Delta Dental of California and the AARP (American Association of Retired Persons) are joining together to offer dental benefits to AARP members. According to Managed Dental Care, a dental insurance industry publication, the AARP Dental Insurance Plan will be offered in all 50 states to over 35 million people. The plan is said to include comprehensive family coverage, the choice of any licensed dentist, and immediate coverage for preventive, diagnostic, basic restorative, endodontics and oral surgery. Major restorative services such as crowns, periodontics, and prosthodontics are covered after a 12-month waiting period.
Two plan schedules are being offered. One has an annual maximum of $1,200 per year, with a $50 deductible. The other has an annual maximum of $1,000 per year, with a $100 deductible. Early reports indicate that one family member must be enrolled in the AARP to qualify, with plans covering a 12-month period. As always, the premium payments will be based on the plan chosen and the person’s zip code area. Currently, the over-50 population is estimated to be at around 27 percent. In 2020, that number is expected to be 35 percent or 115 million people.
Dental insurers see a large potential monetary gain for the insurance industry, since many people over 50 have limited dental insurance - or no insurance - and would like to have coverage. These types of plans also will be good for patients and dentists. Patients with insurance typically have more treatment than those without insurance.
According to some reports, almost 10 percent of all U.S. dental laboratory work is being fabricated offshore. By some accounts, this amounts to around 4 million units per year. Not only are dental labs contracting with the foreign facilities, but dentists also are sending cases directly to these labs. Cheap foreign labor costs can reduce the lab fee for a porcelain-fused-to-high-noble metal crown to as little as $30!
This outsourcing raises many questions. What quality controls exist? As an example, is that really high-noble metal under the porcelain? What about health and safety? Could illness be spread by lack of sanitary lab conditions? What about disclosure? Consumers know where their clothes are made, but rarely know where their restorations are fabricated. Should they? What about benefit plans? If the lab fee per unit is $30, what should the cost be for the patient? What about U.S.-based lab technicians? What will be the long-term effects of a dramatic shift in these types of jobs? Increased debate is expected on these controversial topics.
New 2005 codes
Patients of dentists who are not using the new ADA codes are facing problems with insurance reimbursement for their treatment. In addition, dentists need to be aware of the revised descriptions for D0150-Comprehensive Oral Evaluation, D1110-Prophylaxis, Adult, and D4910-Periodontal Maintenance. Proper documentation of periodontal conditions is even more vital to claims payment. Plans are looking for documentation of comprehensive periodontal probing and charting, bleeding, mobility, furcations, and recession. (See a sample form for listing all five at www.steppingstonestosuccess.com.)
Many offices also are concerned about when a patient’s age dictates using D1120-Prophylaxis, Child or D1110-Prophylaxis, Adult. While current codes describe the procedures in terms of present dentition, many carriers use an arbitrary age, such as 13, as a “cut-off” point for child procedures. The ADA House of Delegates passed resolutions concerning the age of the child and dental plans. According to 1991:635, “Where administrative constraints of a dental plan preclude the use of clinical development so that chronological age must be used to determine child or adult status, the plan defines a patient as an adult beginning at age 12, with the exclusion of treatment for orthodontics and sealants.”
Offices also are wondering about codes for irrigation. There is currently no code for pocket irrigation and few plans provide a benefit. D4999-Unspecified Periodontal Procedure, by Report, might be used for this procedure, although some carriers prefer D9999-Unspecified Adjunctive Procedure, by Report. A better option might be to include any fee for irrigation as part of the fee for the larger service - for example D4910-Periodontal Maintenance.
Carol Tekavec, CDA, RDH, is the author of the Dental Insurance Coding Handbook Update CDT-2005. She is the designer of a dental chart, and is a lecturer with the ADA Seminar Series. Contact her by phone at (800) 548-2164 or visit her Web site at www.steppingstonestosuccess.com for more details about the new code handbook and her patient brochure, “My Insurance Covers This ... Right?”