A 2011 Experience With a New Dental Plan

In mid January of this year I received a phone call from the manager of one of my smaller satellite offices that they had a new Medicare plan with 400 patients eligible and what did I know about it.

I knew nothing about it and was perplexed because Medicare (65+ seniors) does not cover dental.

I contacted the insurance company and discovered that this was a "marketing program" for a medical HMO where they are taking a small part of their income to "buy" a dental insurance product so they can advertise that seniors that sign up with them get "free dental care".

I reviewed the program and all "covered" procedures are "no charge" to the patient.

The dentist that practices in that office called up very upset that he was going to go broke doing free dentistry.

This is a case where the devil is in the details.

A review of the "summary of benefits" given to the patient makes it appear that this is an "impossible" program for a contracting dentist.

A careful review of the detailed Limitations and Exclusions revealed a different story.

The plan provides supplemental payments for many basic procedures (including phase 1 period) as long as ADA claim forms with proper documentation are submitted.

The dental requirements for a benefit for prosthetics, especially fixed, are very strict so that in many, if not most clinical situations the procedure is not covered and the patient has to pay UCR for it.

As I write this article in mid April 2011 the program is working financially. The capitation plus supplemental payments plus patient income from non-covered procedures is making this program profitable for the office.

The dentist at that office had a knee jerk reaction when he saw "no charge" on the summary of benefit. Had I listened to him, not analyzed the complete program, and dropped it from the office, the office would have lost a profitable piece of business.

There are new dental insurance products being marketed all the time.

I want to be pro-active and keep educated as programs change and new insurance products are introduced. The 400 patients that signed up for my office are 400 patients that use to go to other dental offices in the area. My gain is their loss.

AMCD is a great way to stay pro-active. As the dental insurance market changes there will be offices that benefit and offices that are "hurt" by the changes. I want to be on the winning side.