Helping clients pick a medical aid scheme that covers dental requirements

Consumers are increasingly demanding that financial advisers take into consideration their future dental funding requirements when assisting them in the choice of a medical aid scheme that will best meet their long-term needs. 

Dr Kezia Dunn, benefit risk manager at Dental Information Systems (Denis), has noticed that more and more frequently intermediaries are expected to accurately assess whether their clients and any of their dependants may require specialized dental procedures such as orthodontics when advising on a suitable medical aid scheme.

Denis, South Africa’s largest dental funder, provides dental cover to more than 1.5-million people through various medical aid funds.

“While consumers don’t generally factor in the specific chances of having a heart attack or breaking a leg in an accident when picking a medical aid fund, we do find that people are demanding dental benefits that will cover them for a variety of eventualities. Dental care is an emotional issue for most people and given the high costs associated with decent dental care consumers want to know that they are covered.” 

She explains that rising health care claims are forcing medical aid schemes to limit their funding, and because cover for dental treatment is not obligatory in terms of the Medical Schemes Act dentistry is an easy place to apply financial restrictions. Often dental benefits are omitted entirely from product offerings.

While these realities help schemes justify a reduction in dental benefits, a number of medical schemes have realised that providing decent dental benefits to their members is key. In an effort to help medical aid schemes manage costs while at the same time providing members with access to quality dental care, Denis scrapped the financial benefits approach and introduced the clinical benefits approach.

“The clinical benefits approach is paid from Denis’ risk pool and members are not required to dip into their savings accounts. This approach helps medical aid schemes sustain their dental budgets without requiring member’s to co-fund the cost or increase premiums.”

Dunn acknowledges that this approach requires intermediaries to move away from comparing the financial benefits offered by competing medical aid schemes to understanding benefits structured around clinical events.

“The average financial dental benefit offered by medical aid schemes is between R4 000 and R5 000 as an annual family benefit. Generally, however, Denis does not restrict members to a financial benefit, but instead affords generous benefits for essential treatments that people need most often.”

An example of typical clinical benefits available from Denis for members and their dependants would be: two general check-ups a year; fillings, root canal treatment and tooth extraction as required; one denture per jaw every four years; various specialized dentistry procedures provided pre-authorisation is obtained. The exact benefits provided do, however, vary depending on the medical aid. 

She says the Denis approach is that provided there is a good reason for undergoing a dental procedure, Denis will cover it. As a result the dependant of a medical aid member recently had dental treatment to a value of R42 000. 

“While the clinical benefits approach means that intermediaries need to get a better understanding of the range of dental procedures available, this approach also means that advisers can offer their clients benefits that cover their needs and do not dry up when needed most.”  

Dunn says Denis has designed an extensive intermediary support system, which is geared towards helping advisers understand the choices and benefits available to clients.

“We provide regular training sessions and have dedicated team leaders available per contracting medical aid to provide intermediaries with fast and efficient support.”

Denis also provides a broker support section on its web site, where brokers can access clients’ claims records and claims payment updates. Status reports are provided for every pending claim and reasons are given should a claim be rejected. Denis settles all claims electronically directly with dentists and members on a weekly basis.