If you use a dentist who is in private practice, you should consider making provision for the costs of dentistry, even if your medical scheme provides some dental benefits.
The costs of dentistry, as with other medical costs, are rising steadily above inflation, while the benefits offered by schemes to cover dentists’ bills are evaporating rapidly.
Only about two million of the country’s 8.5 million medical scheme beneficiaries are on options that cover the costs of dentistry from their option’s general benefits, or risk pool, rather than from their medical savings account, Dr Gareth Hayton, managing director of Dental Information Systems (Denis), says.
Denis manages dental benefits on behalf of medical schemes and is also one of at least three providers of insurance products for dentistry.
The head of the private practice committee at the South African Dental Association, Dr Ian Erasmus, says the reduction in the amounts that medical schemes spend on dentistry is reflected in statistics produced by the Council for Medical Schemes.
These statistics show that, in 2001, about 5.2 percent of medical scheme benefits (excluding medical savings accounts) were spent on dentistry. Last year, schemes spent 2.8 percent of their healthcare benefits on dentistry.
“We have to find alternative funding for dentistry,” he says.
Insurance products for dentistry are a response to the need for cover for dentistry, and recently a new company launched a policy with a dental health “maintenance plan”.
Possibly one of the cheapest options for financing dentistry is to self-insure by setting aside an amount you can afford to meet these expenses.
The downside of self-insuring is that you may not have saved enough if you require an expensive procedure shortly after you have started saving, but you will at least be better off than if you hadn’t saved anything.
In the absence of any guideline tariffs for dental procedures, the cost of treatment varies widely, and there is obviously merit in shopping around before you decide which dentist should treat you.
Dental Risk Company, which also manages dental benefits on behalf of medical schemes, supplied the following price ranges for some of the more expensive dental procedures, pointing out that both the dentists’ fees and the complexity of the procedures vary greatly:
* A root canal: R900 to R2 500;
* A crown: R2 500 to R4 500;
* An implant done in a dentist’s rooms: R8 000 to R13 000;
* An implant that requires bone augmentation: R20 000 to R25 000, plus R10 000 for theatre costs;
* Removal of four wisdom teeth: R12 000 to R20 000 if done in hospital, R10 000 to R15 000 in a day clinic, or R7 500 to R9 000 in the dentist’s chair under conscious sedation; and
* Orthodontics (device only, but some patients will also require extractions): R12 000 to R25 000.
Medical schemes that do not pay dental benefits from their risk pools either provide no cover for dentistry or expect members to fund these costs from their medical savings accounts. Few members maintain positive balances in these accounts, because the funds are often inadequate for their day-to-day expenses for the year.
Members who are in this position should definitely consider setting aside additional funds for dentistry and their other day-to-day expenses.
Some medical scheme members are entitled to above-threshold benefits, which apply after the money in your savings account has been exhausted and you have settled the doctors’ bills you incur during the self-payment gap – the gap between your savings account being exhausted and the level at which your above-threshold benefits begin.
If you have above-threshold benefits, you may think the most you can be exposed to in any year is the difference between your savings account balance for the year and the amount at which the above-threshold benefits kick in. But medical schemes have rules on the types of claims – and even how much of each type – that count towards reaching the threshold. And once you can access the above-threshold benefits, schemes also have rules on the dental procedures that will be covered and how much will be paid out when you claim.
WHAT ‘BASIC DENTISTRY’ COVERS
Make sure you understand what it means if your medical scheme covers “basic dentistry”.
Lower-cost scheme options often cover only basic dentistry, which means the treatment of pain and abscesses, X-rays, scaling and polishing, fillings, extractions and basic plastic dentures, but usually only once every two years. Basic dentistry sometimes includes emergency root canal treatments.
Treatment that you may consider essential, such as root canals, crowns, implants, bridges and dentures, may be available only on higher options. These procedures are referred to as specialised dentistry, and all medical schemes limit their cover for specialised dentistry, either by capping the payout or requiring members to follow a managed-care protocol.
Medical schemes are unlikely to cover what would ordinarily be understood as cosmetic treatments, such as porcelain veneers, tooth whitening and tooth-coloured fillings.
Dr Gareth Hayton, managing director of Dental Information Systems, says medical schemes should be obliged to provide a package of essential dentistry benefits that covers fillings, extractions, pain control, abscesses and root canals, and this package should be part of the prescribed minimum benefits (PMBs). If this package were in place, members of all schemes would have guaranteed benefits for essential dental treatment, because the PMBs cover treatment for which schemes are obliged by law to pay.
He says an expensive procedure that medical schemes should be obliged to cover is implants after losing teeth as a result of a motor vehicle accident or cancer.
Typically, your scheme will pay for fixing your jaw, because this is covered by the PMBs, but the cost of the implants will be covered only to the extent provided for in your scheme’s dental benefit for implants, he says.
However, Brett de Lange, a director for network and risk at Dental Risk Company, says certain schemes do cover implants under the PMBs. He says schemes decide on these claims on a case-by-case basis.
The cost of implants will be covered if you need them to restore the functionality of your jaw, particularly if the jaw is so badly damaged that implants are regarded as clinical best practice under the circumstances or if you are young and having dentures may cause problems later in life.
Dr Ian Erasmus, chairperson of the South African Dental Association’s private practice committee, says the cost of implants should definitely be covered, because the PMBs should not stop at treating your jaw, and if your scheme refuses to cover the implants, you should complain to the Council for Medical Schemes.
WHAT YOU NEED TO KNOW ABOUT DENTAL BENEFITS
Very few members understand the limitations on their medical schemes’ dental cover, Maretha Smit, chief executive officer of the South African Dental Association (Sada), has said.
The first thing you need to know is that dental benefits vary widely.
A cheaper option may offer only basic dentistry; another, basic dentistry and some cover for specialised dentistry; while a high-cost option could cover both basic dentistry and specialised dentistry without exclusions, such as for surgery to restore bone in which to insert implants, Brett de Lange, director of network and risk at Dental Risk Company, says.
You should also know that dental benefits may have an overall annual limit and/or a limit on what a scheme will pay to reimburse a dentist for a specific procedure – usually indicated as a percentage of the scheme tariff.
In a press release late last year, Smit said that, in many cases, the rates at which schemes reimburse dentists are far below the actual costs of the treatment and service.
Dr Ian Erasmus, chairperson of Sada’s private practice committee, says members should be aware that a scheme may state on its benefit schedule that it will pay for certain benefits – for example, three crowns a year – but the scheme may have protocols, often drawn up by a managed-care provider, that apply before you qualify for those benefits. The protocols may state, for example, that a crown cannot be replaced within five years or that a filling on a particular tooth can be done only once a year, he says.
Practising dentists are concerned about some of the protocols developed by managed-care providers that, they believe, are not evidence-based.
Sada has engaged with medical schemes over a number of cases involving the protocols. For example, it has had discussions with schemes that have mostly stopped paying for fluoride treatments for children and with a scheme that is refusing to pay for the sterilisation of instruments.
Erasmus says schemes are within their rights to curtail benefits for financial reasons, but Sada will lodge a complaint with the Council for Medical Schemes if it believes this is necessary.
Protocols can cause disputes between scheme members and their dentists, on one hand, and a member’s scheme and its managed-care provider, on the other. Orthodontics, which can cost from R12 000 to R25 000, is a case in point, Erasmus says. Benefits are often denied, because the treatment is regarded as elective, but, in most cases, the treatment is functional.
Protocols that save medical schemes money in the short term may have expensive consequences in the long term, when members require extensive treatment to restore the functionality of their teeth, he says.
The danger of scheme contracts with managed-care providers is that they could incentivise the provider to save the scheme money, because this gives the provider greater certainty that it will be re-awarded the contract, Erasmus says.
However, Dr Gareth Hayton, managing director of Dental Information Systems (Denis), says the protocols developed by managed-care providers ensure that dental benefits cover only necessary treatments and, ultimately, ensure that your medical scheme contributions are affordable.
Hayton says that protocols are based on best practices, and in the case of, for example, orthodontics, managed-care companies use the Dental Aesthetic Index, which has been approved by the World Health Organisation, to determine the severity of an orthodontic case and the treatment required.
If your medical scheme offers dental benefits, watch out for co-payments.
De Lange says certain schemes have introduced a co-payment of between 25 percent and 40 percent for orthodontics on their options, to ensure that members use the benefit only when treatment is necessary.
Some schemes cover dental treatment only if you use dentists who are part of a network. Smit says that, in many instances, the fees paid to dentists in these networks are below the cost price of the procedures.
Dentists who belong to networks are not allowed to refuse treatment to members of the medical scheme with which they have contracted if that treatment is specified in the agreement with the scheme, and they therefore often treat patients at a loss, she says.
She adds that the inability of current funding models to provide sufficiently for dental care might ultimately lead to the demise of the profession.
De Lange disagrees, saying that a dentist who participates in a network is guaranteed payment.
He says that 1 890 dentists out of the estimated 2 500 dentists that claim directly from schemes have signed up for Dental Risk Company’s network.
Even where a network limits benefits to basic procedures, a dentist within the network can perform a procedure that is not covered for a good cash price, De Lange says. He cites R900 for a root canal where the cost of the consultation, X-ray and gloves are covered as part of the network benefit.