemnity plans in their class.

Keep the following in mind while reviewing a PPO Dental Insurance Plan.

What is the percentage of the premium used for administration?

Will the discount influence patients to change their regular dentist? Will the amount of the discount the dentist ahs to offer affect the number of treatment options for the patient?

What is the liability of the employer in the event of the plan influencing dentist selection or treatment?

What are the criteria of selection of dentists for the plan? Does it have adequate number of dentists under contract? What is the geographic distribution of dentists? Does the PPO dental insurance plan provide for specialist referrals? If so, are the dentists limited to a specialist on the "list" only?

How does the plan provide for emergency treatment? If so then how does the plan provide for emergencies outside the geographical area?

Dental Health Maintenance Organization (DHMO) or Capitation plans are designed in such a way that the patient does not have any financial payout when he goes for treatment. These plans pay the dentists on their "list" a fixed amount of money monthly per enrolled family or individual, regardless of visits. In return, the dentists provides specific types of treatment to the patients who visit him at no charge, any other types of treatments require co-payment. This way, the DHMO is rewarding dentists to keep patients in good health, thereby keeping the costs low. This kind of plan is one of the least expensive.

Factors to consider while reviewing a DHMO plan.

What is the percentage of the premium used for administration?

Does the employer have access to enough information for him to determine the level and amount of treatment rendered to each of the employees?

What is the utilization percentage for patients in this plan? Average waiting period for an initial appointment and average period between appointments has to be given due consideration.

What is the dentist/patient ratio for the DHMO plan? What is the criterion of dentist selection in the program? What is the geographic distribution of dentists?

What percentage of dentists is selected for from those who applied to participate? How many dentists withdrew from the program in the recent past?

What is the rate of compensation for the dentists? Is it sufficient compensation for the needs of the covered patient population? What are the provisions made for dentists in the event of unforeseen utilization?

What are the benefits for patients needing a specialist's care? How are specialists selected and compensated? Does the plan have adequate specialists?

Does the program provide for any emergency treatment? If so, is it available outside the geographical area?

Fee-for-Service Dental Plans

Direct Reimbursement (DR) plan is a self-funded dental insurance benefit plan which reimburses patients on actual spent on dental care. It is not based on the type of treatment received. The patient has complete freedom in choosing the dentist. The employers are liable to pay a percentage of actual treatment cost, but they do not have to pay monthly premiums for employees who do not need the benefit. Moreover the employer is free of any responsibility to take decisions on mode of treatment due to previous plan selection or sponsorships. Direct Reimbursement Dental Insurance Plan is American Dental Association's preferred method of dental coverage.