Indiana Dental Plans

Dental Insurance Benefits

Before acquiring a dental plan, an individual needs to ask certain questions to get a clear understanding of the plans on offer, which include:

• What are the annual benefits of the plan?
• What is the location of the dentist that takes the insurance?
• What is the frequency at which one can see the designated dentist?
• Does one need to wait before receiving treatment?
• What is the policy on pre-authorization?
• What is the deductible ?

These questions will help the prospecting individual uncover some of the fundamental issues associated with the cover. For instance, finding out the location and availability of the dentist can help prevent time wastage in-case of an accident.

To see a specialist, the patient may either be listed under insurance plans that come in PPO (Preferred Provider Organization) or HMO (Health Maintenance Organization) basis, which essentially means that individuals who have PPO will have access to practitioners who aren’t restricted by the network. It is essentially optional to designate a primary physician, and patients make appointments directly with the physician without the need of a referral. The plan is largely popular due to the freedom it allows members in selecting their own dentist. PPO pans are especially lauded for their flexibility as compared to HMO plans and their low cost as compared to traditional indemnity plans.

HMO’s, on the other hand, are a network of healthcare providers who have essentially agreed to provide services at lower prices as stipulated and negotiated by the insurance company and referrals are given by the primary care physician (PCP). The plan is usually much cheaper than PPO plans and indemnity plans. This type of plan is usually popular with businesses that exploit them to insure their employees at affordable rates.

Indiana Dental Plans

Indiana dental insurance comes with plans similar to medical insurance plans and are categorically stated as either Indemnity or managed-care plans.

• Indemnity plans also known as traditional insurance and offers a wider selection of dental care providers than managed-care. In this type of plan, the policyholder has the freedom to choose any dentist he/she takes a fancy for. In essence, the company pays for the service after a bill is provided, which means that one has to pay for the service then seek reimbursements later. The cover takes up 50%-80% of the total cost of dental work whereas the remaining amount is paid for by the patient. Members of this plan are often subjected to long periods of waiting for the claims after they file their forms to receive reimbursements for services paid from their pockets. Advantages offered by this type of cover is that members have the flexibility to choose their dentist, see other specialists and change dentists without a referral. Despite all these freedoms, this type of plan is not popular due to their exorbitant annual premiums, exhausting claims procedures and high rates of deductibles. The plan is usually structured to appeal to large groups and businesses and cannot be recommended to individuals and families. 
• Managed-care plans basically follows the dental provide networks and will usually submit the claim for the patient, which is convenient considering no other costs may be incurred.

To apply for an insurance coverage, there is a certain criteria that one has to meet including:

• Eligibility- The person seeking for a cover has to consider their eligibility as per the provisions of the healthcare provider including eligibility for dependents.
• Up-to date benefits information- The individual has to ensure that the information one receives on what they are going to accrue in the event of being awarded the cover is crucial.
• Claims information- This can be done by reviewing specific claims transactions, payments and pre-treatment estimates and reimbursements. Another way is to print a copy of Explanation of Benefits (EOB) statements.
• ID Cards- The prospector needs to print a copy of their ID card to give to the dentist. However, this does not imply that the ID card will be used for eligibility, although a great number of dental offices like to keep a copy on file for posterity purposes.
• Paperless EOBs- An individual has the option of signing for paperless delivery of EOB statements for verification.
• Dentist search- One needs to ensure that there is a participating dentist near them.

Other factors to bring into consideration include;

• Inpatient Treatment- Many plans place limits and exclusion on treatments in that; the number of days an individual may stay on the treatment facility or the frequency at which the patient is in for treatment.
• Outpatient Treatment- This may not be an issue unless the patient requires inpatient treatment and the plan doesn’t cover it, which may force the patient to seek alternative means. It is imperative that the cover be flexible and be understood fully by the prospector.
• COBRA- It stands for The Consolidated Omnibus Budget Reconciliation Act, which essentially gives workers and their families the choice whether to continue group health benefits for a certain period of time in the event of voluntary, or involuntary job loss. It also determines transition between jobs, reduction in the hours worked, death, divorce, and other life events. Indiana law stipulates that group health plans sponsored by employers with a total of 20 or more employees in the previous year are essentially offered and their families a temporary extension of coverage basically called "continuation coverage” where the plan’s coverage is usually regarded as ended.

Employers have the responsibility to provide COBRA notifications to covered employees and dependents. Mail detailing an individuals’ rights in the event of experiencing a “qualifying event” is provided. The law defines these situations as qualifying events:

• Employee’s Death
• Employee’s Divorce
• Medicare Entitlement
• Change in Dependent Status (i.e. dependent turns 18 and not a full-time student)
•  Termination of Employment
• Reduction of Work Hours

Medical Terms to Familiarize Yourself:

Coinsurance 

This is the amount one is required to pay for medical service after satisfying their deductible as stipulated by the insurance cover. Coinsurance is majorly a percentage of the total amount charged for services offered by a healthcare provider. For instance, if 80% of the insurance is the designated charge, then the patient pays the remaining 20% as coinsurance.

Copay

The amount required to be paid for a certain medical service or prescription is called a copay. It covers the fee that a good number of insurance covers require the insured to pay for certain medical benefits. For example, a visit to the physician’s office or the amount payable by the insured for certain prescription under a prescription drug plan.

Deductible

This is the amount that one is required to pay from the pocket annually before the health insurance plan starts to make payments for claims. Not every plan has a deductible, essentially most PPOs and indemnity plans have a deductible whereas HMOs do not require one. Copays do not add-up-to a plans deductible.

Effective Date

The date that an individual deems effective for the cover to come into effect. Effective date has to be in the future and may affect the quote one receives. An effective date should be set within 30 days for coverage to begin.

Emergency Care 

Most covers take into account emergency care received in an hospital emergency room in the event of an extremely urgent medical service regardless of whether the hospital one is taken to is in the plan or not. However, it is a common occurrence for patients to be transferred to a participating hospital once their condition becomes stable.

Exclusions and Limitations 

These are situations, conditions and services not covered by the health plan.

Formulary Drugs 

Formulary drugs essentially have the tendency for lower copay and are usually thoroughly reviewed by a team of expert physicians and pharmacists. These drugs have to pass the threshold for safety, effective and have to be beneficial to prospectors in treating existent medical conditions. It is also paramount that the team reviewing the drugs considers the relative cost of the drugs.

Generic Drugs

These are drugs that offer cheap alternatives to brand drugs because the patents under brand names have either been sold or have expired overtime. However the food and Drug Administration has passed a requirement for all generic drug manufacturers to ensure that the drug delivers in the same capacity as the original drug.

Inpatient Surgery

Some procedures may require the patient to stay overnight. Most plans, however, give limits to the amount of time a patient may stay at the hospital after a surgery.

Network

This refers to doctors, healthcare providers and hospitals that are contracting with a health plan, who give special rates to the patients in handling the health plan.

Non-Formulary Drugs

These drugs often require a higher copayment and have not yet been reviewed or have been denied formulary status because they have no extra benefits as compared to drugs already in play in a plans list.

OB-GYN Exam

The exam basically includes screening for certain diseases including cancers of the cervix, breasts, uterus, vagina and surrounding area.

Out-of-Network

Health services accrued outside the PPO network that results in higher expenditure except in emergency situations.

Out-of-pocket Maximum

This is a set amount given by the insurer to the insured to pay out of their pocket for covered expenses during the course of the year.

Outpatient Surgery

These are procedures that don’t require the patient to stay overnight. They include biopsies, tonsillectomies, colonoscopies, and cataract removal.

Pre-existing Conditions

Includes any health complication that one has prior to the issuance of an insurance cover.

Routine Annual Exam

This is a check-up given yearly by the designated doctor and may include checking the patient’s height, weight, vision and blood pressure, as well as screening for problems like cervical cancer, prostate cancer, colon cancer, and high cholesterol. These exams are covered by most but not all plans.

Short Term Medical

These types of coverage give the individual and family covers for short time frames, usually 30 days up to 12 months. They are engineered to give the insured protection in the event of an injury or illness.

Underwriting

Involves the identification and classification of the degree of risk posed by the insured.

Urgent Care

Refers to a medical urgency that calls for immediate care but has not qualified for extreme emergency.

X-ray and Laboratory Procedures

In the event that the plan covers for these procedures in support of basic health service, then the insurance company is obligated to pay for them. Examples of these procedures include outpatient ultrasounds, skeletal plain film x-rays, MRI, and CT scans. Basic health services for laboratory procedures include blood panels and urinalysis. However Dental x-rays are typically not covered.

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