Benefit Amounts

Q: I work for a large, local company. Even though I think we receive good benefits, my dental insurance seems to cover less and less each year. Are supplemental benefits available for dental treatment? W.D. in Wilmington

A: You are absolutely right, dental benefits have been decreasing. If dental benefits had only a minor increase every year since the mid 70's you would now have a yearly benefit of almost $3000.00, nearly double the benefit that most of my patients have. Unfortunately, if you want more coverage, outside of your company, you would probably end up paying more than you would receive in coverage. Remember that the insurance company wants to make some money too.

In my experience, dental benefits are not insurance. When you have car or medical insurance, the worse your problem, the greater the benefits. With dental benefits, the worse your problem, the less they seem to pay. Dental benefits are only an assistance plan paid by your employer. The more your employer pays, the better the benefits.

What are some of your options? First, check with your company's benefits department. Some companies allow you to pay for a better plan. Second, many companies allow their employees to set aside part of their paycheck to pay medical expenses with pre-tax dollars. This allows the government to pay 30% of your expenses. Lastly, many dental offices have a number of long term payment plans available. Just ask, they will be happy to help.

Accepting Medicaid payment for dental work?

Q: I am a single mother of a 7 year old. We have been going to the same dentist for almost 3 years because he accepts Medicaid. The dentist recently dropped the Medicaid program because he said it was too difficult to work with. Do you have any advice for finding a new dentist? A.P. in Middletown

A: My office has also had difficulties with the new Medicaid procedures so maybe I can help. A few years ago some wonderful dentists and legislators got together and developed a dental assistance program to help low income children under the age of 21. An incredible number of dentists volunteered to see children who qualified under the program at a reduced cost and the State pays for the treatment. There were, of course, some limitations on the types of treatment to be done and some growing pains, but in general the program worked.

In the old system, the State issued new identification cards each month so that we knew that the participants were covered. The biggest problems that we ran into were patients not showing up for appointments or ID cards that were out of date. Without verification of coverage the dentist assumes the full cost of the treatment and that wasn't part of the original deal.

Recently, everything seems to have changed. New 'plastic' ID cards, with no expiration dates, have been issued and our office received a book of new rules. The new rules are so cumbersome that even the 'Medicaid people' have difficulty answering our questions. This has led to all of our recent Medicaid insurance submissions being rejected. In this computer age, when most insurance companies have agreed to accept certain forms and codes, standard dental insurance claims can actually be submitted electronically before you leave the office. We have had to fill out each of our Medicaid forms individually. The last straw for us is that each patient must have their coverage verified at each appointment. The problem we are having is that the phone lines are busy all day long at the Medicaid phone number which makes verification almost impossible. Our office has seen several patients in the past that pretended to be covered. Now, without verification, we can't see Medicaid patients.

You can do a number of things to try to get coverage. First, contact the Medicaid office and your legislator. Let them know that you are having problems. They may help to simplify the system and make it more workable. The Medicaid office should also have a list of all participating dentists and I am sure that you will be able to find a dentist that is accepting new patients. If this doesn't work, the State has 8 public health clinics. Additionally, A.I. Institute, Wilmington Hospital, and Delaware Technical and Community College all see children. Their programs are very full but their fees are based on 'ability to pay'.

The Medicaid office seems to have made some mistakes with their new policies, but I am hopeful that they can be corrected soon enough to save a very worthwhile program.


Differences Between Dental and Medical Insurance Plans

Q: My physician is required to accept my medical insurance rates; why can my dentist charge whatever he wants and I have to pay the difference? H.T. in Hockessin

A: You have opened a can of worms and I would like to start by asking a question. Do dentists, and dentistry, want to follow medicine into the insurance/managed care swamp where insurance companies tell the doctors what to do?

I assume that you have noticed that your primary care doctors (family practice, internists, and pediatricians) are working harder, for more hours, for less pay every year. Unless things change I think that 10-15 years from now, you will find that it is harder to find a good doctor because the pay and the long hours just aren't worth the high cost of education, years of training, and time away from their family.

Dentists have seen these problems and have been very reluctant to sign agreements with insurance companies. Your medical benefits are a contract between the insurance company, you, and your doctor. In contrast, your dental benefits are, with some exceptions, a contract between the insurance company and your employer. The dentist doesn't even get a copy of the contract.

So I might suggest that you should consider picking your dentist by how well you think he is taking care of you. Is the staff well trained? Does he/she respect your time (do they keep you waiting)? Is the office clean and modern? Are your questions answered patiently and thoroughly or do you feel like the clock is ticking? Good continuing education is time consuming and expensive. If your office was charging only what insurance would allow (low fees), you have to assume that the office must cut corners somewhere. Would you be happy with a low paid, unhappy grouch at the front desk? What about the cleaning service that cleans your dentist's office? Should they be low paid and unreliable or precise and caring, or do they even have one? Dentists can have your crown made in Mexico for very low cost, but if I have a crown made, I want it done by a ceramicist that is an artist with years of experience.

You pay the difference, at your dental office, because your dentist made a conscious decision not to sign a contract with your insurance company, Or more importantly, maybe your employer recognizes the problems with managed care, and is giving you a better dental benefit plan that allows you and your dentist to decide on the proper treatment.

I hope that this helps. If you are paying more than your dental insurance company says is 'usual and customary,' you should be seeing some benefits in the quality of service and treatment you are receiving. If you don't see the value, maybe you have some choices to make.


Q: I (Dr. Rosen) have received numerous questions regarding dental insurance over the years and I understand that much of the confusion comes from patients' experiences with their medical insurance. The fundamental question seems to be: Are dental and medical insurance plans almost always, completely different?

A: Yes. I'll share an example that explains the difference.

Recently, I had a conversation with a patient who had smoked for many years and had some pre-cancerous changes going on in his mouth. I was at the point of deciding whether to biopsy his mouth or treat it as only 'almost cancer.' I felt that I needed another set of eyes to help me so I referred him to a specialist for a second look. The patient asked me if the consultation would be covered by insurance. I realized that this is probably the same question that physicians get asked twenty times every day. I understand that it is important to maximize your insurance, and minimize the patient's costs, but I am afraid that when a patient must ask a question like this, at a time like this, that it is best we remember who is most qualified to make your medical/dental decisions.

Medical insurance is an agreement (legal contract) between your doctor and the insurance company or government (Medicaid). The doctors have the training, but they don't make the rules, they only follow them. My head spins when I see the hoops that doctors must jump through to take care of you. It is amazing to see the time and dedication that these talented and highly educated professionals exhibit. You may also be interested to hear that there is an increase in the number of primary care physicians going out of business. The Medicaid reimbursement has gotten so low that it no longer pays to keep the office running. But remember, this is insurance, the worse your problem gets, the more money is available to fix it. Your medical insurance company doesn't say "sorry, you can't have that broken bone fixed until you have more money next year."

Then there is dental insurance. Oops, did I say insurance? A dental benefit is basically some money that your employer has put aside to help you take care of your teeth. True, in most cases this money is doled out by an insurance company, but the money is very limited. When you've used your yearly allowance, that's all there is until next year. Sometimes that's OK, you can wait. But, other times you need dental work that must be done that exceeds your yearly 'allowance' and you can't wait. If this were truly insurance, there would still be money waiting in the 'dental pot' at the insurance company for you.

I suppose that what I am saying is that you have choices with regard to your dental health and treatment. I believe that it is important, with the help of your dental office, to maximize your benefits. But don't think that the insurance company wants to make treatment choices for you. Deciding whether you have cancer or not isn't the insurance company's job. They are simply 'doling out your employer's (and your) money.'