Dental benefits: How they compare across medical schemes
Some complaints on Hello Peter show the lack of understanding on what dental benefits are on offer by medical schemes. Moneybags journalist, Sean Binedell, investigates the different dental benefits available.
It is important to check the fine print as the majority of medical aid schemes only offer dentist chair procedures, while you will be required to pay extra for any in hospital work. Studies have shown that poor oral health can lead to an array of problems. Besides the daily brushes and flossing, yearly check-ups at the dentist are important to maintaining your oral hygiene and reducing the potential costs of major dental work due to shoddy upkeep of your mouth.
According to the Council for Medical Schemes, the level of care and funding of dentistry depends on the rules of the scheme and the options the member or beneficiaries choose. Schemes are required to provide Dental Prescribed Minimum Benefits (PMB) which is not only limited to trauma, abscesses, oncology (such as tumours) and the treatment of such, but covers the entire oral health care under ear, nose and throat disease and treatment protocols (DTP).
Examples of dental/oral health PMBs will include the following:
• Cleft palate,
• Oral cancer,
• Mastoiditis (a type of infection),
• Fracture of facial bones and jaw,
• Sialadenitis (the infection of the gland which produces salvia),
• And, stomatitis (an inflamed or sore mount), cellulitis and abscess of oral soft tissue.
Some of the more well-known medical aid schemes in South Africa – Bonitas, Sizwe, and Medishield – are part of a management care organisation, called Denis, which handles the dental benefit aspects of the schemes.
Denis is a credited management care organisation and currently handles the benefit of Bonitas, Sizwe, Alliance Midmed, Keyhealth, Medihelp, Medishield, PG Group and Thebemed.
The Medical Schemes Act makes provision for the use of a Managed Care Organisation. Regulation 15 stipulates the requirements of managed healthcare, and thus managed care organisations may apply evidence based medicine and protocols when making funding decisions with regards to the appropriate measure of care required. Considerations taken into account need to comply with the following:
• Cost effectiveness,
• Evidence based medicine
Denis group benefits
Denis has a pre-defined benefit per procedure which is paid at a dental rate in relation to the medical scheme you are part of. If you are visiting a dentist who is a member of the Denis network they should be able to provide information regarding your benefits, as Denis supplies all dentists with a Chairside Guide , which illustrates the dental benefits.
Benefits for dentistry are paid on a fee for service basis. This means that for every procedure done by a dentist, there is a fee that is charged. These fees may differ from dentist to dentist as not all dentists are part of the Denis network. Your fund pays a benefit for each procedure to a certain limit which may differ from the fee charged by your dentist. According to Denis, it is your right to negotiate that difference in fee with your dentist.
Under the terms of Denis, benefits are divided into three branches: conservative, specialised and hospitalisation and anaesthetics.
Conservative dentistry is also known as basic or routine dentistry. It includes the diagnosis, prevention and treatment of tooth and gum diseases as well as the repair of defective teeth.
The following treatments and procedures are included in Basic Dentistry with Denis.
• Oral hygiene (scale and polish),
• Intra-oral and extra-oral x-rays,
• Root canal treatment,
• And, plastic dentures.
However under some medical aid schemes with Denis, you would have to pay for certain extra which would normally be covered in by Dental Benefits in schemes such as Momentum.
For more information on these extra, http://www.denis.co.za/provider/check-scheme-benefits
Specialised dentistry or advanced dentistry occurs when teeth need to be replaced or when badly damaged teeth need to be repaired and a filling (conservative dentistry) would not be adequate.
Authorisation is required for some treatment before treatment starts. This is dependent on the medical aid scheme cover you choose with your provider.
Specialised dentistry includes the following treatments:
• Partial metal frame dentures,
• Crowns & bridgework (Pre-Authorisation required),
• Implants (Pre-Authorisation required),
• Orthodontics (Pre-Authorisation required),
• Periodontics (Pre-Authorisation required),
• Maxillo-Facial Surgery,
• And, oral Pathology.
Hospitalisation and Anaesthetics
Certain dental procedures that require IV conscious sedation in the rooms or even general anaesthetics (GA) in hospital need authorisation from Denis before treatment. However, it is important to read the fine print of Denis policies, as hospitalisation costs are only covered to a certain amount, whereby the rest will come out of your own pocket.
For more information, click here. Alternate Medical Aid schemes policies do cover dental procedures; however they vary from your basic medical packages to the more expensive options.
Moneybags breaks down some of South Africa’s top medical aid schemes and their offerings in lower, middle and upper range products.
When choosing a medical aid scheme, make sure you know what is exactly covered with regards to dental benefits. As each person has different needs (and we can’t always predict when something major is going to happen) being covered for at least the basic is a good idea.
Call your medical aid provider, or speak to your dentist to find out what you are covered for, or what you will have to pay out of your own pocket. Some may require a self-payment gap, pre-authorisation or entrance fees to be covered by the principal member. Make sure you check with your provider before having a procedure done to ensure you are not liable for any extra costs.