DENTAL INSURANCE: WORTH THE PREMIUM YOU PAY … OR SIMPLY A “TIME PAYMENT PLAN”?

 

 

 

Op-ed by D. Kenton Henry

“Is dental insurance really worth the premium I pay?” is one question I am asked frequently. It is often followed, almost instantly, by―”Or am I simply paying for my dental work on a time a payment plan?”

My answer to both questions is a definitive, “Maybe.”

If you, as the majority do, have dental insurance through your employer, that employer is subsidizing all or part of your premium. This convenience makes for a solution to the equation, more favorable to you. In contrast―if you are self-employed, retired, or otherwise personally have to pay the full amount of a dental insurance premium―the opposite may be true. That is unless you take some straightforward advice, I am about to provide. If you do not, you most likely will only be spreading your cost for dental work over time. Even worse, dental insurance could prove to be a “loss item” in that you will have paid more in premiums than you will ever receive in benefits.

Short of taking a long drive and crossing the Rio Grande into Mexico to obtain your dental work, what can you do to offset the cost of say, a dental implant, which, on this side of the border, is going to run from $3,500 to $7,000?

Let me preface this by with a premise or three:

#1) With no insurance company is “the sky the limit”. I’m referring to the fee they are going to pay a dentist for a particular dental procedure. For example, no insurance company is going to accept a fee of $10,000 for a single porcelain crown. Not even their share of that cost, which is typically 50%. So what is the limit of a fee the insurance company will cover? That limit must be contractually defined, and the limit most insurance companies abide by is, “reasonable and customary” or “reasonable, usual, and customary”. These are empirical standards an insurance company uses to determine whether to pay a fee. Or how much of a fee to pay. If the dentist charges the general prevailing rate in your geographical area, they are going to pay the portion for which they are contractually obligated. Basically, it’s the average charged in your neighborhood. You will be charged more in Beverly Hills, California and less in Brenham, Texas “where the cows think it’s heaven”. Additionally, if “usual” is part of the definition, the fee has to be in line with what this particular dentist charges for a particular procedure. If fee is disproportionate either, or, both, ways―the maximum amount paid by the insurance company will be the limit set in their fee schedule.

#2) A dental insurance plan is either a provider network plan or a non-network plan. If it is a network plan, it is usually either a Dental Preferred Provider Organization (DPPO) Plan or a Dental Health Maintenance Organization (DHMO) Plan. If it is the first, you may go outside the network of dentists with which the insurance company has contracted but will most likely pay a higher cost for doing so. With the latter, you must remain within the network of dentists or, you have no insurance coverage whatsoever. For either of these options, you pay a lower premium than if you purchase a non-network or “any dentist” plan. The reason is that you agree to utilize or, at least, consider utilizing a dentist with whom the insurance company has contracted to charge you a lower fee than they would without the contract. This limits the insurance companies losses and brings increased traffic to the dentist.

#3) This is perhaps the most important part. If you purchase a non-network dental insurance plan, you can, almost, be assured you will be charged more than the insurance company deems acceptable. Additionally, you will be responsible for any dollar amount above their “reasonable and customary” rate. However, if you purchase a network plan, and go within the network of dentists, you will not be held responsible for any “excess” charges. Any charges above the reasonable and customary rate, the dentist will be forced to “write off”. In this situation, you will never have to worry about a surprise bill or claim. If a policy says your share of the bill is 20% or 50%, it will be that and not 20% or 50% plus any excess charges.

Assuming you accept you must acquire a network plan, in order to limit you own losses and surprise dental bills, the challenge becomes, “How do you find a quality dentist willing to accept a lower fee for treating you?” The typical HMO dental provider is typically someone straight out of dental school or who otherwise needs to build their patient base. In return for sending patients their way, the dentist is willing to accept a meaningfully lower fee. If the dentist is a PPO provider, they may have been in business longer, have more experience, and perhaps a reputation for having better skills. But they are willing to accept a somewhat lower fee in return from the many employees a large company may send their way. The dentist who isn’t willing to participate in any network apparently feels they have all the clients they need. That or their reputation is so great it will draw all the traffic they require.

The problem is, unlike a large oil company, as an individual, or family, you don’t bring enough “volume” to the table to bargain for a lower dental fee. At least not by yourself. Therefore, you have to identify and purchase your dental insurance from an insurance company which has the reputation of insuring a large number of employees of that oil company. As well as having a reputation for paying their claims in a timely and efficient manner. A manner such that the dentist wants to be contracted with them. From your standpoint, you want that insurance company to have a reputation for the same when it comes to you and not have to worry about claim disputes.

Another challenge is, at $6,000 for a dental implant, your dental benefit may not go too far. Secondly, does your insurance plan cover implants in the first place? Again, the sky is not the limit. The average dental plan covers a maximum of $1,000 of dental treatment per year. You can pay a higher premium for incremental benefits up to a maximum of $5,000. But a policy which pays that much in year one would cost a fortune and there is typically a twelve-month wait for major dental work to be covered. As such, you may want to find a plan which increases to that limit with each passing year and is available at what you consider a reasonable cost.

How do you find a dental policy which does not subject you to “excess” costs; allows you to see a highly skilled dentist, utilizing the latest technology and performing the most advanced form of treatment; all at a competitive premium? And this from a company which pays the claims they are contractually obligated to pay while doing so in a timely fashion?

This is where I, and my thirty-three years experience in the medical and dental insurance business, come in. My experience as a patient and consumer is even longer. After being in braces for eight years, I had all my front teeth knocked out in an auto accident when they impacted the steering wheel. I was wearing a seat belt, which saved my life, but not a shoulder strap. I’ve had to have the dental work replaced on three occasions since that senior year of high school. This year, I proceeded with what will be one double crown and, ultimately, two implants. (Ouch, is right!) I was not willing to accept this type of work from a mediocre dentist―and certainly did not care to pay cash for it! So I found a policy, issued by a large, financially sound insurance company, with a reputation for excellent customer and claim service. Then I found a policy which ultimately pays the maximum $5,000 annual benefit. In order for it to be affordable to me, it started, December 1 of 2018, at a calendar year benefit of $1,500―immediately went to $2,500 January 1, of this year―and will go to a $5,000 benefit this coming January. So I only paid for a $1,500 benefit for one month before it jumped to a $2,500 benefit! During this year I acquired the double porcelain crown and the bone graft and post for one dental implant. In 2020, I will have the crown for the implant post attached, when my calendar year benefit is $5,000. The second implant is optional, and I will probably have that work done in 2021 when my benefit remains $5K.

Once I knew what company to go with, the final step in selecting my dental insurance policy required finding the right dentist. I reviewed the insurance company’s list of network providers and researched the dentist’s reputation via credentials and reviews. I won’t belabor that but, suffice it to say, I found a dentist who met my requirements. He is very conveniently located relative to any resident of The Woodlands or Spring and, in my opinion, is well worth going to if you reside anywhere in Montgomery County or Northwest Harris County. He utilizes the latest technology, has a great and skilled staff, and a decent, very professional, if not overly effusive, chairside manner.*

 

In summation, in order to make dental insurance worth your while, you need to:

1) accept you need to acquire a “network provider” dental plan

2) find a policy which pays a reasonable benefit based on your foreseeable need, at an affordable premium and

3) allows you to go to a skilled dentist convenient to you

I have done all the homework for you. For over three decades, I have specialized in medical, Medicare-related, and dental insurance. I provide objective quotes from established “A” rated companies and quality customer service. Among the companies I represent are Aetna, Ameritas, Anthem, BlueCross BlueShield, Cigna, Delta Dental, Humana, and UnitedHealthcare. I am located in the heart of The Woodlands and am accessible from my websites Allplanhealthinsurance.com and TheWoodlandsTXHealthInsurance.com. You may also feel free to contact me at my numbers below.

I look forward to working with and assisting you in acquiring any of the above referenced products.

D. “Kenton” Henry                                                                                                               Editor, Agent, Broker Office: 281-367-6565                                                           Text my cell @ 713-907-7984                          http://TheWoodlandsTXHealthInsurance.com                              http://Allplanhealthinsurance.com                                   http://HealthandMedicareInsurance.com https://linkedin.com/in/kentonhenryinsuranceconsultant

*(Neither I nor my agency and websites are affiliated in any way with a particular dentist or dental office. Neither do we receive compensation from the same for any recommendation we may make.)

HIGH SCHOOL CLASS OF ’72! – MEDICARE IS HERE FOR YOU!

By Don Kenton Henry – editor, broker

Fellow classmates of the High School Class of 1972! Congratulations! It’s been thirty-six years since we graduated and went on to build careers and raise families. During this time we dutifully paid into Social Security and paid Medicare taxes. Most of us will be turning age 65 during the next year if we have not already done so. As such, we will be “aging into Medicare”. Never, in my life, have I looked forward to getting older,―until now. Because―as such―I will be eligible for Medicare and finally have an alternative to the Under Age 65 Affordable Care Act (ACA) marketplace for health insurance purposes. As a Medicare-related, private insurance specialist,―knowing all my plan options―along with knowing which plans I will enroll in―I am elated to finally being able to take advantage of the following benefits not currently available to any of us not currently on Medicare:

I know I will I be able to go to any doctor or hospital that sees Medicare patients. Additionally, I will be out of nothing―or virtually nothing―for my Medicare eligible medical expenses, per se, throughout the calendar year! (By “per se”, I mean aside from the out-patient prescription drug costs I will pay at the pharmacy counter.)

Even those of you who have had the benefit of employer-based group health insurance through throughout your working career ― have to had to meet a significant deductible before insurance benefits apply to your major medical expenses. In recent years, that has probably been at least $1,000 and, probably, more. Then you have been responsible for additional costs (coinsurance) thereafter!  Compare that to your share of a maximum of $183 per calendar year, should you go with the plan option I will most likely recommend for you!

Regarding Part D prescription drug plans ― you will have approximately three dozen to choose from. Each of these covers some drugs but does not cover others. And vice versa. The plan that is best for your spouse or neighbor is not necessarily the best plan for you. Our objective is to: (1) cover all your prescription drugs and (2) do so at your lowest possible total cost for both the plan and your prescription drugs for the calendar year. “Total Cost” is the sum of your plan premium, any applicable deductible, and your copays or coinsurance for your Rx drugs.

*If you would like me to identify your lowest cost Part D Medicare Prescription Drug Plan for 2019 email me, at Allplanhealthinsurance.com, a list of your current drug regimen and dosages. I will do so in the order received and forward the results via email.  

CHANGES TO MEDICARE PART D DRUG PLANS IN 2019:

  1. A) Stage 1, the Medicare Part D “Yearly Deductible Stage” is going to require a Medicare recipient member meet as much as a $415 deductible, up from $405. This does not mean a drug plan will increase your deductible, or even charge one in the first place. It simply means the Center For Medicare Services has informed the drug plans they may charge as much as that amount.
  2. B) Stage 2, the “Initial Coverage Stage” is going to $3,820. This is the limit your, and the plan’s, drug cost must reach before you enter the “Coverage Gap”.
  3. C) Your liability for your drug costs has been diminishing each year since 2011. This year, you will pay 25% of the cost of brand-name drugs, plus a dispensing fee, and 37% of the price for generic drugs.
  4. D) When your year to date personal drug costs reach $5,100 you enter the “Catastrophic Coverage Stage”. Therein, you will pay $3.40 of a drug that is treated like a generic and $8.50 or 5% of the cost of the drugwhichever is higher for all other drugs.

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MEDICARE PART B 2019

There has been no announcement on whether Medicare Part B’s calendar year outpatient deductible of $183 will be changing.

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CONSIDERING MEDICARE SUPPLEMENT VS MEDICARE ADVANTAGE to cover those medical expenses not paid by Medicare? Refer to today’s FEATURED ARTICLE 1 on “Denials of Care” below then call me for my opinion on one vs the other.

Should pharmacists be subject to a “gag” clause preventing them from telling you a lower cost for your drug is available at the pharmacy counter? See FEATURED ARTICLE 2, below:

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THOUGHT FOR THE DAY:

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Turning age 65 in April, I am right in this with you. I share a kinship, not only with my personal HS classmates, but everyone of my generation. I began my career out of college as social worker and then―believe it or not―a pharmaceutical sales person. I understand the perspective on brand name vs generic drugs, both from the drug companies’ and the consumer’s standpoint. (If you’d like to me to share this with you, off the record, please call me.)   I still like to help people and I get great satisfaction from ensuring I keep my client’s drug and medical costs to a minimum.

To assist you in this, I represent virtually every “A” rated (AM Best Rating) Medicare Supplement Plan and most of the Medicare Advantage and Part D Prescription plans I feel worthy of your consideration for 2019. I bring thirty-two years of experience in the industry to provide you an objective comparison of your options, simplify the enrollment process, and ensure you maintain the right plans for yourself, thereafter. I charge no fee for my services. I am compensated directly by the insurance company whose product you elect to utilize, and then―if, and only if―you elect to acquire that product through me. The key to you is―you are charged no more for that product than if went through the door of that insurance company to acquire it on your own. Additionally, when you call, text or email me, you know you are communicating with someone who knows your history and has a vested interest in keeping your business. Which means keeping you happy. This as opposed to a different faceless person at the other end of a toll-free number.

SoClass of ’72! Open enrollment begins October 15th for Medicare plans (and November 1st for your Under Age 65 family members in need of health insurance for 2019). Please call, text, email, or visit my websites for information and assistance. I’m certain our life experiences and objectives are much the same and I know peace of mind when it comes to our healthcare and costs is integral to our quality of life

Kenton Henry – Agent, broker, editor                                                                          Office: 281.367.6565                                                                                                  Text My Cell @ 713.907.7984                                                                                          Email: Allplanhealthinsurance.com@gmail.com                                  http://Allplanhealthinsurance.com                                  http://TheWoodlandsTXHealthInsurance.com          https://HealthandMedicareInsurance.com

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*FEATURED ARTICLE 1

BLOOMBERG

Private Medicare Plans Faulted by Watchdog Over Denials of Care

By  John Tozzi

September 26, 2018, 11:01 PM CDT

A new federal watchdog report warns that privately run Medicare health plans used by millions of older Americans may be improperly denying patients medical care.

Federal auditors have found “widespread and persistent problems related to denials of care and payment in Medicare Advantage,” the privately administered plans that insure more than 20 million people, according to the report from the Health and Human Services Office of Inspector General.

Medicare Advantage plans collect a fixed fee from the government for taking care of patients 65 or older who qualify for traditional Medicare coverage. The fixed per-patient rates the government pays may give plans “an incentive to deny preauthorization of services for beneficiaries, and payments to providers, in order to increase profits,” the report said.

Medicare Advantage plans have become popular with consumers because they combine traditional Medicare benefits with additional coverage, such as vision, dental care, and prescription drugs.

The program paid $210 billion to Medicare Advantage plans last year. Companies including UnitedHealth Group Inc.Humana Inc., and Aetna Inc.are the largest sellers of the coverage. Enrollment in Medicare Advantage has roughly doubled in the past decade, and one-third of Medicare patients are now covered by the private plans.

In 2016, Medicare Advantage plans denied 4 percent of requests to approve treatment before it was provided, known as prior authorization, and 8 percent of requests for payment after treatment, according to the report.

Only 1 percent of patients disputed the insurers’ denials, but in those cases, the decisions were overturned three-quarters of the time, according to the report.

Improper denials “may contribute to physical harm for beneficiaries if they’re not getting access to services that they need,” said Rosemary Rawlins, the inspector general’s team leader on the report. Patients and doctors can also be harmed financially if not reimbursed for appropriate care, she said.

If plans aren’t providing the care they’re contracted to, it risks wasting taxpayers’ money. The government “has already paid to cover beneficiaries’ health care,” Rawlins said. Not every denial is an indication that patients are being blocked from needed treatment, however.

“You wouldn’t expect the denial rate to be zero,” Rawlins said. “Part of managing care is denying care that’s not needed.”

There’s a lot of variation in how often Medicare Advantage plan denials were overturned. In 2016, seven Medicare Advantage contracts had almost all of their denials reversed on appeal — more than 98 percent. Another 69 contracts had denial rates above 90 percent. The report doesn’t name specific companies or plans. Individual insurers can have more than one Medicare Advantage contract with the government.

Problems with denials of care aren’t isolated to a few plans, however. The Centers for Medicare and Medicaid Services, or CMS, audits different organizations each year, “but consistently find problems related to denials of care and payment,” Rawlins said.

The CMS audits are one of many factors that affect health plans’ star ratings, which are intended to help Medicare patients shop for plans based on quality. But starting in 2019, as the result of a change by CMS, the audits will no longer be a factor in the ratings, “which diminishes the usefulness of the star ratings system as a tool for beneficiaries,” the report said.

The inspector general recommended that CMS increase its oversight of Medicare Advantage plans and give patients better information about violations. The agency concurred with the findings.

A CMS spokesperson said in an email that the agency is committed to “strong oversight and enforcement of the Medicare Advantage program to ensure that plans are delivering care to Medicare beneficiaries” as required.

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FEATURED ARTICLE 2

WASHINGTON EXAMINER

Senate unanimously passes bill banning pharmacy ‘gag clauses’ in Medicare

by Kimberly Leonard

 September 05, 2018 03:03 PM

The Senate unanimously passed a bill Wednesday that would ban Medicare insurers from enforcing “gag clauses” that forbid pharmacies from telling customers about cheaper ways to buy drugs.

The Know the Lowest Price Act is intended to help patients covered under Medicare to find out if their prescription would cost less if they were to pay for it out of pocket rather than through their insurance plan.

“Passing this bill and eliminating gag clauses gives patients more power to lower their healthcare costs,” Sen. Bill Cassidy, R-La., who helped introduce the plan, said in a statement. “It makes prices transparent so patients can save money with less expensive prescriptions.”

The new rules explicitly apply to Medicare Part D, which pays for prescription drugs, and to Medicare Advantage, a healthcare plan managed by private insurers. Medicare is the program covering adults 65 and older and people with disabilities.

In the complexity of the system that involves pharmaceutical companies, drug reimbursements, middlemen known as pharmacy benefits managers, and health insurance companies, patients can sometimes end up paying more while others in the chain pay less. Private health insurers and pharmacy benefits managers use “gag clauses” in their contracts to prohibit pharmacists from informing customers that they can save money if they don’t go through their health plans.

Another bill passed in committee, known as the Patient Right to Know Drug Prices Act, would provide the same protections for people who have private health insurance coverage. The Trump administration has called for Congress to undo the gag clauses and pass other measures to help reduce what patients pay for drugs.

CENTER FOR MEDICARE SERVICES DELAYS CUTS TO MEDICARE ADVANTAGE – OR DID THEY?

OBAMA CUTS TO MEDICARE

In a surprise announcement today the Center For Medicare and Medicaid Services gave notice they are reversing planned cuts to Medicare Advantage Plans for 2015. But after all variables are factored in will the end result be an increase or decrease in reimbursements for Medicare approved procedures next year?

If implemented the cuts would have resulted in 2% lower payments to Medicare providers on top of the 6% cuts for 2014. Instead, the agency says, payments will instead be increased 0.4%. Still, with all variables in play, Aetna anticipates payment reductions and Humana estimates a funding decline of 3%. (See feature article from Reuters below.)

OBAMA CUTS TO MEDICARE II

What is the end result of all this? 2014 reductions already saw the termination of thousands of providers from HMO and PPO Medicare Advantage networks. Further reductions are likely to result in more of the same along with probable increases in premiums and copays for medical procedures. And–if not now–certainly when they are ultimately implemented as mandated by the Affordable Care Act (ACA). Which begs the question: If all these cuts to Medicare Advantage were for the purpose of financing the ACA, what is the long-term impact of delaying them on the financial solvency of the Act? Or was the latter really ever a concern of the administration? Or is it simply the case that concern over the effect of cuts on this fall’s election over-rides the need for the Act to be financially feasible? (In case you were naïve enough to believe feasibility was realistic in the first place.) In light of all the approximately 38 delays and changes in the law since its passage, it is apparent to this author that political expediency rules the day in Washington. In other words, “business as usual”.

– Admin. Kenton Henry

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FEATURE ARTICLE

U.S. insurers still expect cuts in 2015 Medicare payments

By Caroline Humer

Tue Apr 8, 2014 1:40pm EDT

(Reuters) – U.S. health insurers said on Tuesday they still expected cuts in government reimbursements for privately managed Medicare health plans for the elderly next year even after the Obama administration rolled back the steepest reductions.

The government agency that oversees Medicare said late on Monday that on average, reimbursements to insurers for private Medicare plans would rise 0.4 percent, reversing what it said was a proposed cut of 1.9 percent.

The insurance industry and advocates for the elderly had lobbied against the cuts, which were first proposed in February, saying they would reduce benefits for older people.

Republican and Democratic lawmakers had broadly opposed further cuts as well, adding pressure on the administration at a time when President Barack Obama’s healthcare law was also under attack.

After analyzing the final rate notice from the Centers for Medicare and Medicaid Services (CMS) and comparing it with their own models, health insurers said on Tuesday that the 2015 Medicare Advantage payment rates represented a cut to payments from 2014 levels.

Humana Inc, which derives two-thirds of its revenue from administering Medicare Advantage plans, said it expected a funding decline of about 3 percent for 2015 plans from 2014, according to a filing with the Securities and Exchange Commission.

This is slightly better than Humana’s initial forecast for a drop of 3.5 percent to 4 percent in those rates, based on the proposal issued on February 21.

Aetna Inc, which also provides Medicare Advantage plans, said it also anticipated a decline.

“Despite CMS’s actions, Medicare Advantage plans will still face rate decreases for 2015,” Aetna spokeswoman Kendall Marcocci said in a statement. The company is still evaluating the impact, she added.

CMS officials were not immediately available for comment on the insurers’ or analysts’ analyses.

Humana shares fell 1.7 percent on Tuesday. Aetna was little changed, and UnitedHealth Group Inc slipped 0.4 percent.

APPLES-TO-ORANGES

The comments from individual insurers echoed that of industry trade group America’s Health Insurance Plans, which said it was concerned about how the policy will affect the 15 million people who receive privately managed benefits. The balance of the more than 50 million older and disabled people who use Medicare are in a different program run by the government.

“The changes CMS included in the final rate notice will help mitigate the impact on seniors, but the Medicare Advantage program is still facing a reduction in payment rates next year on top of the 6 percent cut to payments in 2014,” AHIP President Karen Ignagni said in a statement.

Wall Street analysts saw an improvement of 2 to 3 percentage points in the government’s funding proposal, but they estimated about a 3 percent cut overall, not an increase of 0.4 percent.

They described an apples-and-oranges comparison between how they calculate the total impact of Medicare reimbursement rates versus how the government does so.

One difference may be that the government analysis did not reflect the 1 percent insurance tax that funds Obama’s Patient Protection and Affordable Care Act, while some analysts included it.

Another factor, some said, is that CMS adjusted its estimates to reflect the worsening health of some Medicare members, while analysts did not.

Analyst Sheryl Skolnick of CRT Capital described the final funding announcement as being “less worse” than anticipated.

“The market was assuming that the final rate would be better than the proposal, and that’s what it got,” Skolnick wrote in a note.

Each year, the government releases its formulas for determining how it will reimburse the insurers for plan members’ procedures and doctor visits. Insurers use this information to decide on the markets where they will offer plans and what benefits they can provide.

(Reporting by Caroline Humer; Editing by Michele Gershberg, Lisa Von Ahn)

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