PEBB coverage changes bring increased benefit levels
We want to make sure you are aware of benefit changes effective January 1,2008 for one of ODS’ largest groups, the Public Employees’ Benefit Board (PEBB).
Some of the changes include increased benefit levels for employees. Examples include a 75% benefit for crowns, the addition of implant coverage, and a higher annual maximum and orthodontic lifetime maximum.
A change that applies to all PEBB members is that some frequencies, such as cleanings, will now be based on the dentist’s assessment of the patient’s oral health and risk factors. This means that some members, such as those with a history of periodontal therapy or based on medical need (such as pregnancy or diabetes), will be eligible for up to four periodontal maintenance or prophylaxis visits in a calendar year. Other members with healthy mouths and low risk factors will be eligible for one prophylaxis in a calendar year. Both the cleaning and x-ray benefits are based on the dentist’s assessment of the patient’s oral health and risk factors. The exam benefit is twice in a calendar year and is not assessment based.
PEBB envisions the dental cleaning and x-ray benefits to be customized to the individual patient needs and risks based on the dentist’s assessment. ODS provided dentists with a risk criteria list for use only as a general guideline. We understand there will be other scenarios where more frequent service is appropriate. We expect you will make the decision based on your professional judgment. Please note: there is no form to submit to ODS; we simply ask that you document your assessment in the patient’s chart.
The PEBB plan does not cover two cleanings per year when done only because that is your office’s standard practice or when a patient simply wants additional services. In those cases, we ask you to have the patient pay for the additional cleaning and not bill insurance or note the words “patient request” in the claim remarks.
Another element of PEBB’s vision is to encourage discussion with PEBB members about their risk factors, lifestyle changes that could minimize the risk of disease, and the frequency of cleanings appropriate for their oral health.
We understand that this benefit design is very different than the rest of our plans and appreciate your patience as we work to implement and educate on these changes for PEBB. If you have seen a PEBB member in the last year, you will have already received a letter about these changes. PEBB members can be identified by the group name listed on the ODS ID card or on Benefit Tracker.