Selecting the proper dental plan design is key to striking a balance between cost and access. The proper plan design can help mitigate costs while still providing access to care that is usable and offers the best value.
DHMOs MAY NOT BE THE BEST VALUE.
Dental Health Maintenance Organization (DHMO) plans may offer the employer the least expensive price point, but the plans’ capitation reimbursement model can result in:
- A limited network of general dentists;
- An even smaller network of specialists for referrals;
- Fewer available appointments for DHMO patients;
- Unexpected patient expenditures for more costly enhancements or non-covered products and services.
In addition, dentists typically don’t submit any procedure codes or claim information on their DHMO patients, making it difficult to ascertain their oral health status. These constraints can make a DHMO unattractive to members and plan sponsors alike, making a potentially better option an Exclusive Provider Organization or EPO plan.
EPOs AS A DHMO REPLACEMENT.
Although an EPO plan only covers treatment from a participating dentist, an EPO plan does not rely on capitation for its reimbursement model. The difference in the reimbursement models can provide distinct advantages over a DHMO, such as:
- A large network of general dentists and no requirement to select a primary dentist;
- No referrals, giving members direct access to a sizable network of specialists;
- A lower price point associated with in-network-only coverage;
- Actionable claims data to facilitate utilization management and cost containment.
An EPO plan can offer advantages over a DHMO when it comes to accessing a larger network and the convenience of no referrals. In many cases, plan sponsors find that an EPO plan is a much better value than a DHMO because the benefit is more usable than many DHMOs. However, you may want to consider an active PPO plan, which may strike the perfect balance between price point and flexibility.
WHY CONSIDER AN ACTIVE PPO PLAN?
An active PPO plan offers maximum flexibility when it comes to choice because the plan covers both in-network and out-of-network care. In addition, an active PPO plan is more cost effective than a traditional passive PPO plan because the in-network benefit is paid at a different percentage than out-of-network care.
Plan sponsors, who currently offer or are considering a PPO plan, may find it beneficial to price out an active PPO. By varying the out-of-network benefit coverage levels, an active PPO plan could be an attractive alternative to replace a passive PPO or as a buy-up option to an EPO. Offering an EPO and PPO plan side-by-side offers the most flexibility, allowing members to select a plan based on their personal oral health status.
IN A NUTSHELL.
Talk with your benefits consultant to price out a few different plan design options based on your employee’s demographics. The cost differential between a plan that your members have difficulty using and one that is usable and a good value may be inconsequential. A little creativity in plan design can help you offer a benefit that’s both usable and valuable.
BeneCare offers Preferred Provider Organization (PPO) and Exclusive Provider (EPO) plans with customizable options for covered services, deductibles, coinsurance, and annual and lifetime limits.[i] Rates are available in three- and four-tiered plan structures.[ii] Other options are available and multi-year rate guarantees are available for qualified group plans.[iii]
Plan sponsors should contact their benefits consultant for additional details and a quote. Or contact BeneCare Dental Plans directly using an online request or by calling 800.445.6665. Benefit Consultants may also call 800.445.6665 or submit an online request.
[i] Not all plans are available in all states.
[ii] Three-tier structures include subscriber, two-party, and family plans. Four tier structures include subscriber, two-party, subscriber & children, and family plans.
[iii] Rate guarantees are dependent upon group size and other factors.