Dental Judgement Day – Get Help with the Tall Order of Deciding on Dental Plans with our Annual Survey!
Welcome to California Broker’s 2013 Dental Survey. We’ve asked the top dental providers in California to answer 28 crucial questions to better help you, the agent, understand their benefits, features, and services. Read the responses and sell accordingly.
1. What types of plans do you offer?
Aetna: We offer the following dental plans:
• Aetna Dental Maintenance DMO plan, PPO, PPO Max.
• Freedom-of-Choice Plan Design (offering members their choice of two dental plans).
• Aetna Dental Preventive Care, Aetna DMO Access, Aetna Dental Care Reward, Aetna
• DentalFund (our consumer-directed dental plan), indemnity, Vital Savings by Aetna, a dental discount program.
• Aetna ValuePass Card.
Aflac: Aflac Dental — voluntary insurance policy — has the simplicity of a voluntary individual table of Allowances plan that pays a fixed benefit amount for each procedure, regardless of what the dentist charges.
Ameritas: We have the following types of dental plans available nationwide: PPO, indemnity, voluntary, non-voluntary, groups from two lives and up, individual, consumer driven and cost containment plans.
Anthem Blue Cross: Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company offer a comprehensive line-up of dental plans and products that include: PPOs and DHMOs for individuals, small groups, large groups and national accounts. We offer voluntary dental plans for small and large groups.
BEN-E-LECT: BEN-E-LECT offers fully insured PPO, high deductible, pre-paid and self-insured dental plans for the group market. Employer-paid and voluntary plans with multiple network and out-of-network options down to the employee level are available to groups with as few as two lives.
BEST Life: In California, we offer employer-contributory PPO, and indemnity dental plans to groups with two or more employees enrolling. Voluntary PPO/indemnity dental plans are available to groups with five or more employees enrolling. Custom dental plans can be offered for groups with 100 or more employees enrolling. Group term life and vision coverage, as well as personal dental plans are also available.
Blue Shield: Blue Shield provides a wide range of affordable and comprehensive dental products to meet our clients’ needs. From dental PPOs, to in-network only (INO) and HMO plans, our plans offer members a wide variety of plan designs and networks that fit their budget.
For individuals/families, we offer a unique dental PPO plan that provides member copayments instead of the usual coinsurance percentages. Our dental HMO plan offers comprehensive benefits with pre-determined member copayments. Finally, our Duo plan offers members dental and vision coverage at a single price. Our plans can be sold with medical plans or on a standalone basis..
For senior members, we offer two comprehensive dental PPO plans for Medicare supplement plan members. There is also a dental plus vision plan package option for Medicare supplement plan members. For groups, our dental PPO, INO and HMO plans are available on a contributory or voluntary basis, can be sold with or without Blue Shield medical plans and are UCR- or MAC-based.
Cigna: DHMO, DPPO, DEPO (ASO/self-insured only), and indemnity.
Delta Dental: Managed fee-for-service, PPO, and DHMO group dental plans; individual DHMO dental plans and group HMO vision plans.
Dental Health Services: Dental Health Services provides prepaid dental benefit solutions for groups and individuals. We also offer PPO, EPO, and indemnity (reimbursement) products for groups of all sizes and ASO services for self-funded groups.
Guardian: Dental PPO (active or passive), prepaid/DHMO, and indemnity plans are available on a voluntary or employer-sponsored basis. Dual and triple choice, monthly switch (between a DHMO and PPO), and administrative services only plans are also available. Guardian specializes in customized plans based on the needs and price points of the employers and employees.
Health Net Dental: Health Net Dental HMO (DHMO) plans and dental PPO plans offer robust benefits covering most dental procedures. Dental plans may be purchased with a Health Net medical plan or on a stand-alone basis. In addition, the dental plans may be purchased as dual choice. Contributory and voluntary plans are also available.
HumanaDental: PPO, prepaid/DHMO, traditional preferred, and preventive plus plans are available on a voluntary or employer-sponsored basis. Humana also has a robust ASO dental plan available in California.
MetLife: Dental PPO, managed dental plans and indemnity plans, with flexible designs and funding arrangements available to accommodate employer plan requirements – single or multi options, fully insured or self-funded as well as a full range of contribution options.
Principal Financial Group: We offer employer paid and voluntary plans, including PPO, EPO and POS. We also offer a choice between our plans and dental HMO plans through marketing alliances.
Securian Dental: Group Dental PPO and indemnity
United Concordia: United Concordia offers flexible fully insured preferred provider organizations (PPOs) and dental health maintenance organizations (DHMOs) plans, as well as an individual product, iDental. ASO funding arrangements are available based on client size. Most plans are offered on an employer-sponsored or voluntary basis.
Western Dental: Western Dental offers DHMO mixed-model provider panel comprised of (a) contracted independent, general dentist and specialists, along with (b) Western Dental employee dentist and specialists, who work in the company-owned Western Dental Centers. Western Dental currently operates general dentistry and orthodontic offices throughout Calif., Ariz., and Nevada.
2. How do plans you offer for the individual and/or small group compare in rates and benefits to the large-group plans?
Aetna: The key difference between Aetna small group plans and larger group plans is that small group plans are pre-packaged plan designs. While larger groups can select from an array of benefits, the packaged small group plans are comprehensive, yet price sensitive and make it easy for our customers to choose from plans that are competitive in the market.
Aflac: Aflac dental rates and benefits do not vary based on the size of the account. However, when replacing existing dental coverage in larger accounts, waiting periods may be significantly reduced.
Ameritas: Ameritas’ small group and one-life group plans are rated by industry and are pooled in full or in part. Large groups’ experience is rated and includes lower rates in most cases. Ameritas offers a wide variety of plan designs, regardless of group size, to meet the needs of our customers. The pricing of our nongroup individual plans will be higher than group individual because of the nature of the risk.
Anthem Blue Cross: There are different underwriting considerations for each business segment depending on the product offered. With our Dental Prime and Dental Complete plans, small and large groups can customize benefits to fit their employees’ needs.
BEN-E-LECT: The majority of BEN-E-LECT’s plans compete very well in the large group market. The benefit design and structure of these plans remain consistent across the small and large group markets.
BEST Life: Rates vary by plan design, group size and employer contribution. Typically the larger the group, the lower the rates. However, we offer a lot of plan design flexibility for groups with 10 or more enrolling. Waiting periods for major and ortho services are waived for groups with 10 or more employees enrolling — regardless of employer contribution. Some benefits are standard regardless of size. We offer a dental supplemental accident benefit on all our dental plans, regardless of size. A children’s vision benefit is also standard on plans with orthodontic coverage. Other benefits vary by group size: Adult orthodontic benefits are available to employer-contributory plans with 25 or more enrolling. Groups with 100 or more enrolling can customize benefits. Discounts for bundling higher participation, and new voluntary cases for groups of 10 or more enrolling are also available.
Blue Shield: There are different underwriting considerations for each business segment.
Our ability to customize offerings for groups with more than 300 employees typically results in lower rates and more choices to meet the employer’s needs. Group plans come in a range of deductibles and annual benefit maximums.
Our individual, family and Medicare Supplement dental plans may vary in waiting periods, deductibles, and annual benefit maximums based on the plan selection.
All dental plans include generous benefits, competitive premiums, and strong California and national provider networks that are available to all members; we don’t differentiate our provider network for small groups or individual or family markets.
Cigna: There are a series of standard DHMO plan designs and DPPO/indemnity plan designs. Cigna offers an individual plan in the state of California, available as a buy-up option to our medical plan offering. That plan is a DPPO offering, very similar to our group plans aimed at businesses trying to control costs while offering a broad network. Larger groups generally want more robust and flexible plans, while smaller groups gravitate toward standard offerings.
Delta Dental: While benefits offered to smaller groups are comparable to those offered to larger groups, larger groups have more options in terms of plan designs. Rates can be slightly higher for smaller clients and individuals, but Delta Dental strives to be competitive while balancing our financial risk. With individual DHMO plan benefits, we offer three different plan options — two for individuals and families and one customized for seniors. The individual and family plans offer a wide range of covered services. The senior plan is designed to offer services most utilized by this particular population.
Dental Health Services: Dental Health Services works with its group clients on customizing dental benefit solutions that meet their needs. All individual plans offer the same high-quality benefits and services at competitive rates.
Guardian: Guardian offers nearly the same plan options to small group employers as to large employers. We offer an array of cost-reducing options, such as waiting periods, deferral of services, and tie-ins to Guardian vision products. In preparation for Affordable Care Act requirements beginning January 1, 2014, we are developing new options for employers with under 50 lives to ensure they have quality benefits that are compliant with state requirements. We will also be offering dental benefits through the California state exchange.
Health Net Dental: DHMO plans offered to individuals provide a comprehensive schedule of benefits at a monthly fee that is slightly higher than rates quoted for groups. Small groups (two to 50 employees) have two comprehensive Health Net Plus DHMO and 13 DPPO plans from which to choose. Mid-market groups (51 to 250 employees) may choose from five DHMO plans and 15 new DPPO plans. Mid-market rates are based on location, benefit plan chosen, employer contributions, and participation. Individual and small group rates are based on book rates. Risk evaluation is taken into consideration when underwriting larger groups (over 250 eligible employees).
HumanaDental: We offer flexible plan designs with a range of deductibles, co-payments, and out-of-pocket expense limits to meet the needs of small to large groups. We also offer large groups the additional flexibility to customize plan options. All our dental plans provide employees with incentives for preventive dental care, which promotes their overall health. Customers who see dentists participating in the HumanaDental PPO Network receive deep discounts. A vision discount program is included with all HumanaDental plans.
MetLife: MetLife offers individual plans in Calif., Fla., and Texas though SafeGuard, a MetLife company. Dental HMO plans offered to individuals provide a mid-range level of benefits at a monthly fee that is slightly higher than rates quoted for groups. Small groups have a broad range of options within the Dental PPO and Dental HMO/Managed Care benefit plans. Rates are based on location, plan chosen and participation. Risk evaluation is taken into consideration when underwriting larger groups; individual plans are quoted using shelf rates.
Principal Financial Group: We do not have individual dental plans. The only significant rating difference between our small and large group rates pertains to experience rating which is used on groups with 150+ employees. The benefits are the same for small and large groups.
Securian Dental: Small group rates are developed on a pooled basis. Large group rates are developed on a custom basis.
United Concordia: While larger clients have more flexibility in customizing benefit options than smaller clients, United Concordia offers an array of standard client products and options that provide small businesses and individual consumers with cost-effective, quality choices. To control the risk associated with individual insurance, we utilize waiting periods for selected types of procedures. To keep the small client premiums comparable to those found in larger clients, slightly higher deductibles, lower coinsurance percentages and lower maximums are more commonplace within this market segment.
Western Dental: Our individual and small group rates are a little higher for standard benefit plans. Customized benefits plans are available for large groups.
3. Is your plan(s) better than previous incarnations? If so, how?
Aetna: We continuously review which services should be covered based on major dental studies, new clinical advances, recommendations from the leading health and dental organizations, consultations with academic leaders on the latest technology and techniques now taught in dental schools. We offer the following:
• Freedom-of-Choice Plan Design – packages our DMO plan with one of our indemnity or PPO plan options. Members pay one rate and can switch between the plans as often as monthly. It can be a lower cost alternative to a PPO plan.
• Aetna Dental Preventive Care – a low-cost PPO or indemnity plan covers preventive and diagnostic procedures from 70% to 100%. Members may also get reduced fees from dentists who participate in Aetna’s PPO network for non-covered services like fillings, adult orthodontia, and cosmetic tooth whitening.
• Aetna DMO Access – a fixed-co-pay DMO plan offers broader network access at a lower cost. There are no out-of-pocket deductibles for the member to pay and no claim forms to file. It also includes the Aetna Dental Access discount network, which gives members access to more dentists and discounts of 15% to 50% for non-covered services like bleaching.
• Aetna Dental Care Reward – By going to the dentist for preventive services in one plan year, Aetna will cover a greater percentage of coinsurance and/or annual maximum next plan year.
Aflac: Employers are seeking ways to shift costs and employees are looking for more value. The Aflac Dental plan is designed to increase the policy year maximum, which will satisfy employers and employees.
Ameritas: We are known for our flexibility and expertise in dental. We talk to employers all over the country for input on their needs. Our plans are updated constantly to meet those needs. We have released several industry firsts including a rollover maximum product; fully insured LASIK eye benefits; dollar reimbursement plans; combined dental/vision deductible,frequency and maximum plans; shared family maximum plans; $5000 maximum plans, and stand-alone hearing care benefits. Our newest individual plan release, vision, is very popular across the nation.
Anthem Blue Cross: Yes, our plans are significantly better than previous incarnations. Our Dental Prime and Dental Complete plans are open-access models that include the freedom to see any dentist – with lower out-of-pocket costs at in-network dentists. These plans are better than previous incarnations because they (a) incorporate evidence-based benefit designs and claims processing guidelines, for greater savings and consistency with clinical oral health science, (b) include a more robust California provider network and (c) automatically include access to the national Dental GRID, one of the nation’s leading dentist networks, with dentists in all 50 states. The GRID is exclusively for customers of participating Blue Cross and Blue Shield plans. In short: our new plans have better benefit designs and a larger network locally and nationwide.
BEN-E-LECT: BEN-E-LECT plans offer more employer and employee options than any other dental plan in the market. They can be written stand-alone or the employer may combine various BEN-E-LECT plans for a complete package offering PPO, DHMO and fully self-funded options
BEST Life: Our current dental plans offer a lot more options compared to the dental plans we’ve offered in the past. We’ve also recently added a MAC reimbursement option. All of our dental plans can be tailored to offer rich or lean benefits, depending on a company’s needs. We continually evaluate our dental plans to ensure the competitiveness of the benefits, and our underwriting guidelines.
Blue Shield: Yes, we are always looking to enhance our plans and provide richer benefits. For 2014, we are introducing four new group dental HMO plans and four new dental INO plans with a $1,500 calendar year maximum. Compared to our existing dental HMO plans, our new dental HMO plans offer lower copayments to deliver a richer benefit to our members. The new dental INO plans offer a lower price alternative to our INO plans with $2,500 calendar year maximums.
In addition to new plan designs, all BSC plans include oral cancer screening coverage as a value-added benefit, which comes at no out-of-pocket cost to the member.
We also offer enhanced dental services for pregnant women to all dental PPO plans. Pregnant women receive one additional routine adult prophylaxis, and/or one course (up to four quadrants) of periodontal scaling and root planing, and/or periodontal maintenance if warranted by a history of periodontal treatment. Treatment is payable at 100% of the allowable amount for in and out of network.
Cigna: With the additional value added features and expanded offering of covered clinical procedures, our new DHMO plans provide employers with more options than were previously available. Employers now have 100 types of plan coverage to choose from, with a spectrum of preventive coverage only plans to richer plans with surgical implant coverage, providing many choices to meet their needs.
Dental Health Services: Yes. Dental Health Services frequently evaluates its monthly premium rates and copayments for services to ensure that they are appropriate and competitive.
Guardian: The key is flexibility, especially in today’s market as employers and employees are trying to balance costs with benefits. Guardian offers customized options to fit each employer’s needs and budget. Our recent focus has been on innovative plan designs with flexible solutions, things like Guardian Freedom, which is a new lower cost dental option that gives members a choice of networks with access to providers in Guardian’s premier PPO network, DentalGuard Preferred, or in Guardian’s DentalGuard Alliance PPO, which offers even greater claims savings through a select pool of dentists. We also are focusing heavily on developing more voluntary options, a market we see poised for tremendous growth particularly with the legislative changes on the horizon.
Health Net Dental: Health Net offers DPPO plans for small and mid-market groups. All of our DPPO plans include extra services for pregnant women in their second and third trimesters, including extra cleanings, scaling and debridement covered at 100% in and out of network and not subject to the plan’s deductible. Our Classic Plus DPPO Plans include MaxAdvantage, our rewards program that allows members to carry over a portion of their calendar year maximum into the next calendar year. Our Basic DPPO is a unique plan offering in- and out-of-network coverage for preventive, diagnostic and restorative procedures (oral surgery, endodontics, periodontics, major services and orthodontia not covered).
HumanaDental: Yes, we continually explore ways to offer more choices and flexibility for our customers. Please see next response.
MetLife: We are continually improving our program contracts, plan-design flexibility, claims-processing guidelines, customer service, and quality programs based upon clinical research, consumer-value approaches, and dental industry trends. MetLife continues to expand our product offerings and plan design flexibility in the small (<1,000 employees) market by providing customers with more choices to help them meet cost objectives without sacrificing quality.
Principal Financial Group: Our current plan offers significant flexibility in plan design, optional coverage for cosmetic services, TMJ treatment, dental implant coverage, accident coverage, employee choice options and multiple price points. Employers can design any combination of plan options to meet their needs. In addition to our Maximum Accumulation feature, which allows members to carry over a portion of their unused annual maximum for use in future years, we also rolled out a new Preventive Passport feature. This allows for preventive charges to not count/reduce the annual maximum.
Securian Dental: Yes, we have added greater flexibility.
United Concordia: In recent years we have done the following:
• Introduced more voluntary plan options and added optional coverage for posterior composite restorations and implants to clients with 10 or more enrollees.
• We launched Preventive Incentive, which covers diagnostic and preventive services without counting them toward the member’s annual maximum.
• Enhanced our employee oral health educational offerings.
• Launched a series of plan designs through iDental, our dental product for individuals and families without coverage elsewhere.
• New for 2014, we are introducing a value suite of products to include lower premium options, greater discounts on non-covered services and a lean product option.
• Launched a dental discount program for Individuals through DentalPlans.com.
• Introduced the UCWellness Oral Health Rider in 2012, which offers enhanced coverage for members with diabetes and other diseases to clear away concerns they may have on the cost of treatment. UCWellness also provides oral health education and program details for all members and targeted messaging to motivate those eligible for UCWellness benefits.
Western Dental: Western Dental Benefits Division recently launched the DHMO Series 7 dental plans. Our new plans offer an increase of covered procedures to include the availability of cosmetic alternatives and more orthodontic options for children and adults
4. What have been the most recent changes in your plan(s)?
Aetna: New DMO fixed co-pay plans that cover Implants were added. Aetna also added a new plan option to exclude preventive services from the calendar year maximum.
Aflac: Along with an increased policy year maximum, Aflac Dental continues to provide a simple, no direct-cost option for employers to enhance employee benefits offerings. The Aflac Dental plan provides the ease of administration without the hassle of network restrictions, deductibles, precertification for treatment, or annual premium reviews.
Ameritas: Individual vision, dental, dental/vision and a $5000 maximum option for dental.
Anthem Blue Cross: We revised our Dental Net DHMO. Our new Dental Net DHMO plans cover approximately 300 procedures – approximately 62 percent more procedures than our existing Dental Net plans. In addition, our Dental Net network includes more than 8,000 general dentist and specialist access points in California.
And, we still have our Dental Prime and Dental Complete products, which include modernized benefit designs, lower premiums, and a more robust dentist network locally and nationally.These plans include benefits, such as dental implants, annual maximum carryover and composite fillings on all teeth. Plus, there are more options for out-of-network reimbursement, including the 90th percentile of FAIR Health. Voluntary plans are available with a minimum of five enrolled employees.
BEN-E-LECT: BEN-E-LECT has evaluated its Freedom PPO benefits portfolio and narrowed it down to four plans that have proven to be most beneficial to its members. By focusing on development of those four plans, BEN-E-LECT is now more able to create sustainable rates for its groups taking into account size and location. BEN-E-LECT has also eliminated the waiting period for groups and new hires on its employer-paid plans for added convenience.
BEST Life: Our current dental plans offer a lot more options compared to the dental plans we’ve offered in the past. We’ve also recently added a MAC reimbursement option. All of our dental plans can be tailored to offer rich or lean benefits, depending on an employer’s needs. We continually evaluate our dental plans to ensure the competitiveness of the benefits and our underwriting guidelines.
Blue Shield: For 2014, we are introducing two new dental PPO plans in our small group portfolio designed to fill a gap in the upper end of the benefit spectrum.
We are also introducing eight new plans for the 51 to 99 segment patterned after the eight supplemental group dental PPO plans designed by Covered California, California’s state Exchange.
Cigna: The DHMO has had several enhancements including value added features for customers, additional coverage options for employers and new types of patient charge schedules. To complement the Cigna Healthy Rewards Program, customer value added offerings include identity theft protection services and a 24/7 dental information line, staffed by health professionals to assist customers with questions relating to clinical care. In addition, the number of covered procedures available has increased and schedules can now include coverage for TMJ, prosthesis over implant procedures, teeth whitening, and athletic mouthguards. The new schedules also give employers the option to offer employees coverage for additional applications of topical fluoride and topical fluoride varnish at minimal copays, and for same-day, in-office crowns, inlays, onlays and veneers.
The DHMO Patient Charge Schedule choice has also expanded to now include over 100 different plans to choose from. New plan types include plans with lab charges listed separately from base copays, plans with customer copayments expressed as coinsurance (as compared to fixed copays), and plans with coverage for surgical implant and related procedures such as bone grafting, sinus augmentation and cone beam CT X-Rays for diagnostic procedures.
Some of the updates made to our DPPO suite of products and features include enhancing our Cigna Dental WellnessPlus features that provides incentives for our members to get regular preventive care treatment, improving our dental classification shifting process to ensure our clients have access to our unique and cost effective features to offer their employees.
Delta Dental: Delta Dental’s mobile web functionality makes it easy for enrollees to access dental information from a smartphone. The online tools used most often have been streamlined so enrollees can get the information they need faster and easier. Enrollees can log on to:
• Check benefits, eligibility, deductibles and maximums
• Search for benefits by keyword or procedure code
• Check claims status and claims history
• View ID card (pull it up at dentist’s office)
• Go paperless by opting to “Receive Statements Online” under “My Account”
• Eligibility and plan information for enrollees in DeltaCare USA can still be accessed from a smartphone, in a full site view. Our enhanced online dentist directory makes it even easier for enrollees to find a conveniently located dentist.
The Find a Dentist feature at www.deltadentalins.com now offers:
• Easier navigation and a cleaner display.
• The ability to conduct a search using key words, such as the name of a practice (as well as by the dentist’s name).
• Faster narrowing of search results by specialty, language and gender.
• Improved toggling between Delta Dental PPO, Delta Dental Premier and DeltaCare USA network results.
We continue to promote our dental wellness program for our enrollees, the SmileWay Wellness Program. SmileWay provides an array of wellness resources, including plan designs that emphasize preventive care, enhanced oral health communications and promotion of oral health through social media channels such as Facebook and Twitter. Our SmileWay Wellness Program is self-managed, enabling enrollees to determine their level of participation.It encourages users to review their habits and take our free cavity and periodontal risk quizzes, which will indicate their risk level based on oral health habits and lifestyle choices. In the risk assessment results, we encourage users to stay connected with us by signing up for customized communications based on their results. Our extensive dental health article and video library contains more than 100 articles and videos.
Dental Health Services: Dental Health Services now offers dental implants as a covered benefit. Specialized crowns and upgrades are also now available.
Guardian: Guardian constantly develops new, innovative ideas in order to meet our customers’ needs by helping keep their teeth healthy and saving them money. Guardian Freedom allows members to choose between networks. Members are still free to see out-of-network dentists. Members can easily find a dentist near them at www.GuardianAnytime.com or on their smart phones with GuardianAnytime Mobile
Health Net Dental: All of our Classic Plus, Classic, Essential and Basic DPPO plans include extra benefits for pregnant members in their second and third trimesters.
HumanaDental: Plans in our new generation of products are available as voluntary plans, and to groups with as few as two employees. Our new plans offer an extended maximum benefit, in which members get 30% coinsurance on services rendered after they reach their annual maximum (implants and orthodontia excluded). In addition, no waiting periods for major services for voluntary groups with 10 or more enrolled, open enrollment options, and orthodontia benefits. Updates include reimbursement options for out-of- network reimbursement: maximum allowable fee, or based on in-network fee schedules. Additional deductible choices, implant coverage, and acrylic filling coverage have also been added. Due to the connection between oral health and overall health, we have added, free of charge, oral cancer screenings to all of our products, excluding DHMO/prepaid plans.
Principal Financial Group: Our newest feature to our dental plans is the option of Preventive Passport. This feature excludes preventive services/charges from counting towards the annual maximum.
Securian Dental: Enhanced benefit plans. Escalating Annual Maximum and Lifetime Deductible options where available.
United Concordia: Along with our parent company and the University of Pennsylvania, United Concordia recently completed a study that showed treating gum disease can help reduce the cost of medical care in patients who have certain diseases or conditions.
As a result, we now offer our UCWellness Oral Health Rider, delivering enhanced coverage for members with diabetes and other diseases. By providing greater benefits for the full coverage of services, such as surgery, that eligible members may need to treat and control their gum disease, UCWellness clears away any concerns members may have on the cost of getting treatment.
UCWellness makes it easy for employees to start saving employers money. An integrated communication and registration process is easily implemented. UCWellness – My Oral Health delivers:
• Oral health education and program details for all employees
• Targeted messaging to motivate those eligible for UCWellness benefits
Western Dental: Our Series 7 plans cover more procedures and now include Implants, veneers and external bleaching.
5. Can an insured use their own dentist even if they are not on your participation list?
Aetna: PPO — We offer a national network of dentists. Each covered family member can visit any licensed dentist for covered services. When members visit dentists who participate in our network, their out-of-pocket costs are generally lower. Indemnity – Members can visit any licensed dentist.
Aetna: DMO — Members must seek care from a participating DMO provider unless a state allows a member to seek out of network care. We make this easy by consistently offering the largest DMO network in the industry.
Ameritas: Insureds can use any provider, but they may incur additional out-of-pocket expenses.
Anthem Blue Cross: Members of our Dental PPO plans, including Dental Prime and Dental Complete, can see any dentist they want. However, members who choose a network provider generally experience lower out-of-pocket costs. Plus, members never need to file a claim when they see one of our in-network providers – the dentist files the claim for them. The DHMO plans are in-network only.
Aflac: Policyholders may use any dentist they choose since Aflac Dental does not have network requirements.
Anthem Blue Cross: Yes, they can with all of our PPO plans. Members who choose a provider, within the Dental Blue network, get the most savings in their dental costs. However, members can choose a non-Dental Blue dentist, but their out-of-pocket costs may be higher. The same is true for our traditional Prudent Buyer PPO dental plans. The DHMO plans are in-network only.
BEN-E-LECT: Yes, BEN-E-LECT’s plans offer in and out-of-network coverage with multiple options for coverage and benefits. The members maintain complete control over the dentist they choose to utilize.
BEST Life: Yes, group and individual products allow members to visit any dentist of their choice and receive coverage for services.
Blue Shield: Yes, both dental PPO plan members can choose to go to any dentist, although their benefits will be covered at a higher percentage when choosing a network dentist, with less out-of-pocket expense.
Cigna: DHMO — For DHMO, customers generally must use a dentist that participates in the plan’s network to receive coverage, except in emergencies. Once an employee is enrolled in a Cigna DHMO plan, he or she needs to select a participating general dentist. We are continuously adding more dentists to the network, so a network dentist may be available. If a network dentist is not available in a member’s area, a customer service representative will suggest the member select a participating general network dentist near his or her work. If no office is available, the customer service representative will inform the member to contact his or her plan administrator to select another dental plan option.
DPPO — There are no restrictions within the Cigna DPPO plan about the use of non-contracted dentists. Cigna DPPO members always have the choice to receive care from a network dentist at in-network levels and discounts, or from a non-network dentist at out-of-network levels.
DEPO — With the Cigna DEPO plan, members must seek care from network general dentists and specialists. Services provided by non-network dentists are not covered.
Indemnity — The Cigna Traditional indemnity plan is not a network-based plan; members may visit any licensed dentist for care at any time.
Delta Dental: Delta Dental Premier enrollees can visit any licensed dentist for care, although there are advantages to visiting one of more than 48,000 dentist locations for Delta Dental Premier dentists in California. Enrollees can go to any dentist, but they are only guaranteed to get in-network benefits and avoid balance billing when visiting a Delta Dental dentist. Delta Dental PPO enrollees also have freedom of choice, but can benefit from the protections associated with selecting one of more than 31,000 dentist locations for Delta Dental PPO dentists in California. PPO enrollees have access to Delta Dental PPO and Premier dentist networks with different levels of savings. DHMO enrollees must use a participating general dentist or approved specialist, except for emergency care. There are more than 5,100 dentist facilities for DeltaCare USA in California.
Dental Health Services: Members of Dental Health Services’ prepaid and EPO plans choose their dentist from our select, Quality-Assured network. Our PPO and reimbursement plans allow members to receive treatment from any dentist.
Guardian: Members covered under our PPO plans can visit any dentist; however, benefits may be paid at a lower coinsurance rate for non-participating dentists. DHMO members must choose a participating primary care dentist.
Health Net Dental: Our dental PPO plans offer members freedom of choice; members may receive services from any licensed dentist, but we will reduce their out-of-pocket costs by receiving services from a participating PPO dentist. Under Health Net Dental DHMO plan, members must use a participating dentist to receive benefits.
HumanaDental: PPO members can visit the dentists of their choice. Out-of-pocket savings are greater when members visit participating network dentists.
MetLife: For Dental PPO plans, plan participants can visit any dentist and receive benefits. Participants may realize additional expense savings by receiving services from a participating dentist. For Dental HMO/Managed Care plans, members must use a participating dentist to utilize their benefits.
Principal Financial Group: Yes, our members can see any dentist even if the dentist is not on the “participation” list if they are enrolled in our PPO or POS design. If a member is enrolled in our EPO design, however, network dentists must be seen for services in order to receive coverage.
Securian Dental: Yes.
United Concordia: Our FFS and PPO plans allow members to visit any dentist. However, out-of-pocket costs are lower when visiting a participating network provider. DHMO members must use network dentists.
Western Dental: Through the DMO plans, the member must use a dentist who participates in our network in order to have coverage.
6. If the dentist bill exceeds UCR, can the dentist bill the patient for the difference?
Aetna: For covered services, network dentists are contractually prevented from balance billing above the negotiated rate. Non-covered services are also available for a discount in some states. Dentists who are not in our networks may balance bill members.
Aflac: Aflac Dental pays benefits based on a Table of Allowances and not on UCR. If the dentist’s charge exceeds the benefit amount paid, the dentist may bill the patient for the remaining balance.
Ameritas: Ameritas PPO/First Dental Health (FDH) Networks: Ameritas PPO dentists and FDH PPO dentists are bound by contract not to balance bill the difference between their normal charge and PPO maximum allowable charges.
Anthem Blue Cross: No, not when visiting an in-network dentist with our PPO plans, including Dental Prime and Dental Complete. Anthem Blue Cross participating provider contracts include negotiated fee agreements that prohibit balance billing. A participating dentist may not balance-bill members for amounts that exceed the negotiated and contractually agreed on fee. Members are not responsible for amounts in excess of negotiated rates. However, if a member visits an out-of-network provider, there is no contract and the provider can bill the patient for the difference. With our DHMO plans, the patient is only responsible for co-payments and non-covered services when accessing services through their participating dental provider.
BEN-E-LECT: The member does have the option to choose this method upon enrollment.
BEST Life: Members will not be balanced billed if they receive treatment from a contracted PPO provider. All our dental PPO plans offer a regional and national PPO network. Members can access their in-network benefits anywhere in the country and will not be balance billed.
Blue Shield: No, in-network providers cannot bill members for fees that exceed the negotiated rate. Non-network providers, however, may bill for charges that exceed the plan’s allowed amount.
Cigna: When an out-of-network dentist’s charge substantially exceeds our maximum reimbursable charge (MRC) determination, the claim is paid/processed based upon U&C charges, following appropriate guidelines. The claim would be denied if it does not meet required criteria for the procedure; the claim processors review and deny, or provide an alternative covered service, or the procedure is not covered under the plan. If an appeal is filed, we contact the dentist during the appeal process to determine whether unusual circumstances might support the additional amount. Disputes will occur because the work was more extensive than it appears on the submitted claim. In that case, we request a written description detailing the extent of the procedure and reasons why the work involved superseded average charges. Typically, a dispute is resolved within 10 working days. The member is responsible for any charges in excess of MRC for out-of-network DPPO and indemnity claims.
Delta Dental: Contracted dentists agree not to balance bill patients for services covered under the program for which the dentist has contracted service fees. Delta Dental holds its Delta Dental PPO and Premier dentists to their contracted fees when providing services to eligible enrollees. DHMO enrollees do not pay more than their set copayment for covered benefits under the DeltaCare USA plan. Specialists are paid the difference for charges exceeding the enrollee’s copayment for all preauthorized services. When an enrollee chooses a more costly procedure not covered under the plan, the enrollee is responsible for the difference in cost between the network dentist’s usual fees for the covered procedure and the optional treatment, plus applicable copayment for the covered procedure.
Dental Health Services: No. Dental Health Services guards against balance billing for specialty claims and also has separate safeguards in place to protect members from other types of overcharging.
Dental Health Services contracts with participating specialists who specifically prohibit balance billing. The specialist can only charge the agreed-upon fee for a particular service. A member is sent an Explanation of Benefits booklet (EOB) that provides details about charges, contracted rates, and the portion of charges that are the patient’s responsibility. If a plan member is authorized to go to a non-contracted specialist, the company pays the entire billed fee for the specialty service less the member copayment. This ensures that the plan member is only charged for what the plan has specified as their portion. Patients are also encouraged, via member communications materials, to contact Dental Health Services if they suspect any billing irregularities.
Guardian: Guardian’s PPO dentists are prohibited from billing members for any difference between the billed fee and the contracted fee schedule amount, less applicable deductibles and coinsurance.
Health Net Dental: When receiving services from a participating PPO dentist, members cannot be billed any charge in excess of the maximum allowable charge established by the plan. If the member goes to a non-participating dentist, the dentist can bill the patient for the difference between the allowed amount for the plan benefit and the dentist’s submitted charge.
HumanaDental: Members are responsible for any charges that exceed the maximum amount that Humana will reimburse for a specific service. Members are encouraged to visit in-network providers to experience lower out-of-pocket costs.
MetLife: When receiving services from a participating Dental PPO dentist, eligible employees and dependents cannot be billed any charge in excess of our maximum allowable fee (minus any plan benefits). If the patient goes to a non-network dentist, the dentist can bill the patient for the difference between the plan benefit and the dentist’s submitted charge.
When receiving services from a participating Dental HMO/Managed Care dentist, members cannot be billed any charge in excess of the specified plan co-payments listed in the Schedule of Benefits for their plan.*
* Members are responsible for the participating dentistÌs full fee for procedures specifically excluded from coverage.
Principal Financial Group: Dentists cannot bill over the UCR/fee schedule allowance amount if they are part of our PPO or EPO networks. If the dentist is not a part of one of our networks, he/she can bill the amount over UCR.
Securian Dental: If the dentist is part of our network – no. If the dentist is not part of our network – yes.
United Concordia: Contractually, United Concordia participating dentists agree to accept our allowances as payment in full for covered services (less any deductibles and coinsurances or co-payments).
Western Dental: Since this is a managed care plan, members pay only the applicable co-payment listed on their benefit schedule. Members are financially responsible for non-covered procedures at a discount.
7. How does the dental plan protect against over billing or waiver of co-payments?
Aetna: Our explanation of benefits shows the member’s out of-pocket responsibility. A copy is sent to member and provider. If necessary, the provider relations area helps resolve any issues whether related to over billing, waiver of co-payments, or other issues.
Aflac: Aflac Dental does not have network requirements. If the dentist’s charge exceeds the benefit amount paid, the dentist may bill the patient for the remaining balance.
Ameritas: The explanation of benefits automatically calculates the insured’s portion of the bill to prevent these kinds of problems.
Anthem Blue Cross: With our Dental Prime and Dental Complete plans, we protect members against inappropriate billing through our provider contracts, claim review, and our continuous analytic monitoring of the treatment and claim submission patterns of each dentist that submits claims to us. For our DHMO programs, our quality assurance teams assess claims and providers regularly to ensure our DHMO members are getting the highest level of service and satisfaction.
BENELECT: Provider network discounts are applied automatically when a claim is submitted. We also make pre-determination services available to inform members what their charges will be prior to receiving service. The members also receive an explanation of benefits which clearly illustrates network savings and patient responsibility.
BEST Life: We do this in several ways: 1) Provider network discounts are applied at the time a claim is processed; 2) Predetermination services are available to inform members what their charges will be prior to receiving service, 3) We provide easy-to-understand EOBs that clearly illustrate network savings. 4) We have educational flyers that inform members on how their dental plan works and why they should go to a network provider.
Blue Shield: We prohibit network dentists from balance billing a member for the difference between billed amount and the amount received. Members are only charged the applicable copayment or coinsurance. We monitor and address any network dentist who attempts to bill for this difference.
Cigna: Network dentists sign an agreement to provide covered services at agreed upon fees. If a misunderstanding should occur, the member is encouraged to call our toll-free number for assistance from a customer service representative. We will initiate an investigation and resolve the issue as quickly as possible.
DHMO — Network general dentist and specialist contracts contain clauses that prohibit dentists from charging members any additional fee, surcharge, or other cost for services, other than applicable patient charges as defined in the patient charge schedule (PCS) or contract payment schedule for covered procedures. A network dentist will be counseled if they balance bill a member. Failure to comply with corrective action may result in the network dentist’s file being referred to our credentialing committee for review of future participation in the network.
DEPO/DPPO — Balance billing by network dentists beyond the contract fee is not permitted for any service provided to the member.
Indemnity — We do not prohibit balance billing for our traditional indemnity plan coverage; dentists may balance bill the difference between the plan’s payment and their usual charges. Members pay dentists at the time services are rendered and then submit claim forms to us, or dentists submit the claim forms directly to us for payment.
Delta Dental: Delta Dental Premier and PPO dentists contract with us to establish acceptable fees as well as formally agree to certain protections for Delta Dental enrollees. Protections include no balance billing — contracted dentists cannot charge enrollees for the difference between their contracted Delta Dental fee and their submitted charge for a service, and they may only collect the patient portion (copayment plus any deductible and/or amount over the annual maximum) at the time of service. Delta Dental dentists also agree not to unbundle a procedure that is on file with Delta Dental as one procedure.
Waiver of plan copayments and deductibles is considered fraudulent and is handled by notifying the dentist of the violation and possible network termination.
DHMO network dentists agree to be paid by Delta Dental on a guaranteed capitation basis. They also contractually agree to accept enrollee copayments as payment in full for covered dental procedures and not to seek additional fees. If a dentist consistently demonstrates a disregard for their contractual obligations with Delta Dental their participation may be restricted or terminated.
Dental Health Services: Participating dentists’ charts are audited on-site on an ongoing basis to ensure treatment is rendered in accordance with Dental Health Services’ policies. In addition, plan members receive extensive patient education and tools to help them understand their plan benefits so they can question charges that may not be in compliance with plan benefits. Members are encouraged to contact the plan for assistance if they feel they are being overcharged.
Guardian: Guardian’s PPO dentists may only charge members for any covered charges other than the deductible or coinsurance that may apply to the discounted fee schedule amount. Explanation of benefits statements sent to members specifically identify the discounts taken and the member’s responsibility.
Health Net Dental: Under our DPPO and DHMO plans, participating dentists are contractually prohibited from balance billing a member more than the maximum allowable charge or the contracted copayment amount. Practices are in place to discipline network dentists who attempt to bill members more than these contracted amounts.
If it is determined that a participating dentist has overcharged a member, our Customer Service team will contact the provider on behalf of the member to confirm benefits and re-educate the office about proper plan collection from a member. If the provider refuses to comply with the plan design, the issue is escalated to the Professional Relations Department for follow-up with the provider. Depending on the circumstances, the issue could be escalated to our Quality Management Team, which follows state mandates for a full investigation, including the request for patient records from the office and a review by a dental professional. These investigations must be completed within 30 days and written communications are sent to the member and provider. If the provider still refuses to comply, our Legal Department would be contacted and steps may be taken to terminate our relationship with the provider. In these rare instances, it might become necessary for the plan to reimburse the member or provider depending on the circumstances and to ensure a positive member experience.
HumanaDental: The dentist and the patient get an explanation of benefits to ensure that the dentist does not overcharge or omit fees. The claims processing systems adjudicates the claim based on the contracted fee schedule. Waiving co-payments does not apply under a PPO.
MetLife: For Dental PPO, our first protection for the patient against over-billing is our explanation-of-benefits, which clearly identifies the charges for services that the patient has a responsibility to pay. In addition, our customer service area is responsive to patient inquiries about questionable billing items. This area gathers information from the patient and investigates the issue fully. A response with our findings is provided to the patient. Waiver of co-payments can also be identified from calls to our customer service center and our auditing unit, which looks for atypical billing patterns.
For Dental HMO/Managed Care, the dentist’s agreement prohibits billing a member above the specified co-payment. The plan conducts a thorough orientation with each dental office. The Quality Management department reviews member complaints that relate to charges. The Office Quality Assessment reviewer notes any apparent overcharges during the patient-record audit and works with the dentist’s office to correct the issues.
Principal Financial Group: Provider utilization patterns are studied and issues are addressed as uncovered.
Securian Dental: We systematically check every submitted claim.
United Concordia: United Concordia participating dentists contractually agree to only bill members for applicable deductibles, coinsurance, or amounts exceeding the plan maximums. In addition, members receive explanations of benefits that clearly describe the services received and their financial responsibility.
Members can also access the My Dental Benefits tool on our website (UnitedConcordia.com) to view their benefits and eligibility information, claim details, procedure history, maximum and deductible accumulations and more. Plus, United Concordia’s responsive customer service representatives are available to assist members with questions regarding their benefits. Our Utilization Review area also analyzes thousands of claims each year to ensure the acceptability of treatment and quality of services. Our dental advisors and consultants also continuously review dentists’ fees and practice patterns for statistical variation from their peers. Dentists who fall outside of the norm are targeted for education and additional monitoring.
Western Dental: Providers are bound by contract to accept the member’s schedule of benefits. Members can also access the My Dental Benefits tool on our website (www.UnitedConcordia.com) to view their benefits and eligibility information, claim details, procedure history, maximum and deductible accumulations, and more. Plus, United Concordia’s responsive customer service representatives are available to assist members with questions regarding their benefits. Our Utilization Review area also analyzes thousands of claims each year to ensure the acceptability of treatment and quality of services. Our Dental Advisors and consultants also continuously review dentists’ fees and practice patterns for statistical variation from their peers. Dentists who fall outside of the norm are targeted for education and additional monitoring.
8. How many provider locations do you have?
Aetna: As of 6/1/13: DMO over 74,000 dentist locations nationally and 98,000 in California, PPO: over 203,000 dentist locations nationally and 26,000 in California.
Aflac: Aflac Dental does not have network requirements. Policyholders may visit any provider they choose.
Our Dental Complete network includes 16,230 unique dentists and 35,570 access points in California alone. Our Dental Prime and Dental Complete members also have seamless access to the national Dental GRID, administered by GRID Dental Corporation. One of the nation’s leading dentist networks, the Dental GRID has providers in all 50 states – with 87,000 unique dentists and 185,355 access points
Additionally, Dental Prime and Dental Complete members have access to our international emergency dentist network, with 24/7 assistance with locating an English-speaking provider for dental emergencies in approximately 100 countries worldwide.
Our Dental Net DHMO network includes more than 7,300 provider locations in California to choose from.
Ameritas: Ameritas/FDH Network: 69,675 California provider access points, (49,551 Ameritas; 20,124 FDH); 19,172 California locations, (12,391 Ameritas; 6,781 FDH)
BEN-E-LECT: BEN-E-LECT’s dental plans utilize the Health Smart (Interplan), First Dental Health, Dentemax, PPO USA and Western Dental networks which contain thousands of offices statewide.
BEST Life: We offer access to a regional and a national PPO networks – First Dental Health (FDH) and DenteMax. Our California network has over 58,402 access points and an additional 9,277 provider locations throughout the state of California. Our national network has over 163,000 provider locations, which offers our members network access when they are outside of California.
Blue Shield: Members have network access to over 16,000 dental HMO and 25,000 dental PPO providers in California, and more than 218,000 providers nationwide. These are two of the largest statewide provider networks in the industry.
Cigna: Not Available.
Dental Health Services: As a prepaid dental plan, Dental Health Services currently has 927 general practice offices with 4,354 participating dentists and an additional 1,924 specialists.
Delta Dental: Our networks offer access to more than 48,000 dentist locations for Delta Dental Premier, more than 31,000 dentist locations for Delta Dental PPO and more than 5,100 dentist facilities for DeltaCare USA in California.
Guardian: There are over 215,846 PPO dentist-locations across the country and more than 31,959 in California. We are one of the largest PPO networks in the state based on unique dentists. The DentalGuard Alliance PPO network has over 8,094 dentist-locations in Southern California. For the DHMO, there are 13,992 locations across the country and 6,914 in California. Guardian’s PPO network now includes more than 30 dental offices in Mexico. International Assist, a value-added service available, provides dental members with access to dental care if needed while traveling outside of the U.S. Also, a supplemental listing of out-of-network dentists, Out-of-Network Plus, provides Guardian members greater selection in finding an affordable dentist.
Health Net Dental: As of April 2013, our California PPO network includes 36,483 access points in 10,962 locations. Our California DHMO network includes 2,020 locations.
HUMANA Dental: Nationally, Humana has more than 200,000 provider locations. In California, we have approximately 29,000 provider locations.
Principal Financial Group: We have approximately 41,400 PPO provider locations and 24,000 EPO provider locations.
Securian Dental: 163,000 dentist access points.
United Concordia: To support our diverse product portfolio consisting of fee-for-service, DHMOs and PPOs, we maintain some of the largest dentist networks in the nation. Our largest network provides access to 92,500 dentists at almost 235,000 access points. In California alone, we have 15,800 providers at 37,833 access points. Our DHMO network includes more than 2,600 primary dental offices and almost 1,700 specialists nationwide, with over 1,657 primary dental offices and 776 specialists in California.
9. Can Insureds change providers easily if they are unhappy?
Aetna: Yes, members in our PPO/indemnity plan can change any time and do not need to notify us. Members in our DMO plan can choose a new provider as often as once per month through Navigator, our online web tool for members, or by calling the toll-free telephone number on the back of their ID card.
Aflac: Yes. Policyholders can change providers at any time.
Ameritas: Ameritas PPO and the FDH Networks: Insureds can choose any provider at any time for procedures.
Anthem Blue Cross: Yes. Our PPO networks, including Dental Prime and Dental Complete, are open-access models: The member does not have to pre-select a dentist and can always see the dentist of his/her choice. DHMO members can change providers once a month.
BEN-E-LECT: Yes. Members may change providers at any time by selecting to use another provider. No further documentation or process is necessary. Freedom Pre-Paid Dental is the only plan in which a member must select a specific provider.
BEST Life: Members may choose any dentist they desire without calling BEST Life to switch providers. We also provide immediate access to Customer Service, who can assist members with