Do MAPD Dental Benefits Coordinate with Stand-Alone Dental Policies?

[InsuranceGuy29]

Somehow I've never come across this situation. I have a client on an MAPD PPO and she's (a very youthful) 91 and doesn't qualify for GTL. She wants to try and stack as much dental as possible, and GTL usually solves this problem. If she goes with a regular stand-alone dental policy with co-pays, would this be a waste of money for her? I know I'm able to write her a stand-alone policy, but I don't want to waste her money if it's not gonna cover much. My intuition tells me they don't, and this is not gonna be a good idea, but just want to make sure.

 

[goillini52]

Somehow I've never come across this situation. I have a client on an MAPD PPO and she's (a very youthful) 91 and doesn't qualify for GTL. She wants to try and stack as much dental as possible, and GTL usually solves this problem. If she goes with a regular stand-alone dental policy with co-pays, would this be a waste of money for her? I know I'm able to write her a stand-alone policy, but I don't want to waste her money if it's not gonna cover much. My intuition tells me they don't, and this is not gonna be a good idea, but just want to make sure.

They'd both pay.

 

[LostDollar]

Somehow I've never come across this situation. I have a client on an MAPD PPO and she's (a very youthful) 91 and doesn't qualify for GTL. She wants to try and stack as much dental as possible, and GTL usually solves this problem. If she goes with a regular stand-alone dental policy with co-pays, would this be a waste of money for her? I know I'm able to write her a stand-alone policy, but I don't want to waste her money if it's not gonna cover much. My intuition tells me they don't, and this is not gonna be a good idea, but just want to make sure.

Caveat, not an agent.

I don't know how it works with MAPD.

With stand alone plans it depends on how the second plan processes second claims.

For example:
I have a UHC dental plan as primary.

BCBSKS and Delta Dental KS receive the processed EOB from the primary carrier and then process their own payments.

Ameritas has told me they will pay the amounts their plan specifies regardless of payments made by other companies.

MetLife has told me their company will not make any payments as secondary for their take-along plans if they receive a claim and EOB showing any payment on the claim by another carrier. I don't know how they can do that, but that is what they told me.

My first thought in reading your post was that the NCD plan that Sam reps might be good for this situation but I don't know how any of their versions in general or the newer MetLife version in particular will pay as a secondary plan.

Waiting periods will probably also be an issue for you, at least for major services, although some plans may give you immediate coverage for everything at lower % levels for the first 1-2 years.

The Manhattan plan that goillini and rousemark like will probably make their payment regardless of what another plan has done, but I believe they have waiting periods.

(If implants are a desired service, look also for plan maximums for that service. My personal experience doesn't go beyond fillings, root canals, and crowns.)

I have no idea how all that works if there is an MAPD dental plan as primary.

 

[LostDollar]

Forgot to mention, in regard to waiting periods, some carriers will give credit for other coverage if it covers basic and major services as well as preventive. Again, I don't know if dental coverage embedded in an MAPD would qualify for this waiver. You would have to ask questions of the carriers involved.

In the stand alone world, as an example, my UHC coverage of several years counted as prior coverage for BCBSKS and DeltaDentalKS waivers of waiting period requirements.

 

[Midlevel]

LD would be the expert on dental plans even if he doesn’t have a license. I use Aetna MAPD and it is a straight 1000.00 reimbursement for dental. If someone takes an Ameritas dental plan out then anything the client pays out of pocket gets sent to Aetna for reimbursement up to 1000.00/year. 50.00 deductible, send it to Aetna. 20% copay on filling, sent it to Aetna. Check sent right to client’s house.

 

[adjusterjack]

My advantage plan (Humana) has two and a half pages about coordination of benefits. It doesn't distinguish between coverages and it's at the end of the manual, so I guess it also applies to dental.

 

[LostDollar]

LD would be the expert on dental plans even if he doesn’t have a license. I use Aetna MAPD and it is a straight 1000.00 reimbursement for dental. If someone takes an Ameritas dental plan out then anything the client pays out of pocket gets sent to Aetna for reimbursement up to 1000.00/year. 50.00 deductible, send it to Aetna. 20% copay on filling, sent it to Aetna. Check sent right to client’s house.

(this is not throwing rocks, just an additional information for op question.)

How do you think this would work for dental services not covered by the standalone plan.

Say adult orthodontics like invisalign. I believe most of the stand alone dental policies I looked at that covered orthodontics would only do so up to age 18. While hunting for dental insurance and for local dentists, I was seeing a lot of ads for invisalign. My starting assumption would be that treatment is not covered by traditional stand alone policies. Do you think the Aetna MAPD would reimburse for it?

Implants the same way. As an example, the Manhattan DVH policy limits implants to a $1,500 lifetime amount. Do you think the MAPD plan would cover implant work even when a stand alone plan would not?

 

[LostDollar]

Somehow I've never come across this situation. I have a client on an MAPD PPO and she's (a very youthful) 91 and doesn't qualify for GTL. She wants to try and stack as much dental as possible, and GTL usually solves this problem. If she goes with a regular stand-alone dental policy with co-pays, would this be a waste of money for her? I know I'm able to write her a stand-alone policy, but I don't want to waste her money if it's not gonna cover much. My intuition tells me they don't, and this is not gonna be a good idea, but just want to make sure.

If you want to pursue this with her, I think you need to find out why she wants to do that. If she is expecting some very specific needs you would then need to look at stand alone plans from the perspective of BOTH how the specific treatments wants are covered and provider networks.

Using a stand alone plan with an in-network provider gets you Two Benefits, a network price reduction and a payment on the services.

This could work nicely with an MAPD plan that works the way Midlevel is talking about (subject to any restrictions the MAPD plan might place on the types of services they will reimburse for).

I'm making these numbers up, I am not taking the time to go back through my claims and get actuals. Also assuming plan deductible has been met.

Say one needs a crown. The dentist charges $1000. No stand alone coverage, submit the claim to the MAPD and get $1000 back. $0 left at MAPD with $1000 limit.

You have a stand alone policy, but the provider is out of network. The policy pays something. Let's say the policy pays $300, $700 goes to the MAPD for reimbursement. $300 left at MAPD with $1000 limit.

You have stand alone coverage and the provider is in network. Provider charges $1000. Network pricing is $800. Policy pays 50% on major services. Policy pays $400, $400 goes to MAPD for reimbursement. $600 left at MAPD with$1000 limit.

If deductible has not been met, it might look something like this. Provider charges $1000. Network repricing to $800. carrier subtracts deductible. $800-$50=$750. Policy then pays 50% of $750=375. Patient's liability of $50 ded + $375 for services goes to MAPD. $575 left at MAPD with $1000 limit. (something is wrong with my math there but I can't figure it out quickly while editing post. There should not be quite that much left at MAPD.)

The stand alone policy could stretch the MAPD benefit if the stand alone is matched to dental needs and provider networks. That could then benefit the patient if she has a lot of dental needs.

 

[ICACharleston]

The caveat with a stand alone policy would be the waiting period, which essentially functions as another deductible. At 91, does she have more time or money?

 

[LostDollar]

The caveat with a stand alone policy would be the waiting period, ......

I agree but this can be at least partially addressed with some stand alone policies.

I am not taking the time to go re-look at policy specs, but, for example, off the top of my head, Ameritas and some UHC senior versions of their dental plans have annual tiered phase ins of the no waiting period.

For example they might cover major services with no waiting at 10% of their allowed amount in year one, 30% of the allowed amount in year 2, and then get to the policy maximum of 50% of their allowed amount in year 3. This could still serve to stretch the MAPD reimbursement amount.

I'm not sure if the NCD plans offer coverage with no waiting periods, but if they do, that would be another (even more expensive) option to address the concern.