Sitting here desperately trying to sip a glass of red wine through still-numb lips following several shots of Novocain this afternoon at my friendly neighborhood dentist, I find myself wondering why on earth a self-respecting risk and benefits manager would run through an entire year's dental plan in only one sitting. Am I missing the boat when choosing the coverage to be offered to my fellow employees?

Since the county offers a generous health plan, group dental plans have traditionally been offered on a voluntary basis. The plans serve the county's bottom line while offering employees a better deal than they might be able to find on their own through convenient, pretax payroll deductions. The triple-option plan includes a DHMO, "low" PPO and "high" PPO.

County employees, a cost-conscious bunch even during the Florida real estate boom, overwhelmingly choose the DHMO plan year after year. With premiums as low as $13 per month, you can't really blame them.

But, since the DHMO is a prepaid program only, these employees often seek me out during open enrollment with tales of how they found themselves in situations where their benefits didn't stretch nearly as far as they thought they should have. Then they promptly re-enroll in the DHMO for the next year. This plan has a large network, however, and generously covers preventive care.

The high PPO and low PPO provide truer or more traditional coverage than the DHMO, but these plans have an annual cap - $1,000 and $1,250, respectively.

These plans can be purchased with higher annual caps, but because of a well-negotiated fee schedule, most employees never reach the cap.

They also provide the highest percentage of coverage on preventive care, with increasing cost-sharing percentages for more involved treatment.

Dental insurance is an important recruiting tool in any workplace, but rarely something to write home about.

But in a local government setting, with the next request for proposal always right around the corner, I ask myself: How can I improve such an important benefit - especially in Palm Beach, where Hollywood smiles are as important as Botox?

Managed care dental programs continue to be popular choices among employers. But while offering a dental PPO plan may give employees greater choice in dentists than the network-insistent DHMO, the size of the network must still be carefully considered.

It's time-consuming and tedious, but before choosing to partner with a dental PPO, the savvy benefits manager will take the time to compare the ZIP codes of the participating providers to the ZIP codes of employees, to ensure the geographic distribution is adequate to serve the employee base. Also, what specialties are participating? How many endodontists, orthodontists and pedodontists are participating?

Also, I wasn't very long in the tooth before I realized that not all DHMO plans are created equal.

Turns out some carriers capitate their orthodontists and some don't. Changing plans from the former to the latter while employees are in the middle of treatment can cause serious issues if the former carrier chooses not to cover work in progress.

Capitated orthodontists agree to provide the complete service at predetermined copayments.

Other carriers, however, may choose not to offer capitation to plan orthodontists in favor of offering a certain percentage discount below usual and customary rates. Know this going in or expect many, many angry phone calls from people with orthodontia-related lisps!

But what else is out there beyond the typical coverage options? Perhaps the American Dental Association-endorsed direct reimbursement plan, also known as a direct assignment plan, is worth consideration.

A DR plan is a self-insured option where employees are reimbursed a certain percentage of dollars for treatment actually received.

According to the ADA, only 35% of employees with health insurance actually use it and when they do, the average dental patient spends only $350 per year on services.

For employers already funding dental insurance, this plan might be a savvy way to control costs - rather than paying premiums on 100% of the employee population, pay benefits on only a third of it. Often, stop-loss insurance can be purchased to assist employers in the budgeting process, and TPAs can be hired to handle the claims process.

This type of plan offers employees considerable freedom in choosing a dentist because services are reimbursed by their employer. Disadvantages include the employee's need to front the cost of services, but these plans dove-tail nicely with FSAs, so in lieu of monthly premiums, employees can participate in FSA via monthly payroll deductions.

Another option to consider is bundling of dental benefits with health benefits. There is a multitude of medical evidence that oral health affects overall health.

Most large carriers know this and will often discount health premiums for employers that add dental coverage to the contract. The dental treatment data is then compiled in the carrier's data vault and can serve as preventive meicine on the health side.

As I continue to thaw out, I realize that as an employee who has reached my plan maximum in one afternoon, I am in the minority. But as coverage opportunities continue to evolve as a tool with which to attract and retain the best employees, I'll continue to smile big at the possibilities!

Contributing Editor Nancy L. Bolton is the director of risk management for the Palm Beach County Board of County Commissioners in West Palm Beach, Fla.