Embedded Insurance: Combined Medical and Dental Insurance with Denial of Benefits Till Annual Medical Deductibles are met- Juniper Publishers
Juniper Publishers-Open Access Journal of Dentistry & Oral Health
In an age where economic times are challenged,
innovative measures are often sought in an effort to maintain and
enhance corporate profits. This is becoming no different in the health
care industry, particularly the insurance side of things. Over the span
of six months one subtle yet noticeable phenomenon that has invaded the
realm of dental insurance benefits and claims has become the concept of
“embedded health care.” Regrettably this has progressed from conceptual
to harsh reality. Both major carriers and others are falling in line to
seek strategies to improve their bottom lines and avoid paying claims
which until now have been taken for granted by most everyone with
conventional forms of dental insurance.
For patrons of the same medical insurance company as
their dental coverage, the bulk of carriers are beginning to consolidate
medical with dental benefits into what is termed “Embedded Health
Care.”
It is unclear if either employers or employees have
been accurately informed in timely fashion of this change in their
health care programs. The end result if not well known or understood can
be expected to infuriate huge numbers of families when they learn
through explanation of benefits that usual and customary charges and
services for common dental procedures, i.e. examinations, radiographs,
cleanings, restorative, and surgical care, will be overlooked and denied
until the family’s medical deductible for the year is met.
In today’s healthcare marketplace, it is not uncommon
that young families, (and older ones) with favorable health care
histories, no known or impending medical problems, in an effort to
reduce premium costs will opt for high deductible medical healthcare
policies. This editorial has the intent to bring to light the impact of
Medical insurance programs that embed medical with dental coverages for
families who unknowingly will be denied coverage until deductibles have
been met. For example, a family of four may knowingly choose a medical
plan with a $5,000 or greater annual medical deductible. They may rarely
be sick or encounter acute or chronic medical visits and prefer to pay
lower premium costs and pay for out of pocket expenses till meeting this
deductible. Participating in embedded programs, dental costs for even
preventive dental visits, once covered at 80-100%, might now endure full
out-of-pocket cost at the time these services are rendered. The
insurance company which presented its options as comprehensive and
all-inclusive now is able to improve its bottom line by in reality not
providing basic dental health care coverage. A tactic now playing out
with embedded insurance carriers is only paying for fluoride
applications ($38.00) yet defraying coverage for all other basics
(examinations, cleanings, X-rays, etc.) till medical deductibles have
been met.
What are the alternatives for the consumer? Purchase
more comprehensive medical policies at higher premiums with lower
deductibles, or simply pay as their dental health care needs dictate.The
illusion or masquerade of having comprehensive or higher-end dental
coverage no longer appears to exist for embedded health care policy
holders.
The realization of the medical insurance carriers is that opportunity to avoid dental claims closes the gap
between more comprehensive and costly claims and
fulfilling earlier medical deductibles for low-users of health care. In
either case, no consequences befall the insurance carriers, and the
public is provided fewer benefits than previously promised.
What can be done to address this dilemma? As Hillary
Clinton, first lady during Bill Clinton’s first term, assigned the
immense task to propose health care reforms learned, the problem is very
complex and solutions were scarce if not impossible to implement.
Sixteen-plus years later, favor and disfavor of existing health care
remains a major issue of contention from
the perspective of both sides of the aisle. In this person’s opinion,
no imminent solutions are likely to emerge on the horizon
until scrutiny of insurance companies and the pharmaceutical
industry is undertaken. Lobbyists and politicians influenced by
political contributions to maintain the status quo remain a major
obstacle to lowering the cost of health care while expanding its
availability to those who can least afford care. An initial solution
might be ademand to un-embed medical and dental benefits
under one extended deductible. A return to previous policies may
conceivably result if sufficient voices are raised in opposition.
The insurance companies as yet do not seem concerned from
such an occurrence.
A less than stealthy question of health care benefits provided
to congressional members would be what might be their
motivation to explore legislative avenues for change if they were
forced to accept the same health care afforded the public?
While cynical in nature, if not purely unrealistic, from the
perspective of this private practitioner, it is my firm belief that
public anger levels for these insurance policy alterations are only
going to exacerbate.
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