One increasingly popular way to offer dental insurance is a through the use of a prepaid dental plan. Under such a program, a corporation, partnership, or other entity provides or arranges for the provision of dental care services to enrollees or subscribers in return for a prepayment. These plans operate in much the same way as health maintenance organizations (HMOs). They offer services based on capitation (or fixed per member per month payments), where the provider assumes the full risk for the cost of contracted services without regard to the type, value, or frequency of the services provided. Any licensed dentist may participate as a service provider. Some other necessary features of prepaid dental plans are listed below:

Evidence of coverage

All enrollees must be issued an evidence of coverage describing the dental services covered, limitations on those services (including deductibles and co-payments), how to obtain services and information, and methods for resolving complaints.


Individual group contracts, evidences of coverage and solicitation materials must provide a statement of the services and benefits each member may receive. Reasonable exclusions, limitations, co-payments, and deductibles may be included, provided that they're clearly disclosed in those documents. For instance, under a pre-certification or prior authorization requirement, when the enrollee's dentist prescribes any course of treatment expected to exceed a specific amount (such as $200, for example), the treatment must be outlined on a pre-certification form and submitted to the insurer for review and approval before it can be undertaken.

Subscriber may choose a provider

The Plan must publish a list of participating providers, and enrollees have their choice of a primary provider. Subscribers must have the right to select any participating dentist as their primary. If a prepaid dental plan restricts an enrollee's ability to receive services from a class of providers, the limitations must be described in the evidence of coverage as well as in all solicitation documents.

Provider contracts

The prepaid plan may contract with licensed dentists to provide dental care to subscribers in a specific service area or geographic location. The dentists are paid (other than co-payments and deductibles) by the prepaid dental plan. Provider contracts are also subject to state laws designed to protect enrollees from becoming liable for services that the prepaid dental plan fails to pay due to insolvency.

In an open panel system, dentists render services to both prepaid dental plan subscribers and to nonmembers. In a closed panel system, services are provided only to plan subscribers.

Complaint procedure

The complaint system must establish reasonable procedures for resolving written complaints from both providers and subscribers. The organization must respond promptly to all written complaints. Responses to written complaints concerning quality or appropriateness of care must include a statement that the complainant may have the complaint reviewed by a consulting dentist and that the complainant may also submit the complaint to a professional peer review organization.

Service area

Subscribers must have reliable access to qualified providers in the geographic area served by the prepaid dental plan. They also must have access to short-term emergency dental care services within the areas served, and the Plan must pay for services when a dental emergency occurs outside the service area.

Quality Assurance program

Every prepaid dental plan must provide appropriate, necessary, cost-effective, and professional services. Plans must provide for a quality assurance program to evaluate the quality of care given to subscribers, and offer ways to correct deficiencies in provider or organizational performance. Furthermore, provider contracts must include disincentives (including termination) for providers who render inappropriate, unnecessary, excessively costly or low quality care.

blog comments powered by Disqus