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Private Health Exchange Survey 2014

Welcome to our first annual private exchange health care survey. Private exchanges gave detailed information about their plans. We hope that this valuable information will help you better serve your health care clients. 1. 
How much experience does your company have in the private exchange market? Benefitfocus: Benefitfocus, Inc. was founded in 2000 and is a leading provider of cloud-based benefits software solutions for consumers, employers, insurance carriers and brokers. We have 13 years of domain expertise in the benefits market tailoring our solutions to the complexities of this fast evolving market. Benefitfocus has served more than 20 million consumers on its platform, that consists of an integrated portfolio of products and services enabling clients to more efficiently shop, enroll, manage and exchange benefits information. With a user-friendly interface and consumer-centric design, the Benefitfocus platform provides one place for consumers to access all their benefits. Benefitfocus solutions support the administration of all types of benefits including core medical, dental and other voluntary benefits plans as well as wellness programs. CaliforniaChoice: 18 years. CaliforniaChoice, the small group private exchange for California employers with one to 50 employees, was launched in 1996. Mercer Marketplace: Mercer Marketplace was launched in the forth quarter of 2013, with clients going live on January 1. 2. Where is your company located? Benefitfocus: Benefitfocus is headquartered in Charleston, S.C. with additional offices in Greenville, S.C., Tulsa, Okla and San Francisco. CaliforniaChoice: CaliforniaChoice, the small group private exchange for California employers with one to 50 employees, is offered by CHOICE Administrators headquartered in Orange, Calif. Mercer Marketplace: Mercer, a subsidiary of Marsh & McLennan Companies, is headquartered in New York City, with locations nationally and globally. 3. 
Does the exchange offer a guided shopping experience to help people choose a plan based on their circumstances, such as the doctors they use, the medications they take and what they value in a plan? Benefitfocus: Benefitfocus provides a guided shopping experience consisting of a series of questions to identify a set of products that meet the needs of the employee. This interview approach is designed to capture details about employee preference and priorities to deliver a set of best-matched plans and benefit packages. This interview approach allows employees to focus on the plans that are best suited to their needs. In addition, employees are able to filter and sort plans based on specific attributes. CaliforniaChoice: Yes, the CaliforniaChoice small group private exchange website helps employees look up current or prospective physicians or other healthcare providers to determine what health plans each is associated with. We also provide information about what’s covered by each plan, so employees can determine if the plan is a good fit for their healthcare needs and their budget. Our employee worksheet also aids in the decision-making process. Mercer Marketplace: Yes, we believe personalizing the decision process for the consumer is key in driving the consumer to the plan that best meets their needs. That guided shopping experience is available online or through phone discussion with a benefits counselor. 4. 
Is the exchange integrated with federally facilitated marketplace and state-based exchanges? Benefitfocus: Benefitfocus technology is designed to allow for integration with the Federally Facilitated Marketplace (FFM) and state-based exchanges. Benefitfocus has designed a dynamic, blended workflow that exchanges eligibility information directly with the FFM in real-time, offering consumers a streamlined enrollment experience. A comprehensive rules-based engine collects data from consumers to then route shoppers to the subsidy eligibility application within the FFM. Once the FFM determines an individual’s subsidy, the consumer is sent back to the insurance carrier-sponsored marketplace to apply the given subsidy and purchase qualified products. CaliforniaChoice: No, CaliforniaChoice. is a small group private exchange. Mercer Marketplace: Planned for this year. 5. 
Is the exchange easily configurable? Benefitfocus:  Benefitfocus Marketplace is easily configurable to present employees with only the benefits options for which they are eligible within an engaging enrollment workflow. CaliforniaChoice: Yes, CaliforniaChoice offers small businesses access to six of California’s leading health plans (Aetna, Anthem Blue Cross, Health Net, Kaiser Permanente, Sharp Health Plan, and Western Health Advantage), including multiple HMO, EPO, PPO, and HSA-compatible plans. Based on the metal tier or tiers selected by the employer, employees have the option to choose the health plan and benefit that best fit their needs. We also include value-added benefits and services in our Business Solutions Suite, which is provided at no additional cost. It includes employer benefits like a premium only plan, COBRA services, FSAs, online HR services, payroll services, employee discounts through Cal Perks, and discount Dental, Vision, and Hearing. Mercer Marketplace: Yes, Mercer Marketplace allows employers to select the carriers, plan designs, funding, and contribution strategy they want to put in place through a configurable (i.e., no custom coding) technology platform. 6.  
Can it support multiple contribution methods and employees? Benefitfocus: Offering a full-service private exchange platform, the Benefitfocus Marketplace platform supports traditional, employer-sponsored enrollment, as well as defined contribution models. CaliforniaChoice: Yes, with CaliforniaChoice employers can choose a fixed percentage contribution toward employee coverage or a fixed dollar amount contribution toward coverage. Mercer Marketplace: Yes, we handle a wide variety of contribution methods (including but not requiring defined contribution), which can vary by different employee classifications. 7. 
Does it allow for flexible employee contributions? Benefitfocus: Yes, CaliforniaChoice: Yes, defined contribution gives each employee a fixed dollar amount or percentage to spend on healthcare, similar to a healthcare allowance. Employees use their employer’s contribution and apply it to the health plan and benefit plan they like best. They have complete flexibility if an employee wants an option that is more costly than the employer contribution, the employee simply pays the difference. Mercer Marketplace: Yes, 8.  
Does it offer easy renewal processing? Benefitfocus: The Benefitfocus platform supports renewal processing by allowing administrators to do the following: •
Configure the time frame for initiating the renewal process. •
Easily identify groups and members approaching renewal dates. •
Easily search for and identify different plans that best meet their business needs. •
Receive automatic email notifications when employers are ready for renewal processing. •
Eliminate paper reports and keep all processes in one place. CaliforniaChoice: Absolutely, CaliforniaChoice makes renewals easy for the broker and the employer. We have bilingual renewal specialists to help brokers with groups that want to renew their coverage. We make it easy by using just one form for employers to confirm or alter their contribution amounts, and employees can switch health plans and benefit levels based on their individual needs without leaving the CaliforniaChoice program. Mercer Marketplace: Yes. 9. 
Does it have a broker portal that allows authorized agents to assist prospects and customers? Benefitfocus: Yes, Benefitfocus eEnrollment, eSales, and the Benefitfocus Marketplace enable brokers to provide administrative support for employers, employees and consumers. Brokers can facilitate the new sales and renewal sales processes on behalf of employers and consumers as well as manage the benefit enrollment and application processes throughout the year. When a broker has access to a group or consumer, the broker will be able to fully support the ongoing benefits administration for that group or consumer. Mercer Marketplace: Not at this time. 10.  
Does it offer prospect/client management tools for brokers? Benefitfocus:  Brokers are provided a home page with an activity tracker that summarizes the number of prospects and groups in specific statuses in various sales workflows. Brokers can quickly select a given status to see the specific groups and begin working with those groups. In addition, from the home page, the broker can initiate key activities such as adding a new prospect or tracking all groups that are in open enrollment.  When a broker accesses a specific prospect or group, the broker will also have access to to-do lists, actionable messages as well as workflow, event, and status tracking on the summary tab for the given group. This allows the broker to track exactly what actions are needed at that point in time. Tasks can include key actions necessary for the group as part of a group sales workflow and employee-level tasks that may require attention. CaliforniaChoice: Yes, CaliforniaChoice provides a variety of broker tools, including online quotes (initial and enrollment), new hire worksheets, and the ability to schedule meetings. We also offer email notifications for terminations, late pays, and renewals, as well as 24/7 online access to group account information Mercer Marketplace: Not at this time. 11.  
Does is offer predictable employer costs? Benefitfocus:  Yes CaliforniaChoice: Yes, CaliforniaChoice is built on a defined contribution platform, so an employer can choose a fixed percentage contribution toward employee coverage or a fixed dollar amount contribution to coverage. Through defined contribution, small businesses are also able to achieve a higher level of employee retention because employees are empowered to make their own healthcare decisions, and both the employer and employee know what they’re going to pay to each month. Mercer Marketplace: Yes, through use of a defined contribution strategy. 12.  
Does it offer a broad array of plan choices? Benefitfocus: With more than 900 established data exchange connections, the Benefitfocus Platform offers clients the ability to support more than 100 types of benefits including health, life, voluntary and financial benefits. CaliforniaChoice: CaliforniaChoice offers dozens of plan designs (including HMO, PPO, EPO, and HSA-compatible coverage) from Aetna, Anthem Blue Cross, Health Net, Kaiser Permanente, Sharp Health Plan, and Western Health Advantage, and there are no participation restrictions between health plans. Mercer Marketplace: Yes, for example, Mercer Marketplace currently offers five different standard medical plans from 14 different regional and national carriers (and growing). We also offer a broad array of choices in over 20 lines of coverage (dental, vision, life, disability, and a variety of voluntary products). 13.  
Does it offer a single preferred carrier in each geographic area and offer plans just from that carrier? Benefitfocus: Our platform supports all types of plan and can be configured to enforce business rules at all levels including rates, eligibility, etc CaliforniaChoice: No, CaliforniaChoice offers dozens of HMO, EPO, PPO, and HSA-compatible plan designs (and 14 health plan networks, including full and limited networks) from Aetna, Anthem Blue Cross, Health Net, Kaiser Permanente, Sharp Health Plan, and Western Health Advantage. We also offer a choice of a single metal tier or tiered choice, which gives employees access to the health plans and benefits available in two neighboring metal tiers. Mercer Marketplace: No, we have significant flexibility in carrier offerings, including multi-carrier by market. 14.  
Does it offer plans with narrow provider networks and strong managed care? Benefitfocus: Our platform supports all types of plan and can be configured to enforce business rules at all levels including rates, eligibility, etc CaliforniaChoice: Yes, CaliforniaChoice offers 14 health plan networks, including full and limited networks, from Aetna, Anthem Blue Cross, Health Net, Kaiser Permanente, Sharp Health Plan, and Western Health Advantage. Mercer Marketplace: Yes, subject to the employer’s discretion. 15.  
Does it offer regional rates or composite rates across the population? Benefitfocus: Our platform supports all types of plans and can be configured to enforce business rules at all levels including rates, eligibility, etc. CaliforniaChoice: CaliforniaChoice is a small group private exchange (for groups with one to 50 employees); rates are guaranteed and are based on group size and ZIP code. Mercer Marketplace: Mercer Marketplace has the flexibility to support either approach, subject to consultation with each individual employer. 16.  
Can the exchange handle other benefit programs beyond health coverage? Benefitfocus: Yes, third party apps are a cornerstone of the Benefitfocus system, allowing employers to enhance their traditional employee benefit offering with voluntary benefits, health and wellness programs, financial tools and additional decision support. CaliforniaChoice: Yes, in addition to the health coverage offered by CaliforniaChoice, employers have access to premium only plans, online HR services, payroll services, COBRA billing, FSAs, Cal Perks employee discounts, and a prescription drug discount card — some available at no additional cost. Mercer Marketplace: Yes, Mercer Marketplace offers over 20 types of products, from supplemental medical products to disability products to pet insurance and more. 17.  
Do you require the employer to move other benefit programs to the exchange as a condition of doing business? Benefitfocus: No. CaliforniaChoice: No. Mercer Marketplace: No, retirement and other programs not on Mercer Marketplace do not need to move. 18.  
Does the exchange offer implementation assistance? Benefitfocus: No, CaliforniaChoice: Yes, we work with brokers and their clients to make offering the CaliforniaChoice small group private exchange a positive experience including onsite enrollment assistance (with a bilingual enroller). We also offer the simplicity of one enrollment form for all coverage, one contact number for questions, one website to manage benefits, and one streamlined monthly bill for all lines of coverage. Mercer Marketplace: Yes. 19.  
What kind of data and reports are provided? Benefitfocus: HR administrators, brokers and insurance carrier representatives have access to a suite of tools to help them support employees and manage the enrollment process. Tools include tasks lists to help HR administrators and brokers manage their employee-initiated updates and a series of reports that provide visibility into an employer group’s activity and current state. Some of these reports include employee detail and change history reports, as well as valuable employer reports, such as the employee census, relationship change and participation reports. CaliforniaChoice: CaliforniaChoice offers brokers online reports regarding commissions, sales history, and quote history. Mercer Marketplace: Mercer Marketplace provides a comprehensive reporting suite, including employee detail reports, employee/dependent census information, benefit enrollment summaries, open enrollment participation, premium reporting, COBRA participation, HSA administration, payroll reporting, and more. 20.  Is their transparency of fees? Benefitfocus: Yes, Mercer Marketplace: Yes, 21.  Does it offer a call center and/or instant chat? Benefitfocus:  The Benefitfocus HR Support Center (HRSC) provides clients with navigational and technical assistance. In addition, clients have the option to contract with Benefitfocus to support telephonic enrollment and manage administrative tasks through HRSC. CaliforniaChoice: Yes, CaliforniaChoice understands the unique needs of small businesses, and we are committed to providing our customers and members with the assistance they need. Our customer care center has earned a 96% service level rating from our members. Our sales staff is also always here to help brokers, and we can often provide answers more quickly than calling the carriers directly. Mercer Marketplace: Yes, we offer a telephonic call center. 22.  Please provide contact information for brokers who want to find out more Benefitfocus: CaliforniaChoice: For sales, call 800-542-4218 or email For public relations or partnership opportunities, call Polly Neves at 714-567-4592 or email Our website is Mercer Marketplace: Jim Zedella partner,, 440-717-3250 ... Continue Reading →

Employer-Sponsored Family Health Premiums Rise a Modest 4%
by Leila Morris

Annual premiums for employer-sponsored family health coverage reached $16,351 in 2013, up 4% from in 2012, with workers paying an average of $4,565 toward the cost of their coverage, according to a report by the Kaiser Family Foundation/Health Research & Educational Trust. The rise in premiums is moderate by historical standards. Since 2003, premiums have increased 80%, nearly three times as fast as wages and inflation. “We are in a prolonged period of moderation in premiums, which should create some breathing room for the private sector to try to reduce costs without cutting back benefits for workers,” said Kaiser President and CEO Drew Altman, Ph.D. Firms with many lower-wage workers (at least 35% earning $23,000 or less annually) required workers to pay $1,363 more toward family premiums than did companies with fewer lower-wage workers ($5,818 versus $4,455 annually). The lower-wage firms offered less costly coverage too, creating a big disparity in the share of the premium that their workers pay (39% versus 29%). In 2013, 78% of all covered workers had an annual deductible, up from 72% in 2012. Typically, workers pay this deductible before most services are covered by their health plan. The average deductible for worker-only coverage was $1,135 in 2013, similar to the $1,097 average deductible in 2012. In 2013, 38% of all workers had a deductible of at least $1,000 or more compared to 58% of workers at small firms. In fact, 31% of workers at small firms had a deductible of at least $2,000 in 2013, up from 12% in 2008. In 2013, 35% of employers said that wellness plans are very effective in controlling costs compared to 22% who cited disease management, 20% who cited consumer-driven health plans, and 17% who cited higher cost sharing. Nearly all large employers (at least 200 workers) offered at least one wellness program. Thirty-six percent of large employers that offered wellness programs provided financial incentives for participation, such as lower premiums or deductibles, a larger contribution to a tax-preferred savings account, gift cards, cash, or other direct financial incentives. Fifty-five percent of large firms that offered health benefits also offered biometric screenings, and 11% rewarded or penalized workers financially based on whether they achieve biometric outcomes. The Affordable Care Act (ACA) includes provisions that allow broader use of financial incentives to encourage workers to improve their health status and outcomes. “This will be an important issue to watch next year, as employers will have more flexibility and could ask workers to pay more because of their lifestyles and health conditions,” said KFF vice president Gary Claxton. Thirty-six percent of covered workers were in grandfathered plans, down from 48% in 2012. The slow growth in premiums also means that fewer employer plans will be subject to the ACA’s high-cost plan tax that takes effect in 2018. The Congressional Budget Office recently reduced its estimate of the number of plans that would trigger the tax, and a continued low growth rate could further reduce the effect of this provision. In 2o13, 29% of employers with at least 5,000 workers were considering offering benefits through a private exchange. These jumbo firms employ almost 40% of all covered workers, so their interest could indicate a significant shift in the way many people get their health insurance. Fifty-seven percent of firms offered health benefits in 2013, which is statistically unchanged from the 2012 and 2011. Nearly all firms with at least 200 workers offered health benefits to at least some of their workers. Forty-three percent of the smallest firms (three to nine workers) offered health benefits in 2013 compared to 50% in 2012. Also, 23% of firms with a lot of low-wage workers offered health insurance compared to 60% of firms with few low-wage workers. For more information, visit Sluggish Economy, Not Health Reform, Drove Spending Slowdown The economic downturn can take the credit for about 70% of the recent decline in health care spending growth from 2009 to 2011, according to a study published in the August issue of Health Affairs. As the economy recovers, health spending is likely to increase at a faster pace. “The slowdown was mostly due to the sluggish economy, not to structural change in the health care sector. The Affordable Care Act may ultimately succeed at reducing costs, but it hasn’t done so yet,” said study co-author David Dranove of the Kellogg School of Management at Northwestern University. “There has been disagreement, over the years, as to whether health spending is recession proof. This study shows it’s not. The analysis, which focuses on privately insured people, highlights that the slowdown in health spending was not only caused by people who lost their jobs and employer-provided health insurance. Even people who retained insurance during the downturn reigned in their health spending. This demonstrates the broad effects of a recession on health spending,” said Co-author Craig Garthwaite, an assistant professor at the Kellogg School of Management. Health spending growth slowed 2.6% from 2009 to 2011. The authors predict that health-spending growth would have been 1.8% higher if the economy had not faltered in 2008.  Insured people living in the hardest hit areas experienced the smallest increases in health spending. Thus, they concluded that 70% of the decline in health care spending growth was the result of the stagnant economy.  For more information, visit -and-future-research-projects@healthcostinst. Higher Ed Employees Face More Cost Sharing Colleges and universities are passing more healthcare costs to their employees, according to a report by the College and University Assn. for Human Resources. Forty one percent have increased the employee share of premiums since the ACA went into effect. Additionally, 26% have increased in-network deductibles; 27% have increased out-of-pocket limits; 20% have increased the employee share of prescription drug costs; and 24% have increased the employee share of dependent coverage costs. Thirty-six percent of colleges and universities have adopted or expanded a wellness program; and 21% have adopted or expanded financial incentives to encourage healthy behaviors. The survey also reveals the following about colleges and universities: 50% of part-time staff and 80% of part-time faculty work less than 30 hours a week. The average annual premium was $6,501 for employee-only coverage and $17,484 for the employee plus family coverage for all four plan types (PPOs, HMO, POS plans, and HDHPs). 82% offer PPO plans; and 44% offer HDHPs — up from 17% in 2009. 60% offer healthcare benefits to same sex domestic partners or spouses (up from 46% five years ago). 42% offer healthcare benefits to part-time staff and 36% offer healthcare benefits faculty. Most of those also pay part of the premium. Colleges and universities that don’t offer healthcare benefits for part-time employees are not providing financial support for enrollment in a public exchange, and only 2% are considering doing so next year. Almost all colleges and universities provide basic life insurance, long-term disability, paid time-off, tuition assistance and retirement benefits. But only 64% offer short-term disability coverage. For more information visit The Most Influential People in Health Care Modern Healthcare magazine released its 12th annual ranking of the 100 Most Influential People in Healthcare. Quite a few are in the insurance industry. The award honors people who are the most influential in the health care industry according to their peers and an expert panel. They are listed as follows: 1. Kathleen Sebelius, secretary of HHS, 2. Dr. John Kitzhaber, governor of Oregon 3. President Barack Obama 4. Stephen Hemsley, president and CEO of UnitedHealth Group 5. Marilyn Tavenner, CMS administrator 6. Mark Bertolini, chairman, president and CEO of Aetna 7. Richard Bracken, chairman and CEO of HCA in Nashville 8. Joseph Swedish, CEO of WellPoint 9. George Halvorson, outgoing chairman of Kaiser Permanente in Oakland, Calif. 10. Sister Carol Keehan, president and CEO of the Catholic Health Assn. 11. Kent Thiry, co-chairman and CEO of DaVita HealthCare Partners, Denver 12. Glenn Hackbarth, chairman, Medicare Payment Advisory Commission 13. Judith Faulkner, CEO of Epic Systems Corp. in Wisconsin. 14. Jan Brewer, governor of Arizona 15. Dr. John Noseworthy, president and CEO of the Mayo Clinic 16. Dr. Delos Toby Cosgrove, president and CEO of the Cleveland Clinic 17. Wayne Smith, chairman, president and CEO of Community Health Systems in Tennessee 18. Trevor Fetter, president and CEO of Tenet Healthcare in Dallas 19. Joel Allison, president and CEO of Baylor Health Care System in Dallas 20. David Cordani, president and CEO of Cigna 21. Maureen Bisognano, president and CEO of the Institute for Healthcare Improvement 22. Paul Diaz, CEO of Kindred Healthcare in Kentucky 23. Patricia Hemingway Hall, president and CEO of Health Care Service Corp. in Chicago 24. John Hammergren, chairman, president and CEO of McKesson Corp. in San Francisco 25. Michael Dowling, president and CEO of the North Shore-Long Island Jewish Health System in N.Y. 26. Dr. Gary Gottlieb, president and CEO of Partners HealthCare in Boston 27. Dr. Farzad Mostashari, outgoing national coordinator for health information technology of the ONC 28. Bruce Broussard, president and CEO of Humana 29. Richard Umbdenstock, president and CEO of the American Hospital Assn. 30. Kevin Lofton, president and CEO of Catholic Health Initiatives. 31. Dr. Gary Kaplan, chairman and CEO of the Virginia Mason Medical Center in Seattle 32. Drew Altman, president and CEO of the Kaiser Family Foundation in Menlo Park, Calif. 33. Chip Kahn, president and CEO of the Federation of American Hospitals 34. Lloyd Dean, president and CEO of Dignity Health in San Francisco 35. RoseAnn DeMoro, executive director of National Nurses United. 36. Sen. Max Baucus, Senate Finance Committee chairman (D-Mont.) 37. Ron Pollack, founding executive director of Families USA 38. Dan Wolterman, president and CEO of Memorial Hermann Health System in Houston 39. A. Barry Rand, CEO of AARP 40. Bill Carpenter, chairman and CEO of LifePoint Hospitals in Tennessee. 41. Dr. Susan Turney, president and CEO of MGMA-ACMPE 42. Pat Fry, president and CEO of Sutter Health in Sacramento, Calif. 43. Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention 44. Dr. Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation 45. Dr. Margaret Hamburg, commissioner of the FDA 46. Alex Gorsky, chairman and CEO of Johnson & Johnson 47. Susan DeVore, president and CEO of Premier in North Carolina 48. John Castellani, president and CEO of Pharmaceutical Research and Manufacturers of America 49. Dr. Charles Sorenson, president and CEO of Intermountain Healthcare in Salt Lake City 50. Dr. Jeffrey Drazen, editor-in-chief of the New England Journal of Medicine 51. Dr. Atul Gawande, professor of surgery and Harvard Medical School and professor of health policy and management at the Harvard School of Public Health 52. Cecile Richards, president of Planned Parenthood 53. Alan Miller, chairman and CEO of Universal Health Services in Pennsylvania 54. Dr. Ardis Hoven, president of the American Medical Assn. 55. Margaret Peggy O’Kane, president of the National Committee for Quality Assurance 56. Dr. Glenn Steele Jr., president and CEO of Geisinger Health System in Pennsylvania. 57. James Skogsbergh, president and CEO of Advocate Health Care in Illinois 58. Dr. Georges Benjamin, executive director of the American Public Health Assn. 59. Jay Grinney, president and CEO of HealthSouth in Alabama 60. Dr. Mark Chassin, president of the Joint Commission. 61. Anthony Tersigni, president and CEO of Ascension Health Alliance in St. Louis 62. Alan Aviles, president and CEO of the New York City Health and Hospitals Corp. 63. Doug Hawthorne, CEO of Texas Health Resources 64. Richard Feinstein, former director of the Bureau of Competition for the Federal Trade Commission 65. John Bardis, chairman, president, and CEO of MedAssets in Georgia. 66. Mary Brainerd, president and CEO of HealthPartners in Minneapolis 67. Leah Binder, president and CEO of the Leapfrog Group in Washington 68. Daniel Levinson, inspector general of HHS 69. Jeffrey Romoff, president and CEO of UPMC in Pittsburgh 70. Bobby Jindal, governor of Louisiana 71. Suzanne Delbanco, executive director of Catalyst for Payment Reform in San Francisco 72. Dr. Christine Cassel, incoming president and CEO of the National Quality Forum 73. Dr. Francis Collins, director of NIH 74. Nancy Schlichting, CEO of the Henry Ford Health System in Detroit 75. Karen Ignagni, president and CEO of America’s Health Insurance Plans 76. Bill Gates, co-chair of the Bill & Melinda Gates Foundation 77. Sen. Charles Grassley (R-Iowa) 78. Dr. Jeffrey Cain, president of the American Academy of Family Physicians 79. Gail McGovern, president and CEO of the American Red Cross 80. Dr. Harvey Fineberg, president of the Institute of Medicine 81. Dr. James Madara, executive vice president and CEO of the American Medical Assn. 82. Scott Armstrong, president and CEO of Group Health Cooperative in Seattle 83. Deborah Bowen, president and CEO of the American College of Healthcare Executives 84. Scott Serota, president and CEO of the Blue Cross and Blue Shield Assn. in Chicago 85. Dr. Darrell Kirch, president and CEO of the Assn. of American Medical Colleges 86. Dr. Ralph de la Torre, chairman and CEO of the Steward Health Care System in Boston 87. Dr. Benjamin Chu, group president of Kaiser Permanente Southern California and Hawaii, Kaiser Permanente, Oakland, Calif.; and board chairman of the American Hospital Assn. 88. Mary Kay Henry, president of the Service Employees International Union 89. Kenneth Raske, president and CEO of the Greater New York Hospital Assn. 90. Dr. Eric Topol, chief academic officer for Scripps Health and director of the Scripps Translational Science Institute in San Diego 91. Eric Shinseki, secretary of the Veterans Affairs Department 92. Donald Fisher, president and CEO of the American Medical Group Assn. 93. Dr. David Blumenthal, president of the Commonwealth Fund 94. Dr. James Weinstein, president and CEO of Dartmouth-Hitchcock in N.H. 95. Alan Morgan, CEO of the National Rural Health Assn. 96. Val Halamandaris, president of the National Assn. for Home Care & Hospice 97. Dr. Bruce Siegel, president and CEO of America’s Essential Hospitals 98. Helen Darling, president and CEO of the National Business Group on Health 99. Dr. Brent James, chief quality officer and executive director of the Institute for Health Care Delivery Research for Intermountain Healthcare in Salt Lake City 100. James Hinton, president and CEO of Presbyterian Healthcare Services in Albuquerque Read the full article as published in the August 26 issue of Modern Healthcare at: Top Trends in Medicare Part D Now in its ninth year of operation, the Medicare Part D program has had consistently high levels of plan participation, offering dozens of plan choices for beneficiaries in each region and broad access to generic and brand name drugs. But there are some sobering trends beneath the surface, according to a report by the Kaiser Family Foundation. Cost and access trends could pose challenges for Part D enrollees. Although premiums have been flat for several years, average premiums have increased nearly 50% from 2006 to 2014. Median cost sharing for brand-name drugs has also increased. Finally, many low-income beneficiaries are paying steadily higher premiums for coverage when they could be enrolled in premium-free plans. Sixty-two percent of Part D enrollees are in PDPs, but enrollment in MA-PD plans is growing faster, representing half of the net increase in enrollment from 2013 to 2014. About 6.5 million Medicare beneficiaries with drug coverage from their former employers now get that coverage through a Part D plan designed for that firm’s retirees. Enrollment in employer plans has quadrupled since 2006, partly due to changes in law that took effect in 2013. In 2014, three Part D sponsors account for half of all Part D PDP and MA-PD enrollees. UnitedHealthCare, Humana, and CVS Caremark have enrolled half of all participants in Part D, which is relatively unchanged from 2006. UnitedHealthCare and Humana have held the highest shares of enrollment since the program began while enrollment in CVS Caremark has grown through the acquisition of other plan sponsors. UnitedHealthCare has maintained the top position for all nine years of the program, and provides coverage to more than one in five PDP and MA-PD enrollees in 2014. Average monthly PDP premiums have been flat since 2010; premiums for some of the most popular plans increased for 2014; and premiums for other popular plans fell. On average, PDP enrollees pay premiums of $37.75 per month in 2014. However, PDP premiums vary widely even for plans with equivalent benefits. Premiums range from $12.80 to $111.40 a month for plans offering the basic Part D benefit. UnitedHealthCare’s AARP MedicareRx Saver Plus PDP, which was new in 2013, raised its premiums by 54% in 2014 (an average increase of about $8 per month). In contrast, WellCare’s Classic PDP lowered its premium by 38% (an average decrease of about $13 per month) in 2014. Part D enrollees in MA-PD plans pay lower premiums on average ($14.70) than those in PDPs. Cost sharing for brand-name drugs has been relatively stable in recent years, but has risen substantially since the start of Part D.  MA-PD plan enrollees generally have somewhat higher cost sharing than do PDP enrollees. Cost sharing for brands increased by about 50% from 2006 to 2014 for beneficiaries in PDPs and about 70% for those in MA-PD plans. Median cost sharing in a MA-PD is $45 for preferred brands and $95 for non-preferred brands plans. Median cost sharing in a PDP is $40 for preferred brands and $85 for non-preferred brands. Seventy-six percent of PDPs and 75% of MA-PDs use five cost-sharing tiers including preferred and non-preferred tiers for generic drugs, preferred and non-preferred tiers for brand drugs, and a tier for specialty drugs. Four-tier arrangements were most common until 2012 when plans began shifting toward the five-tier cost-sharing design. Part D plans typically use specialty tiers for high-cost drugs and charge coinsurance of from 25% to 33% during the benefit’s initial coverage period, as in previous years. These initial high out-of-pocket costs may create a financial barrier to starting use of specialty drugs, which are expected to be a significant cost driver for Medicare. Users are likely to reach the benefit’s catastrophic threshold in a short period, and see their coinsurance reduced to 5%. The number of Part D stand-alone drug plans with a preferred pharmacy network grew from 7% in 2011 to 72% in 2014. Enrollees have lower cost sharing with preferred pharmacies. However, in some plans, there is no preferred pharmacy within a reasonable travel distance, which could make it hard for enrollees to take advantage of the lower cost sharing. Only 5% of PDP enrollees are in plans with the highest star ratings (four stars or more out of five). More than half are in plans with 3.5 stars. Nearly one-fourth of are in plans with fewer than three stars; plans at this level for three years in a row can be removed from the program. For more information, visit HIV Medical Organizations Challenge Insurer Restrictions The American Academy of HIV Medicine (AAHIVM) and the HIV Medicine Assn. (HIVMA) are challenging new health plan policies that bar many HIV care providers from prescribing certain medications to treat hepatitis C (HCV). “Thanks to the treatments available today, most of our patients with HIV do not die from AIDS-related illness, but from other conditions including liver disease. Many people co-infected with HIV and HCV have been waiting a long time for more effective and tolerable HCV treatment. Now that a cure is available, it is unconscionable to deny them access to medical providers who are well qualified to administer and manage this treatment,” said Joel Gallant, MD, MPH, FIDSA, chair of HIVMA. A new drug approved for the treatment of HCV earlier this year offers a significantly improved cure rate over older treatments. “Of the 1.1 million Americans living with HIV, approximately 30% are co-infected with HCV. Many of these patients are being successfully cared for by an HIV practitioner. Yet some insurers are now enforcing policies to limit or remove HIV care providers’ ability to prescribe new HCV medications. These restrictive insurance policies exclude HIV providers who are not trained as gastroenterologists, hepatologists, or infectious diseases specialists from prescribing some medicines to treat HCV, and create other barriers to providing the best available care to patients with HCV infection. There is no medical rationale for excluding some HIV providers from prescribing HCV medications,” said Donna Sweet, MD, AAHIVS, chair of the AAHIVM Board of Directors.She added, “HIV providers who have been treating HCV/HIV co-infected patients for years are uniquely qualified to manage potential drug toxicities and side effects stemming from combining treatment… These restrictive policies not only limit access to the new HCV treatment for many people with HIV, but could also lead to treatment disruptions and other serious adverse health consequences for patients.” AAHIVM and HIVMA have sent letters to insurers urging them to reevaluate and discontinue these policies immediately. For more information, visit Medical Tourism Webcast The Medical Tourism Assn. is hosting a webcast tomorrow at 7:00 AM. For more information, visit NEW PRODUCTS Self-Service Enrollment Navera is offering employers and brokers a suite of educational and decision support software for self-service enrollment in Humana’s workplace voluntary benefits. Humana Inc. and Navera will include education and decision support software for other Humana benefits, including medical, dental, and vision products. For more information, visit Health Exchange Aon Hewitt is expanding coverage options under the Aon Active Health Exchange for 2015. Employers can offer a wide range of elective benefit plans during this fall’s annual enrollment season. The following elective benefits that can be offered on the Aon Active Health Exchange for coverage beginning January 1, 2015: • Critical Illness • Accident • Hospital Indemnity • Life • Long-term Disability • Identity Theft • Legal • Home/Auto • Pet Insurance For more information, visit Education on Fiduciary Risks The Guardian launched The Fiduciary Awareness Quiz to help plan sponsors understand their fiduciary obligations. For more information, visit Global Health Budget Tool The Kaiser Family Foundation has launched an interactive tool that provides the latest data on the U.S. government’s global health budget in an easy-to-access form. The U.S. Global Health Budget Tracker lets users follow the budget from the President’s budget request through the appropriations process in Congress, and see trends over time. The Foundation will host an interactive web briefing on the new tool on Thursday, September 11 at 10:00. To view the tool, visit To register for the briefing, visit CALIFORNIA Court Clarifies Definition of Independent Contractors The Ninth Circuit Court of Appeals ruled that 2,300 people working for FedEx Ground were misclassified as independent contractors instead of employees. As a result, FedEx may owe its workforce of drivers hundreds of millions of dollars for illegally shifting to them the costs of such things as the FedEx branded trucks, FedEx branded uniforms, and FedEx scanners, and missed meal and rest period pay, overtime compensation, and penalties. The case, known as “Alexander v. FedEx Ground,” covers employees in California from 2000 to 2007. The ruling can be found on the Leonard Carder website at The court’s findings could influence the outcome in over two dozen cases nationwide in which FedEx Ground drivers are challenging the legality of their independent contractor classification.  FedEx requires its so-called contractors in California to hire a secondary workforce of FedEx drivers, who do the same work as the plaintiffs under the same contract. The Alexander decision calls into question FedEx’s strategy of making plaintiffs the middlemen between the secondary workforce of drivers and FedEx. Background on the everyday experience for FedEx Ground drivers includes the following: • FedEx Ground drivers were required to pay out of out of pocket for everything from the FedEx Ground branded trucks they drove (painted with the FedEx Ground logo) to fuel, various forms of insurance, tires, oil changes, maintenance, etc. and their uniforms, scanners and even workers compensation coverage. • In some cases, workers were required to pay the wages of employees who FedEx Ground required them to hire to cover for them if they were sick or needed a vacation, to help out during the Christmas rush, and in some cases to drive other FedEx Ground trucks. • After paying these expenses, a typical FedEx driver makes less than employee drivers at FedEx Ground’s competitors like UPS, and gets none of the employee benefits, like health care, workers compensation, paid sick leave and vacation, and retirement. • In addition, their employment was subject to the whims of FedEx management and FedEx Ground’s decisions on staffing and routes left the employee drivers stuck with expensive long-term truck leases on FedEx branded trucks. The drivers’ attorney Beth Ross added, nationally, thousands of FedEx Ground drivers must pay for the privilege of working for FedEx 55 hours a week, 52 weeks a year. These workers were granted rights and benefits entitled to employees under California law. To be clear, the Ninth Circuit exposed FedEx Ground’s independent contractor model as unlawful. For more information, visit   California and Virginia join international information exchange agreement Insurance supervisors of California and Virginia have joined an international supervisory cooperation and information exchange agreement. There are now 42 jurisdictions admitted as signatories to the IAIS Multilateral Memorandum of Understanding (MMoU), representing nearly 60% of worldwide premium volume. MMoU, supervisors exchange relevant information and provide assistance to other signatories in order to promote  financial stability and sound supervision of cross-border insurance operations. California Insurance Commissioner Dave Jones said, “The MMoU is an essential regulatory tool, not only in crisis situations, but also on a day-to-day basis for supervisors to foster safer and more stable insurance markets.” For more information, visit LONG TERM CARE Motivating Clients to Plan for Long Term Care ACSIA Partners has introduced the concept of “empowered living,” which it hopes will catch on to help solve a big national problem: the lack of planning for long-term care. Denise Gott, CEO of ACSIA said, “It used to be that long-term care was a rather passive and dreary thing. People ended up in a nursing home or relative’s spare bedroom…But the care scene has changed, and will change even more in the years ahead…With good financial planning, you can look forward to years of rewarding, self-empowered living in spite of needing care.” A variety of senior and assisted-living communities have sprung up. They’re a far cry from yesterday’s nursing homes, and they’re transforming the quality of our later years. Some are plush and many offer amenities such as libraries, recreational facilities, support for business and professional pursuits, and cultural events such as lectures and concerts. Some operate with universities, providing rich cultural opportunities. One’s own home can be made care-friendly, she said. Retrofitting homes for people needing care is now a big business. Gott explained that Middle-aged Americans tend to associate needing care with becoming passive, losing control, declining, being  dependent, and being a burden on others. They sometimes even feel shame, fear, or repulsion just thinking about it. So they put it out of mind. Today’s 40-somethings and 50-somethings most need to think about LTC insurance because they’re usually fit enough to qualify for it and can get the best rates, she added. “They just need to look at it positively, from the upbeat perspective of empowered living, and then make a plan. Our belief is that many more will do that if we paint the right picture. One’s care years can be an upbeat stage of life — a period under their complete control, full of fresh, rewarding activity, interaction, and effectiveness.” For more information, visit . FINANCIAL PLANNING Making Financial Plans for Pet Care Forty-four percent of pet owners surveyed by Securian Financial have made plans for their pets’ future care. For one-fifth of those owners, those plans are financial. Michelle Hall, manager of Market Research for Securian Financial Group said, “Pets may provide opportunities for financial advisors whose clients consider their pets members of the family and spend large sums on their care. The American Society for the Prevention of Cruelty to Animals urges owners to plan for their pets’ care. Forty-six states have passed pet trust laws. Pet protection agreements, wills, powers of attorney, and letters of instruction are also available. The pet industry has more than tripled from $17 billion in 1994 to $59 billion in 2014, according to the American Pet Products Assn. Sixteen percent of pet owners say they would spend $10,000 or more to save a pet’s life while 29% would spend $2,000 to $5,000. Nearly 60% now spend up to $1,000 a year on food, grooming, toys, etc.; three-fourths spend up to $1,000 a year on veterinary bills; and 18% say their largest single pet-related expense was $2,000 or more. These costs add up to many thousands of dollars over the years, especially for long-lived pets. If the owner  dies suddenly or becomes disabled, the person who inherits the pet may not be financially prepared for ongoing care or life-saving procedures. Thirty-eight percent added the pet’s future caregiver as a beneficiary to a life insurance policy; 35% added more coverage to their life policies; and 13% purchased annuities naming the pet’s caregiver as the beneficiary. ... Continue Reading →

Greater Insurer Competition Found To Lower Health Care Premiums

Although it is “reasonable” to think that U.S. residents can save money via “more competitive health insurance markets,” there needs to be “enough competitors to reap the benefits,” according to an analysis by the New York Times.‘ The study found that among partial or federally run insurance exchanges created under the Affordable Care Act, premiums for the second-lowest cost silver exchange plan would have been 5.4% lower had UnitedHealthcare — the largest health insurer in the U.S. — sold plans through the exchanges according to a recent report that was published at ... Continue Reading →
Bernard Tyson, CEO Kaiser Permanente, Voted 2nd most influential healthcare player

9 of the 100 Most Influential People in Healthcare are Californians

Several California health experts have been named to Modern Healthcare‘s list of the top 100 most influential leaders in the health care industry. The list was compiled from more than 15,000 nominations by Modern Healthcare readers from March 17 through April 18. The final ballot consisted of the 300 candidates who received the most nominations. Readers then voted for their top five nominees, amounting to more than 31,000 ballots cast. Their votes counted for 50% of the outcome, while votes from senior editors at the publication counted toward the other 50%. Some of the California health care professionals that made the 13th annual list include: Bernard Tyson, president and CEO of Oakland-Kaiser Permanente, who ranked second and Lloyd Dean, president and CEO of San Francisco-Dignity Health, who ranked 21st according to a recent report at California Healthline. ... Continue Reading →

You Know the Drill! Our Annual Dental Survey

Welcome to California Broker’s 2014 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.  California’s top dental providers answer crucial questions about their benefits, features and services. 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, EPO, 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. 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. BRIGHTER: Brighter offers two unique dental solutions: 1) An administrative services only (ASO) solution that utilizes revolutionary technology to reduce costs for self-funded employers; and 2) a savings-only plan for employees not wishing to purchase traditional coverage. Cigna: We offer a full spectrum of dental solutions, including the Cigna Dental Care® (DHMO) plan, Cigna DPPO plan, Cigna DEPO plan, Cigna Traditional indemnity plan, and Cigna Dental Shared Administration. We also offer product features like Cigna Dental WellnessPlus®, Cigna Dental Waiver Saver®, and CignaFlex Advantage® that enhance our plans. We also offer CignaPlus Savings®, a discount dental program for retirees, part-time or seasonal employees, or anyone else not eligible for insurance coverage. All plans are available on a stand-alone basis. All plans except the discount card are also available alongside medical and/or vision plans. Cigna also has three WellnessPlus features, which can be paired with DPPO, DEPO, or dental indemnity products. Individuals who get any preventive care in one plan year qualify for increased benefits in the following plan year. All plans are available on a contributory or voluntary basis. In addition to WellnessPlus, Cigna offers Cigna Dental Waiver Saver, where customers Class 1 (preventive) services can be waived for maximums and deductibles, providing an incentive for customers to seek preventive care. Delta Dental: Managed fee-for-service, PPO, and DHMO group dental plans; individual DHMO dental plans and group HMO vision plans. Also, in response to the Affordable Care Act, Delta Dental of California and its affiliated companies now offer pediatric and adult dental benefit plans in 27 health exchanges around the country, covering more than 300,000 new enrollees since the inception of the ACA. This required us to design pediatric and family dental plans based on different sets of rules for the federal and state exchanges, for stand-alone versus bundled scenarios, and for differing market conditions. Dental Health Services: Dental Health Services offers high-quality, affordable prepaid (D-HMO) dental benefit solutions for large & small employer groups and individuals. Other plans are also available, including PPO, EPO, 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. Principal Financial Group:  We offer both 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 Dental rates and benefits do not vary based upon the size of the account. 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, both 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 of our dental plans. A child vision benefit is also standard on plans with orthodontic coverage.. 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. BRIGHTER: Our small group plans enable employees to reduce dental expenses for their families by an average of 30 – 50% without paying high dental premiums. So, in any given year they can often receive the same amount of care that they would through a large group plan, and do so at a fraction of the cost they would have otherwise paid through premiums, deductibles & co-insurances. Cigna: Dental plan designs and rates for small groups are similar to those of large groups. 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. We can custom-fit DPPO plans to offer a variety of cost-savings options for employers that want to keep claims costs low, such as missing tooth limitations, class shifting, low maximums, varying coinsurance, deductibles, waiting periods, etc. Our DHMO plans start with basic coverage, specialty discount, split copays, and other cost savings mechanisms and go up to very rich, low-copay plans at the higher end of the cost spectrum, including plans with coverage for surgical implants and related procedures. Cigna can also deliver solutions for the smaller employer segment through the Cigna Voluntary limited benefit dental plan as well as leveraging the small segment capabilities of the former Great West distribution channel. 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, plus an array of cost-reducing options.  We also offer 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 3 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. 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 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 both employers and employees. Ameritas: We are known for our flexibility and expertise in dental.  We listen to employers all over the country to learn about 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 offer a MAC reimbursement option and 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. BRIGHTER: Brighter has introduced the industry’s first Proactive Remittence Organization (PRO) which is a dental care system enabled by our cloud-based platform that streamlines the interactions amongst members, providers and payers to lower claims costs through new efficiencies in benefits payments, network fee schedules, utilization review and group plan designs. Cigna: The new Cigna Dental Care® DHMO 09 Series of patient charge schedules (PCSs) includes many features and options from which to choose. This series provides a spectrum of schedules with multiple copay structures, so we can design the plan that meets our clients’ needs.  Below is a summary of new features and enhancements that only apply to the 09 Series of schedules: • Surgical Placement of Implant Coverage – We are one of the few DHMO carriers to offer coverage for surgical placement of implants and related procedures such as sinus augmentation, bone grafting, and cone beam CT x-rays. • Same Day, In office Services – Members are able to take advantage of upgrading certain procedures which require material fabrications (veneers, crowns, inlays, onlays, and post and core) to same-day, in office service using CAD/CAM technology for a fixed copay. • Temporomandibular Joint (TMJ) Coverage – TMJ coverage is now standard on our plans and coverages, and includes an exam, diagnostic cone beam CT x-ray, and an orthotic occlusal devise to treat TMJ. • Expanded Periodontal Maintenance Coverage – We have expanded coverage for periodontal maintenance cleanings to four per year to increase our focus on prevention. Additional Application of Fluoride and Fluoride with Varnish – At a minimal copay, we now allow additional applications of fluoride for those members who may need them. Delta Dental: Most mid- to large-range plans offered by Delta Dental are customizable within basic parameters, and we incorporate changes in treatment standards and technology as they evolve. Dental Health Services: Yes. Dental Health Services’ plans are better than previous incarnations. The company frequently performs comprehensive evaluations of its plans to ensure covered benefits, monthly premium rates, and copayments for services 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, options like Guardian FreedomSM, 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 Mid Market 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. 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 have a Preventive Passport feature.  This feature allows for preventive charges to not accumulate towards 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 • 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. 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: Ameritas developed ACA-certified plans that are offered in most states. We also have developed our new Better Benefit product, through which certified pediatric dental benefits can be added to traditional dental plans. Pediatric dental claims are processed through both their traditional plan design and the ACA-certified design, and Ameritas pays the better of the two.. 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. We have also added an EPO option to our portfolio which allows for even more cost savings and offers one of the strongest networks available. BEST Life: Beginning in 2015 we will offer certified-pediatric plans that meet or exceed ACA standards to complement our product offerings. So the great Dental solutions from BEST Life continue to meet the changing needs of our groups in California. 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. BRIGHTER: Brighter has introduced the industry’s first Proactive Remittence Organization (PRO) which is a dental care system enabled by our cloud-based platform that streamlines the interactions amongst members, providers and payers to lower claims costs through new efficiencies in benefits payments, network fee schedules, utilization review and group plan designs. Cigna: Cigna Dental Oral Health Integration Program® We developed the Cigna Dental Oral Health Integration Program® in 2006 to reinforce the importance of good oral health in relation to overall health. We continue to stay abreast of new clinical research showing associations between oral health and certain medical conditions and as a result, we have enhanced the program to reflect the latest medical and dental research. The new program includes the following list of clinical conditions: • cardiovascular disease • cerebrovascular (stroke) • maternity • diabetes • chronic kidney disease • head and neck cancer radiation • organ transplants The program also provides 100 percent reimbursement of copays and coinsurance on certain dental procedures associated with treating gum disease. In April of 2014 we enhanced our customer experience with this program.  Previously, customers submitted a reimbursement form each time an eligible service was performed.  Now, customers only need to register once (for each eligible condition) and their coinsurance/copays for qualifying procedures will automatically be reimbursed within 2-3 weeks from when we receive the claim from their dentist. We have made several enhancements to our DPPO products to provide additional benefit flexibility including cost saving capabilities with our dental code classification process thru improved class shifting functionality. Delta Dental: To help make dental plan administration even easier for our network fee-for-service dentists, Delta Dental launched new online Provider Tools — a suite of helpful services that enables real-time processing of certain claims and pre-treatment estimates (those that don’t require clinical review, for example). With real-time processing, dentists and patients can see the patient’s payment portion and what Delta Dental will pay within moments. Provider Tools also gives dental offices other useful features, including a list of their Delta Dental patients and eligibility and benefits details, access to the status of submitted claims, a reference library, a list of Delta Dental’s payments and more. Provider Tools are fast, friendly, free — and an easy way to reduce paper use, too. In addition, Delta Dental recently introduced a new online health risk assessment tool that provides a structured set of questions that produces a risk assessment score that identifies specific issues related to the individual’s oral health. The tool’s risk assessment form is meant not only to inform the respondent as to likely risks of oral disease, but also to serve as a discussion piece with the individual’s dentist. The risk assessment form can be printed and shared with the patient’s dentist at their next appointment. The intent of this risk assessment tool is to inform the patient and their dentist of specific risk factors for oral disease and help guide preventive measures. 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, and members are still free to see out-of-network dentists. We also offer dental benefits through the California state exchange.  Members can easily access an electronic ID card or find a dentist near them (in English or Spanish) at or on their smart phones with GuardianAnytimeSM 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 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 have a Preventive Passport feature. Securian Dental: Enhanced benefit plans. Escalating Annual Maximum and Lifetime Deductible options where available. United Concordia: In recent years we have done the following: •Expanded our PPO network by 12,000 dentists, to create our Alliance network. ?? not exactly sure of the final #s, but something to this effect. • We re-credentialed our PPO network of dentists, and now more than 8X% accept our discounted allowances for non-covered services and services over the annual maximum.  Members can find which dentists have agreed to this cost saving measure, by looking at our website. The dentists are clearly noted. • 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. • Introduced Smile for Health – Wellness®, which offers enhanced coverage for members with diabetes and other diseases to clear away concerns they may have on the cost of treatment.  This coverage is now standard with all plans.  Smile for Health – Wellness also provides oral health education and program details for all members and targeted messaging to motivate those eligible for Smile for Health – Wellness 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. 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, 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. BRIGHTER: Yes Cigna: Insureds can use their own dentist in the DPPO and dental indemnity plans. However, there are no out-of-network benefits with DHMO, CignaPlus Savings dental discount plans (not insurance) or with DEPO. Individuals can nominate their dentist to join our plan and if the dentist wants to participate and meets our criteria, he/she will be credentialed and added to the network. Additionally, DPPO and DEPO plans may include savings on most non-covered services (in states where allowed by law). Most of our DPPO network dentists offer their negotiated contracted fees to customers and their covered dependents for most non-covered services (in states where allowed by law). And the savings also apply to covered services when an individual exceeds his or her annual maximum or other plan limitations, such as frequency, age or missing tooth. We are continuously expanding our network to meet the needs of current and potential clients. 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 (D-HMO) and EPO plans choose their dentist from the company’s exclusive Quality Assured network. Participating dentists on all prepaid (D-HMO) plan networks are subjected to credentialing, background checks and a 107-point quality checklist. They are also regularly monitored by the company’s Professional Services staff, and plan benefits are only available at these Quality Assured dentists. The company’s 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. 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 either our PPO or POS design.  If a member is enrolled in our EPO design, network dentists must be seen for services in order to receive benefits under the plan. 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 U&C, 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. BRIGHTER: Not if the dentist is participating on our platform. Cigna: 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. For services we do not cover, dentists may charge their usual fees. For certain orthodontic procedures, network dentists may charge incremental costs associated with optional/elective materials, including, but not limited to ceramic, clear, lingual brackets, or other cosmetic appliances. DEPO/DPPO. Cigna’s network dentists’ contracts include language to ensure that members are only charged in accordance with the contracted fee schedule amounts. They are prohibited from balance billing members. Network fee schedules apply for covered services even after members have reached their annual maximums or exceeded frequency limitations, or if the applicable dental plan imposes missing tooth limitations or other similar limitations. For noncovered services, members are responsible for paying the dentist’s usual fee or contracted fee for that procedure. Since the DEPO plan does not cover out-of-network services, members are responsible for the out-of-network dentist’s usual fees for any treatment received out-of-network. Out-of-network dentists may balance bill the difference between the DPPO plan’s payment and their usual charges. 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: 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 your clients’ 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. This and other proactive initiatives designed to advocate for members have resulted in Dental Health Services’ 97% retention for satisfied group clients and their members. 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 encouraged to visit in-network providers to experience lower out-of-pocket costs. In-network providers have agreed to accept the amount listed on their PPO fee schedule as payment in full, less all copayments, coinsurance, deductibles and non-covered services.  They may not balance bill for amounts that exceed their PPO fee schedule. Out-of-network members are responsible for any charges that exceed the maximum amount that Humana will reimburse for a specific service. 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. Additionally, the vast majority of our network dentists accept the contracted amount for non-covered services and any services over the annual maximum 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. BRIGHTER: We track all utilization of the plan to ensure both the members and sponsor are billed appropriately. Cigna: Balance billing for covered procedures is strictly prohibited. We counsel network dentists who do not comply. Continued balance billing may be referred to our Credentialing Committee for review of future participation in the network. Cigna monitors allegations of overcharging through enrollee feedback, surveys, and the dental network management staff. For DHMO plans, the collection of copays is between the patient and the dentist. We encourage dentists to collect copays at the time treatment is rendered. For DPPO/Indemnity plans, it is illegal in some states for dentists to routinely waive deductibles. Since our group contracts indicate that Cigna is not responsible for any charge the patient is not required to pay, we may reduce our claim payment by the copay amount waived by the dentist. Our Special Investigations Unit may also contact the dentist and the patient for further information and has the ability to review claims on an ongoing basis. 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: Dental Health Services’ Professional Services Staff regularly audits the company’s participating dentists’ charts on-site to ensure dental care and treatment provided to members meet the company’s quality standards and 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 identifies 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 adjudicate the claim based on the contracted fee schedule. Waiving co-payments does not apply under a PPO. 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 ( 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 ( 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 6/1/14: DMO over 11,000 dentist locations nationally and 98,000 in California, PPO: over 225,000 dentist locations nationally and 37,000 in California. Aflac: Aflac Dental does not have network requirements. Policyholders may visit any provider they choose. Ameritas: Ameritas/FDH Network: 79,516 California provider access points, (54,542 Ameritas; 24,974 FDH); 19,172 California locations, (12,582 Ameritas; 7,090 FDH) Anthem Blue Cross: We’ve had a lot of growth in our dental networks the last couple of years. Dental Complete members have access to more than 16,600 unique dentists and nearly 40,000 access points in California alone — and more than 96,000 unique dentists and 228,100 access points nationwide. That’s 75% more dentists nationwide than we had in 2011. Our Dental Net DHMO network includes nearly 10,000 provider locations in California to choose from.  Additionally, all Anthem dental 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. Services received through this program do not count toward the member’s annual maximum if their plan has one. 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 68,672 access points and an additional 9,593 provider locations throughout the state. Our national network has over 285,000 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. BRIGHTER: While Brighter can be used at any dentist, with discounts at over 190,000 Access Points nationwide, it currently is only available to employers with a significant portion of their employees located in Southern California as that is where we deliver the greatest savings and member experience. Cigna: Across all specialties, Cigna has over 131,300 unique DPPO dentists nationally and over 20,500 in California.  For DHMO, Cigna offers access to 19,200 offices across the country, with 5,020 DHMO offices in California. 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. Dental Health Services: Dental Health Services’ exclusive, Quality Assured dental network consists of 927 general practice offices with 4,354 participating dentists and an additional 1,924 specialists. Guardian: There are over 244,321 PPO dentist locations across the country and more than 34,882 in California. We are one of the largest PPO networks in the state based on unique dentists.  The DentalGuard Alliance PPO network has over 5,803 dentist-locations in California.   For the DHMO, there are 14,367 locations across the country and 7,093 in California.  Guardian’s PPO network now includes more than 56 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 May 2014, our California PPO network includes 40,722 access points in 11,367 locations. Our California DHMO network includes 2,382 locations. HUMANA Dental: Nationally, Humana has more than 215,000 provider locations. In California, we have approximately 30,000 provider locations. Principal Financial Group:  We have approximately 48,000 PPO provider locations and 25,700 EPO provider locations. Securian Dental: More than 190,000 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. 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 selecting a provider. Blue Shield: Yes. Dental PPO plan members have the flexibility to see in-network or non-network providers while dental INO members can only see network providers. However,  dental PPO and dental INO plan members may change providers at any time without notice; Dental HMO plan members may change their primary care dentist as needed; changes will be effective the first of the following month. BRIGHTER: Brighter members can choose the best dentist that matches their needs. Using our online dental shopping platform, members choose dentists based on location, ratings or price. Cigna: DHMO – Members may transfer to a new dental office once a month and for any reason, as long as the member has paid his/her account, in full, at the current office. Members can call our customer service department to speak with a representative, transfer using the online Dental HealthCare Professional Directory on or use our automated transfer option which can process transfers 24 hours a day. Transfers are effective the first of the following month. We suggest that members complete any dental treatment-in-progress before transferring to another dental office. DPPO — Cigna DPPO members have the freedom to visit either a network dentist or any licensed dentist at any time. However, we do recommend that they complete any treatment-in-progress and pay outstanding balances full before changing dentists. DEPO — Cigna DEPO members may seek care from any ­network dentist; however, we do recommend that they complete any treatment-in-progress and pay outstanding balances in full before changing dentists. Indemnity Cigna Traditional indemnity members have the freedom to visit any licensed dentist at any time. Delta Dental: Fee-for-service enrollees can change dentists any time without notifying us. DHMO enrollees can change their contract dentist by contacting customer service or online at Requests submitted prior to the 21st of each month are effective the first of the following month. Dental Health Services: Yes. Member satisfaction is Dental Health Services’ top priority, which is why members can change their dentist at any time by contacting their Member Service Specialist or by simply visiting the Dental Health Services website at Guardian: Members covered under Guardian’s PPO plans can change dentists at will, regardless of whether the dentists are participating or non-participating. Members covered under our DHMO plan may change dentists by using our on-line web tool,, or by calling our toll-fee number.  We also offer a dual choice monthly switch plan which enables members to switch between the DHMO and PPO as often as desired on a monthly basis. Health Net Dental: With our PPO plan design, there is no need to select a primary care dentist or to obtain referrals for specialty care. Under our DHMO plans, members may change their primary care dentists once a month by calling Health Net Dental Member Services or via our on-line Web portal. The change is effective the first of the month, provided that the request is made by the 20th of the previous month. HumanaDental: With the PPO plan design, the member can change dentists without notifying the dental plan. Principal Financial Group: Yes Securian Dental: Yes. United Concordia: Yes, members can change PPO providers at any time without notice. DHMO participants may change dentists by writing or calling our customer service department and requesting a new DHMO provider, as long as there is no existing balance due to the current dentist or treatment in progress. Western Dental: Our membership can change providers, on a monthly basis, by phone or in writing. 10. How do you ensure that your dentists are aware of the benefits of your plan(s)? Do you have a way of knowing if the dentists are soliciting or recommending services that are not compensated for by your plan? Aetna: Participating dental offices receive our helpful Dental Office Guide, which provides clear information about plan designs, policies, and procedures. We also offer a website specifically designed for dentists. The site includes real-time eligibility and benefits information, a 24/7 speech recognition system called “Aetna Voice Advantage.” Also, our dental solutions team is trained to know what is important for provider service. Unusual treatment patterns may be discovered during our review of utilization reports. This usually results in an office audit that includes a review of patient files and general office practices. We talk with the dentist about the findings and develop recommendations for improvement where needed. Aflac: Aflac has materials that may be provided to dentists with information on how to file claims and access online materials. A dedicated section on provides dentists with claim forms and instructions, as well as online access to verify policy benefit amounts. If the dentist has any additional questions, he or she may call Aflac’s Customer Service Center toll-free -1.800.99.AFLAC. Ameritas: Providers can access individual plan information using the toll-free voice response system, the fax-back system, or our online benefit Website.  We hope this educates both the provider and insured about covered benefits.  If not, periodic surveys and automated utilization review mechanisms help provide a way to monitor issues regarding plan coverage misunderstandings. Anthem Blue Cross: We inform participating dentists of plan benefits through a variety of communication vehicles. Dentists can access updated information on our Website, through our interactive voice response system, directly from our provider relations and customer service representatives, and through our provider mailings. Practice patterns of participating providers are monitored continuously and reported through monthly utilization reports and claims experience. We involve our dental director when we suspect over- or under-utilization patterns. In such cases, our dental director contacts the dentist to discuss findings along with a plan of action to help bring the practice within the standard. BEN-E-LECT: The members are given material specific to the dentist to ensure benefits are understood. BEN-E-LECT also offers extended customer service hours with a department dedicated to assisting dentists with benefits information. BEN-E-LECT also has regular outside auditors review claims for this information in addition to scrub during time of payment. BEST Life: Dentists may contact BEST Life for information about member benefits by calling 800-433-0088. All calls are answered by a live person, every time, no exception. We also have a fax back line dentists can use to obtain benefit information. Blue Shield: We strive to make it easier for dentists to participate in our network by automating as many administrative processes as possible. Because administrative capabilities vary among dental offices, multiple approaches exist to facilitate dentist communication-from web-based applications to direct telephone contact-to ensure that all offices have access to critical dentist information and support. Communication channels available 24 hours a day, seven days a week, include: • The Interactive Voice Response (IVR) system offers real-time eligibility verification and claims status inquiry. The IVR also provides fax-back capability for hard copy eligibility verification. • A website enables eligibility verification, benefit confirmation and claims status inquiry. • Electronic Claims Filing — we contract with a number of clearinghouses or trading partners to receive electronic claims submissions. • Electronic Claims Payment — The capability exists to pay our providers electronically if they so choose. Claims are paid on a daily basis (Sunday-Friday). Network dentists can control costs and increase efficiency by submitting data electronically, using our website and interactive voice response (IVR) system. BRIGHTER: Our dentists utilize our simple online platform to process interactions with our members so mistakes are minimized. This also empowers us to track all recommended treatments and proactively remove providers that are over-utilizing (recommending unecessary services) from being seen by our members. Cigna: Our Internet-based platform allows contracted dentists the ability to conduct transactions over a secure website directly linked to Cigna. This website provides one-stop online access to information that the dental offices will find helpful to manage day-to-day operations and increase operational efficiency. Our website at also provides an easy way for dental offices to access information about participating in the Cigna Dental Care or Cigna DEPO/DPPO network. The network management staff communicates regularly with dental office personnel by phone, periodic newsletters, site visits to provide information about regulations, practice management, patient satisfaction, policies, procedures, and high level news about Cigna. DHMO –The Cigna Dental Care Reference Guide, Patient Charge Schedules (PCSs) at a Glance and Specialty Referral Guidelines are provided to each network dental office on the plan. We produce a periodic newsletter to communicate information about regulations that affect dentists, nationwide and state-specific policies, procedures. This bulletin is mailed with monthly payment packages to the dental offices to which the information is applicable. DEPO/DPPO – The Cigna DPPO Office Reference Guide and fee schedules are provided to each network dental office on the plan. These documents describe the policies and procedures to administer the plan, assist members; contracted fee schedules for the dental office and the advantage of participating in the Cigna DEPO/DPPO network. In addition to the savings generated by our thorough and efficient claims and treatment plan review process, another key aspect of the utilization management program is the analysis of network dentist practice patterns (dentist profiling). Our utilization database containing millions of claims and encounters from more than 140,000 dentists across the country provides us with a comprehensive and statistically sound basis for establishing utilization norms. DHMO – When a dentist submits an encounter form, we enter and store in our database. We generate a statistical report monthly for each network dental office. This report provides a means to systematically evaluate each facility by presenting a clear profile of our dentists’ practice patterns. The report also includes state and regional normative data to facilitate the identification of outliers for each listed category, as well as the development of appropriate follow-up action plans. Based on the evaluation of the outliers by our dental directors, we initiate corrective action activity. If unacceptable practice patterns continue, we may end the network dental office contract. DPPO/DEPO – Cigna Dental uses our provider profiling application as part of our utilization review program. The application uses claims data to generate a report showing the practice profile for a given provider that can be compared with the average practice profile of his or her peers. The profiling report provides details on the following types of practice patterns: The database for any given period compares a single dental office with submitted procedures of over 400 American Dental Association (ADA) codes, with a frequency total of tens of millions of procedures. action. Through our utilization review and dentist profiling efforts, as part of our overall utilization management program, Cigna has been able to ensure network dentists provide adequate and appropriate care. Plus, we have saved our clients billions in the process. . Delta Dental: Detailed program information for all enrollees, including maximums, deductible and benefit levels, is available through a secure area of our website and through a toll-free telephone number. Additionally, Delta Dental issues a bimonthly newsletter to network dental offices, which covers Delta Dental policy, industry news, seminars, new Delta Dental clients, tips on submitting claims and other useful information. We issue a quarterly quality-related newsletter to participating dentists that provides useful information to help improve the quality and efficiency of the care they provide. In addition, Delta Dental holds regular seminars to keep dentists up to date. Regular enrollee surveys seek information on various quality issues, such as services rendered that are not covered by the program; services delivered as claimed; office cleanliness and appearance; and customer service. Dental Health Services: Dental Health Services regularly provides on-site training, auditing, and service visits for the company’s participating prepaid (D-HMO) dentists. Additionally, each dental office receives a manual that contains comprehensive information about Dental Health Services’ dental benefit plans. The company monitors all services and treatment received by its members through monthly utilization reports. Guardian: Dentists can access plan benefits online at or through their practice management system. All PPO dentists receive information about Guardian’s plans through local network recruiters as well as email newsletters or mailings of pertinent information. Our claim system tracks and monitors each dentist’s practice patterns for bundling, over-utilization, etc.  We consult with dentists who are not meeting our expectations, and if they are unable to do so, we may discontinue their network participation. All offices that join our DHMO network receive an orientation that fully explains the plan.  Additionally, our DHMO Regional Network Managers periodically visit the offices to review the plan.  Dental Offices submit encounter data of services provided to DHMO members which is reviewed quarterly by our Quality Assurance Committee. Health Net Dental:  We educate our providers about our administrative policies, including guidelines on appropriate care. Providers are encouraged to submit pre-treatment plans for review in order to learn what procedures would be covered under the member’s benefit plan and the level of reimbursement. In the process of reviewing pre-treatment estimates and in completed claims, we track and monitor each provider’s practice patterns. Providers with aberrant patterns receive focused review, including statistical analysis and record audits, which may result in appropriate corrective action plans. Our Professional Network Relations Reps meet with providers to counsel them and to answer any questions about planning care for members. Our Internet portals provide real-time information to providers and members on their benefits. HumanaDental: HumanaDental notifies dentists, according to their contract, of any new product 45 days in advance of introduction. Providers are encouraged to check eligibility and benefits prior to treatment. Through monitoring of member communications and through utilization review, we would become aware of any situation where a dentist may be recommending non-covered procedures on a routine basis. Principal Financial Group:  We provide online, telephone and fax service options for providers to verify benefits and eligibility.  We encourage pre-determinations to be performed for inlays, onlays, single crowns, prosthetics, periodontics and oral surgery. Securian Dental: Dentists can verify benefits by calling our toll-free customer service phone number or via our Web site. United Concordia: Dental offices can confirm benefit coverage information on our website via “My Patients’ Benefits,” through our telephone interactive voice response (IVR) system, or by speaking to a customer service representative. In some instances, we also inform dentists of important benefit changes through written communications, via our quarterly newsletter, through a stuffer included with dentist checks and/or with an automated telephone call. Dentists can also reference benefit information using our Dentist Reference Guide, available on our website. Professional relations representatives are also available to provide assistance when necessary. We identify abnormal practice patterns through a comprehensive quality assurance process. United Concordia reviews thousands of claims each year to ensure the acceptability of treatment and quality of services. Advisors and consultants also review dentists’ fees and practice patterns. Dentists who fall outside of the norm are targeted for education and additional monitoring. Western Dental: Each provider is trained and given training materials to ensure that they are knowledgeable about Western Dental programs. Western Dental Services also monitors customer service inquiries and grievances in addition to reviewing utilization data supplied by each provider.   11. How many provider offices have you lost over the past year? If asked, will you provide the names and phone numbers of at least three of these offices? Aetna: In 2013, we lost 1.9% or providers in our DMO network and 1% in our PPO network. This is the voluntary termination rate. We are not at liberty to provide specific dentist information, such as names and phone numbers. Aflac: Aflac Dental has no provider networks. Policyholders have the freedom to choose any dentist without restriction. Ameritas PPO: 12,171 provider access points were lost (Ameritas = 3,808, FDH = 8,363). Yes, we would provide names, if requested. Anthem Blue Cross: In the past 12 months, our Dental Prime and Dental Complete networks have grown significantly and less than 1 percent of dentists have terminated participation (primarily through retirement or death). Anthem does not make it a practice to provide names and phone numbers of dental offices that have left the network. BEN-E-LECT: For all plans combined, the turnover is less than 2%. Many offices have been terminated due to lack of meeting credentialing standards, retirement or death of the provider. BEN-E-LECT does maintain the information for these offices; however it is not common practice to release the information. BEST Life: (First Dental Health (FDH) and DenteMax: We have no control of this number. However, our provider locations have actually increased a total of 11,398 locations in the past 12 months. Less than 2.5% of providers have left our PPO networks in the past 12 months. The majority of these terminations are due to a provider’s retirement, death or the moving or closing of a practice. We maintain a clean and thorough network that involves regular network clean-ups. For the sake of privacy, our network does not share such information for the purpose of a general interview. Our networks also focus on growth. Our national network has added 249 access points in California in May 2014. Blue Shield: Dental PPO: For 2012, the voluntary turnover rate (excluding deaths, retirements and practice relocations) was less than 1%. Dental HMO: For 2012, the voluntary turnover rate (excluding deaths, retirements and proactive relocations) was 2%. If requested, Blue Shield can provide the names and phone numbers of at least 3 offices that have left our network within the past 12 months. BRIGHTER: Brighter maintains a high retention rate of 97% annually. Cigna: Cigna’s dental network turnover rates have been lower than published industry average data. Dentist and dental office information can be shared with clients and brokers if required. Delta Dental: Nationally, the dentist locations for our Delta Dental Premier network increased by 10.7%; our Delta Dental PPO network increased by 14.35%; and our DHMO network increased by 9.69% general dentist facilities. In California, there were 270 Premier terminations and 311 PPO terminations. Delta Dental does not release specific information on its contracted dentists. Dental Health Services: Although roughly 5% of participating dentists have been lost over the past 12 months, our overall network size has made up for this and has increased by 5% over the previous year through a focus on seeking out only the most qualified dentists while improving accessibility and availability. The names and phone numbers of all offices are available on request. Guardian: Guardian has a 97% network retention rate. Health Net Dental: In 2013, our DHMO turnover rate for voluntary terms was 0.67% and our PPO turnover rate was 0.25%. We do not release specific information on our contracted dentists. HumanaDental: In the past 12 months, there were 97 providers termed in California, including 5 due to not meeting our credentialing requirements. We do not provide the names and phone numbers of termed offices. Principal Financial Group: Less than 5%. Securian Dental: Very few providers choose to leave the DenteMax network. Less than 3 percent of our network dentists discontinue participation with DenteMax every year. The majority of these terminations are due to a provider’s retirement or death or the moving or closing of a practice. We would be willing to provide names and phone numbers of terminated offices upon request. United Concordia: In California, we grew our PPO network from 15,800 individual dentists and 37,833 access points to 16,240 dentists and 41,168 access points. In addition, our DHMO network of primary dental offices remains consistent with just over 1,652 primary dental offices. Yes, if requested, we can provide the names and phone numbers of dental offices that no longer participate in our network. Western Dental: Turnover is about 3% for the past year. Yes, we will provide the names and phone numbers for 3 of these offices, if requested. 12.What percentage of your network is closed to new enrollment? How many offices does this represent? Aetna: For California, approximately 4% of our DMO participating providers are closed to new patients. All of our PPO providers are open to new patients. Aflac: Aflac Dental has no provider networks. Policyholders may visit any dentist they choose. Ameritas PPO: Only 106 Ameritas Offices and 26 FDH Offices are closed to new enrollment. This represents approximately 0.2%. Anthem Blue Cross: Our Dental Prime and Dental Complete network model is open-access, and we do not contractually require providers to report on new-patient status. We have not heard reports of any members having issues with finding a participating dentist that is open to new patients. BEN-E-LECT: All of BEN-E-LECT’s dental PPO providers are accepting new patients. For the DHMO product, less than 3% of the offices are closed to new enrollment representing approximately 60 offices. BEST Life: All participating PPO dentists are accepting new patients. Blue Shield: In 2012, less than 1% of dental HMO plan network providers maintained closed practices; this represents approximately 30 offices. BRIGHTER: All Brighter dentists are accepting new patients. Cigna: DHMO — Our systems include data on dentist capacity and current and projected Cigna Dental Care member loads. Network managers regularly monitor capacity and projected growth. They contact dentists as necessary to discuss capacity expansion through staff increases or office hour changes. If these actions are not feasible, we will consider adding more dental offices. Nationwide, approximately 8 percent of the Cigna Dental Care network dental offices are closed or capped to new members. DPPO/DEPO — Network dentists do not cap or close their offices. Members are not required to select a primary network dental office Delta Dental: 0%. Under the PPO/Premier plans, enrollees are free to see any licensed dentist. Contracted dentists can close their practices to new patients but cannot close their practice exclusively to new Delta Dental patients; 2.92% DHMO dental facilities are closed to new enrollment. Dental Health Services: About 8% of network general practice dentists are closed to new enrollment (63 offices). No specialty offices are closed to new members. Guardian: In California, only 0.4% of our PPO network and 5.7% of our DHMO network is closed to new patients. Health Net Dental: As of April 2013, for DHMO, currently 3% of our General Dentist unique locations are closed to new enrollment. For PPO, currently 0.8% of our dentists’ offices are closed to new enrollment. HumanaDental: Under HumanaDental’s provider contract, participating dentists have payer differentials. Because this is a fee-for-service reimbursement program, closed practices are not common. Principal Financial Group: Less than 1% of the offices participating in our network are  closed  to new enrollment. Securian Dental: All of our network dentists are open to new enrollment. United Concordia: In California, more than 99% of our PPO dentist network is open to new enrollment, as well as more than 95% of our DHMO dentist network. Western Dental: Less than 3% of our network providers are closed to new enrollments – about 60 offices. 13. Do all of your contracted offices accept every benefit level sold by your company or do they have the option to pick and choose only the programs with co-payments they want to accept? Aetna: For California, approximately 4% of our DMO participating providersare closed to new patients. All of our PPO providers are open to new patients. Aflac: Aflac Dental has no provider networks. Ameritas: All providers accept patients from all plans sold through Ameritas Group Dental. Anthem Blue Cross: Anthem Blue Cross recommends all participating providers accept all plans offered. Providers cannot cherry pick DHMO plans, they either accept all DHMO plans under the specific contract, or they do not contract. Providers can choose to participate with Dental Prime and Dental Complete, or Dental Complete only; however as for plan or benefit designs under each product, providers cannot cherry pick which PPO design they will accept. BEN-E-LECT: All benefit levels are accepted and to date no offices have limited or requested to limit the programs they will accept. BEST Life: All contracted offices accept every benefit level. Furthermore, by contract, all providers will honor the PPO discounts on all procedures, including non-covered services. They must also honor a discount for members who are within a waiting period or who have exceeded their annual maximum. Blue Shield: Offices are not allowed to  pick and choose  which plan designs they accept. BRIGHTER: All contracted offices must participate in each benefit level we sell. Cigna: All contracted DPPO offices accept all of the insured benefit DPPO plan designs that we offer. All contracted DHMO offices accept all of the DHMO plan designs that we offer. For our discount dental programs, not all DPPO contracted dentists are required to participate. They may opt out of participation in these discount dental programs if they desire. Delta Dental: Delta Dental holds contracts with individual dentists for participation with each network (Premier, PPO and DeltaCare USA [DHMO]). Dentists can choose to participate only in those programs with copayments they wish to accept. Dental Health Services: All new dentists are contracted for all plans offered by Dental Health Services. Guardian: All contracted PPO and CA DHMO offices accept all of the plan designs that we offer. Health Net Dental: All participating PPO dentists accept all of our plan designs. Contracted DHMO providers accept all Health Net Dental DHMO plans. HumanaDental: The PPO contract is for all network-based programs, excluding DHMO, which requires a separate agreement. Dentists can opt-out of participation in the Medicare and Access (discount) programs, which are a subset of the PPO. Principal Financial Group: Providers can choose to participate in our PPO and/or EPO networks. Within each option, providers need to accept all benefit levels sold by our company. Securian Dental: Yes, they accept every benefit level sold by our company. United Concordia: All contracted PPO dentists accept all United Concordia PPO plans. All contracted DHMO dentists accept all United Concordia DHMO plans. Western Dental: The entire network accepts all of the new Series 7 plans. 14. Do you have a way to monitor the length of time patients have to wait in the doctor’s office? Aetna: We do not monitor average wait times in a dentist’s office. Aflac:  Since policyholders can choose any dentist without restriction, Aflac does not monitor wait times. Ameritas: We monitor patient wait time through random customer and patient surveys. Providers are contacted, if necessary, to discuss specific feedback. Anthem Blue Cross: Yes, we monitor this as a metric in our member satisfaction surveys. Through our complaint/grievance tracking processes, issues such as wait times are logged and monitored. Additionally, we monitor appointment wait times and emergency wait times through surveys conducted by our organization. BEN-E-LECT: This information is tracked closely for Freedom Pre-Paid Dental Plans. Surveys and questionnaires for the PPO products track this information. BEST Life: Network accessibility and wait times are included as part of the credentialing and ongoing monitoring processes. Blue Shield: Yes. We monitor and track wait times several ways. We document member complaints on this issue in our customer service workbench and track them electronically until they are resolved. We also conduct an annual member satisfaction survey, which contains specific questions about wait times with our network offices. BRIGHTER: Yes. Additionally, Brighter maintains an unprecedented high level of member satisfaction through an exceptional member service team that follows up with each patient to ensure their experience at the Brighter dentist met their expectations. Brighter backs this up with a satisfaction guarantee. Cigna: The dental network management team monitors wait times in our DHMO general dentist facilities via monthly telephone calls. Additionally, we are able to identify lengthy wait times through our patient satisfaction surveys.We investigate inquiries about excessive wait time and take corrective action if we determine that timely and efficient dental care was available, but not provided. If we determine that excessive wait time was the result of insufficient patient capacity, we initiate actions to expand the dentist’s capacity or recruit additional dentists in that particular area. Delta Dental: Delta Dental conducts random enrollee surveys semi-annually for the fee-for-service enrollees and annually for DHMO enrollees. Surveys include questions about dentist access (for example, number of dentists from which to choose and appointment availability with their dentist) as well as other customer satisfaction issues. For the DHMO, the appointment availability is also monitored via regular office visits from a Delta Dental representative. Dental Health Services: Yes, we monitor our members’ experiences through frequent member surveys, regular on-site dental office visits and quarterly access surveys. Guardian: We send monthly member satisfaction surveys, which include questions concerning wait times, to randomly chosen PPO members who have been to a network dentist within the previous 90 days. The DHMO has established access standards and monitors this quarterly through access monitoring forms, member satisfaction surveys, and transfer and grievance data.  Telephone calls are utilized on an  as-needed  basis. Health Net Dental: We monitor individual wait times in the dentist’s waiting room through our member satisfaction surveys and provider access surveys. Results of these surveys are a critical tool in assessing a member’s experience with network dentists and their specific offices. In addition, we receive feedback on office wait times from members calling our toll-free Health Net Dental Member Services number. HumanaDental: We rely on member calls to keep us apprised of scheduling issues. Sometimes, the member is limiting their options (i.e., after 5 p.m.), which is discovered through discussion with our customer-relations representatives. If the issue becomes chronic, the information is forwarded to our National Dental Network department because additional providers may be needed in the area. Principal Financial Group: We do not monitor this. Securian Dental: We do not monitor this. United Concordia: Yes, it is monitored through member surveys, a customer service grievance process and periodic phone and written survey audits of the offices. Western Dental: Western Dental monitors patient’s length of time by onsite reviews, surveys, and questionnaires. In addition, our staff model offices use the Quality Assurance Management System. The state-of-the-art, proprietary software tool tracks measurable items, such as wait times, which ensures that our members have timely access to quality dental care. 15. Are there plenty of providers who stay open late and are open on Saturdays? Aetna: Office hours are set by each individual dental office. We document dentists’ office hours as part of the credentialing process. We use the information to balance networks by contracting with dentists who offer weekend and evening hours. Aflac: Aflac Dental does not have a network of providers. Policyholders may visit any dentist they choose, which includes those with extended hours. Ameritas PPO: Yes, each office sets its own hours. Those hours are available to all our members on our on-line provider listings. Our goal is to balance care availability throughout the area to ensure needed care. Anthem Blue Cross: Each dental office sets its own office hours. However, as part of the credentialing process, we document dentists’ office hours and use the information to ensure our networks include dentists who offer weekend and evening hours. BEN-E-LECT: Yes, many of BEN-E-LECT’s provider offices offer extended evening and early morning hours in addition to weekend hours for ease of access. BEST Life: Yes, many providers have extended and flexible hours. Blue Shield: This varies by provider, but many do stay open late and/or are open on Saturdays. BRIGHTER: Yes, Brighter’s provider network includes practices that are open late and/or on the weekend. Cigna: DHMO — There are 3,405 network offices (24 percent of the total DHMO network) offering Saturday office hours, and 5,353 network offices (38 percent of the total DHMO network) offering evening hours (6:00 p.m. or later). DEPO/DPPO — Members are able to visit any licensed dentist for care; therefore, we do not measure evening or weekend hours for DPPO network dentists. Additionally, our dentist contracts require dentists to provide or arrange for emergency care 24 hours a day, 7 days a week and to provide emergency appointments within 24 hours. Delta Dental: Our online dentist directory contains information on hours and access, including maps, directions and languages spoken. In addition to posting hours and access, DHMO network dentists are required to provide 24-hour emergency service to enrollees seven days a week. Guardian: Many PPO and DHMO provider locations have extended or weekend hours. Health Net Dental: The office hours of each dentist location is listed in our online provider directory. This information is also available to all members through Health Net Dental Member Services. As part of our dentist agreement, all locations are required to have an emergency contact available for members whenever the dental office is closed. HumanaDental: Members can see the provider of their choice and they are encouraged to contact their dentist for appointment availability. Based on today’s busy lifestyles, many providers are extending their hours to meet the needs of their patients. Principal Financial Group: Members can see any provider of their choice, which can include those who have extended hours. United Concordia: Yes. Western Dental: Yes, many of our IPA providers have evening and Saturday hours. The Western Dental Staff Model Offices are open from 9:00 AM to 8:00 PM, Monday through, Friday and 8:00 AM to 4:00 PM on Saturdays. 16. With respect to your mid-range benefit level, what is the specific amount of capitation paid to the general dentist? Do you offer validation for these amounts? Aetna: We establish varying compensation rates under each customer’s benefits plan for subscribers, spouses, and children. Monthly compensation rates are based on community averages and plan design. Actual capitation amounts are proprietary. Aflac: Aflac Dental does not offer capitation plans. Ameritas PPO and the FDH Networks: Neither of these networks is used for dental HMO purposes, so no capitation is paid. BEN-E-LECT: This is not applicable for BEN-E-LECT’s PPO plans. All dentist capitation has been added to the dentist premium amounts collected for the DHMO products. BEST Life: We do not compensate our providers through capitation. Our Indemnity and PPO plans allow patients to utilize providers of their choice. Blue Shield: This information is considered proprietary. BRIGHTER: N/A Cigna: Network general dentists’ payment consists of the following four components: fixed monthly payments (capitation), patient charges (copays), office visit payments, and supplemental payments for certain covered procedures. Network specialists are paid based on a fixed fee schedule. Delta Dental: Capitation rates are developed based on the plan design, annual utilization data, enrollee/dependent mix and employer contribution. Compensation is designed to reimburse approximately 60% to 65% of usual fees. Dental Health Services: Dental Health Services’ compensation system involves many more components than capitation and is designed to keep the participating dentists whole while providing incentives for appropriate treatment and care. Guardian: DHMO capitation amounts paid to the general dentist vary based on plan design, adult or child, and region. Health Net Dental: Capitation information is proprietary. HumanaDental: Managed dental care capitation varies by plan schedule and geographic location. Principal Financial Group: N/A Securian Dental: We do not offer capitation plans. We offer PPO and Indemnity plans. United Concordia: Specific capitation amounts are considered proprietary information. United Concordia also compensates participating DHMO providers with supplemental payments on over 80 procedures. The supplemental compensation not only provides incentives for participating dentists to appoint patients and render necessary care but also provides a mechanism for the dentists to report utilization and thus allowing United Concordia to report DHMO utilization to our customers. Western Dental: Series 7 plans reimburse providers with capitation and supplemental payments. Total compensation, as with fee-for-service designs, depends on how much treatment is provided. 17. Are there incentives for the provider to be thorough? Aetna: Quality management programs are designed to help protect members and providers. Aflac: It is expected that the dentists selected by the policyholders treat their patients with the utmost respect and provide the highest standards of quality care without requiring incentives to do so. If the policyholders are unhappy with the service received, they may change dentists at any time. Ameritas PPO: Provider thoroughness is an expectation; we do not offer an incentive for this. We do, however, monitor patient care through quarterly utilization review. If standards are not met, it could result in the provider’s termination from the network. Anthem Blue Cross: We do not offer incentive programs to dentists because we expect quality of care with or without incentives. BEN-E-LECT: Yes. BEN-E-LECT may offer bonuses to providers who exceed quality of services and accessibility standards. BEST Life: Our networks administer comprehensive utilizations reviews for dental necessity and appropriateness of care. Blue Shield: We expect all network dentists to provide our members with high-quality, thorough care; we continuously measure appropriateness of care through numerous oversight methods. While routine treatment plans are carried out by dentists without prospective review, more complicated treatments are evaluated by our dental consultants who assess the proposed treatment(s) for appropriateness and benefit determination. All dentists involved in our review process are fully licensed. Our clinicians are also actively involved in the annual review of dentist records. These quality-of-care audits involve the use of comprehensive guidelines established by the American Academy of Dental Group Practice, the California Dental Association, and the American Dental Association (through the University of North Carolina School of Dentistry). A random sample of each dentist’s records is selected for scrutiny by our dental consultants. Recommendations are made to any dentists who do not meet our quality standards, and follow-up audits are conducted to verify corrective action has been taken. BRIGHTER: All Brighter members have the ability to rate their experience with a Brighter dentist. Poor ratings will impact their visibility on Brighter’s online shopping platform and, ultimately, ability to attract new patients. Cigna: Our Integrated Quality Management Program drives overall quality across our all of our dental networks. While we do not provide incentives as part of our Quality Management Program, the expectation is that the dentists in our networks meet professionally recognized standards of care. DHMO — Incentives play an important role at increasing participation. Payment for network dental offices is made up of four elements: fixed monthly payments, office visit payments, supplemental payments from Cigna, and patient payments made directly from the member to the dentist. This model is designed to encourage preventive dentistry and to protect the dental office from over-utilization. When these standard forms of payment do not satisfy a quality dentist, Cigna will work with the dentist to achieve the best outcome. Cigna’s network general dentists are able to earn bonus payments when they meet performance goals set for preventive care, specialty procedures and patient satisfaction through the DHMO pay for performance rewards program. DEPO/DPPO — Network dentists are paid based on discounted fee schedules that vary by 3-digit zip code. Our discounted schedules encourage preventive dentistry by offering more aggressive payment on preventive services while holding deeper discounts on Class II and Class III procedures. For noncovered services, members are responsible for payment of the dentist’s usual fee for that procedure. Delta Dental: Delta Dental does not pay any special incentives. We expect all credentialed network dentists to provide high-quality care within professionally accepted standards and to maintain the dental health of enrollees, with the intention to reduce the need for more invasive care later. Dentists who provide quality care and service retain their assigned enrollees, and as a result, gain enrollment and greater overall compensation. Dental Health Services: As a prepaid dental plan, Dental Health Services provides plans designed to remove the incentive for dentists to over treat, by using a different reimbursement structure. Through a combination of guaranteed monthly capitation payments, selected supplemental payments and reasonable patient copayments, dentists are rewarded for bringing patients to a state of optimum oral health and then maintaining this state. Dentists are required to submit encounter (utilization) data to the plan so that the services performed can be monitored and compared to expected parameters, resulting in the same monitoring ability as claims-based dental programs, while leaving very few actual submitted claim forms. (Specialty claims and claims for out-of-network emergency care being the common exceptions.) Guardian: Our PPO fee schedules and plan provisions encourage proper care. Guardian requires participating dentists to treat PPO members the same as any other patients and we investigate all quality of care complaints from members. Our DHMO reimbursement schedules, capitation payments, office visit fees, supplemental payments, and chair-hour guarantees encourage appropriate care. Participating dentists treat DHMO members the same as any other patient, and we have a grievance process in place to follow up on all quality of care complaints from members. Health Net Dental: We do not offer financial incentives to our dentists. Our expectation is that our dentists perform in accordance with high professional standards without incentives. Our extensive credentialing process ensures that our contracting dentists are of the highest caliber. HumanaDental: Fee-for-service reimbursement encourages thorough treatment. Member complaints are reviewed by our Quality Assurance Department and through our standard grievance process. Principal Financial Group: Being thorough is an expectation and we do not provide incentives to meet expectations. All providers in our networks must meet strict credentialing requirements. This means they have all been independently reviewed and found to have proper professional credentials and a verified history of responsible billings. However, a member is free to choose any provider. Securian Dental: All DenteMax dentists undergo a rigorous credentialing process to ensure the highest quality dentists are treating our members. United Concordia: Our expectation is that all services performed by participating dentists will meet the high standards of the dental industry. In addition, participating DHMO primary dentists get supplemental reimbursement on the most highly utilized procedures in addition to monthly capitation and member co-payments, which encourage dentists to provide the services necessary to ensure the oral health of members. Participating providers are routinely evaluated through utilization analysis and onsite quality assurance assessments. Western Dental: Western Dental Services Inc. may pay the dentist a bonus based on exceeding standards specified by Western Dental with regard to accessibility of services and quality of care.   18. Do you provide coverage for all types of specialist referrals? Aflac: The Aflac Group Dental plan does not require referrals. Assurant Dental Network: Yes. Ameritas PPO and the FDH Networks: Yes, specialty coverage can be a part of any Ameritas plan design. Our networks comprise a full spectrum of specialists to cover the needs of our customers. Aetna: Yes Anthem Blue Cross: Yes, specialist care is available for both our Dental PPO and DHMO plans. No referrals are required on our Dental PPO plans, including Dental Prime and Dental Complete. On our DHMO plans, the member’s general dentist can refer them to a specialist when needed. BEN-E-LECT: Specialist referrals are not necessary. Coverage is available for all types of specialty procedures including, but not limited to, endodontic, periodontic, cosmetic, orthodontics, oral surgery and pedodontics. BEST Life: Yes, specialists are covered at full contract benefits as describe in our Indemnity and PPO plan certificates of insurance. Our orthodontic plan is available for all of our PPO and Indemnity plans either at a deductible or lifetime maximum. Blue Shield: Specialist care is available for all dental plans. Dental PPO/INO plan members may self-refer to any specialist, although INO members can only see network providers. For dental HMO plan members, the primary care dentist is responsible for referring the member to a participating specialist; however, there is no coverage for prosthodontic specialists. BRIGHTER: Yes and Brighter features a provider network with specialists in all areas of dental. Cigna: DHMO – Network general dentists initiate patient referrals for endodontic, oral surgery, and periodontal treatment. Referrals are valid for 90 days from the approval date. Specialty referrals are not required for orthodontic treatment, if covered on their plan design or for pediatric care for children up to age seven as long as individuals visit network specialists. The network dentist may submit a request for pre-authorization to Cigna Dental for oral surgery, endodontic and periodontal services. Individuals are responsible for the applicable patient charges listed on the Patient Charge Schedule for all covered procedures. After specialty treatment is complete, the individual should return to the network general dentist for care. If it is determined that a network specialist is not available, the general dentist will refer the patient to a non-network specialist and the patient will only be responsible for charges listed on the Patient Charge Schedule. DPPO –There is no need for a referral by a primary care dentist to obtain services from a specialist with the Cigna Dental PPO plan. Members may choose to seek service from any in- or out-of-network specialist or general dentist at any time. Of course, network dentists have agreed to our reduced fee schedules, which lower out-of-pocket expenses. DEPO –There is no need for a referral by a primary care dentist to obtain services from a specialist with the Cigna Dental EPO plan. Members can visit any network specialist or general dentist at any time to receive coverage. INDEMNITY – Cigna Traditional indemnity members are always free to seek care from any licensed dentist at any time. Delta Dental: Fee-for-service enrollees can self-refer; referral by the general dentist isn’t required. For DHMO enrollees, the primary care dentist is responsible for submitting the predetermination request and directing the enrollee to the appropriate specialist once authorization is received. Dental Health Services: Yes. Dental Health Services’ plans provide specialty coverage for endodontics, periodontics, oral surgery, pedodontics, and orthodontics. Guardian: We provide coverage for all types of dental specialists. Health Net Dental: Health Net Dental DHMO plans cover a wide range of specialty care, including endodontics, periodontics, oral surgery, pedodontics and orthodontics. If the procedure is covered under the plan, the member must first see general dentist for a specialty care referral to a general dentist HumanaDental: HumanaDental provides coverage for specialist referrals; members are encouraged to refer to their certificate of coverage to confirm the service being sought is a covered benefit under their plan. Humana- Dental encourages members to check if the specialist referred by their dental provider is in-network. Humana has a provider directory available on our website, Members can also call the customer service number on the back of their insurance card. Members should request a pre-treatment estimate from the provider. Principal Financial Group: Generally yes. Securian Dental: Our plans do not require referrals. We provide coverage based on plan benefits. United Concordia: Our PPO plans do not require specialist referrals. Our DHMO plans require referrals from the general dentist office for specialty coverage for endodontics, periodontics, pedodontics, oral surgery and orthodontics. However, the DHMO referral process is open, in that there is no requirement for United Concordia to pre-authorize the referrals. The services provided by specialists that are considered for benefit reimbursement are limited to the specifics of the dental contract for each covered member. Western Dental: Specialty coverage is available in all of our group plans. Oral surgery, periodontics, endodontics, pedodontics, and orthodontics are covered specialties. 19. If covered, explain the process that allows the general dentist to refer to the specialist. Aetna: For DMO plans, general practitioners can refer to a participating specialist directly based on published guidelines. DMO members have direct access to participating orthodontists and do not need a specialty referral. Indemnity and PPO plans have direct access for specialty services. Aflac: The Aflac Group Dental plan does not require referrals. Ameritas PPO and the FDH Networks: Specialist referrals are allowed at any time from our general dentists. There is no gate-keeper involved in this process. Anthem Blue Cross: With our Dental Prime and Dental Complete plans, we do not require referrals. For the Dental Net DHMO, referrals that do not include high-risk procedures are reviewed post-treatment. Using the direct referral program, the participating general dentist can refer a patient to a specialist without prior authorization. Dentists’ practice patterns are reviewed to help ensure that they share in our commitment to providing access to effective healthcare. For the Dental Net DHMO products, the member’s assigned general dentist can call the customer service hotline in an emergency to get an immediate authorization for emergency services. Assurant Dental Network: The member does need a referral from the dentist. They may self-refer to a specialist. BEN-E-LECT: Referral is not necessary for any of BEN-E-LECT’s plans. The member may select a specialist and schedule an appointment upon making a phone call or personal visit. BEST Life: No referral is necessary. Insureds can visit a specialist at any time. Blue Shield: For DHMO plan members, the general dentist completes a specialty care referral form and provides a copy to the member, who provides the form to the participating specialist at the time of the appointment. Dental PPO plan members may self-refer to a specialist. BRIGHTER: There is no formal referral process with Brighter. Members are free to choose their dentist or specialist using our online platform. Cigna: DHMO – Network general dentists initiate patient referrals for endodontic, oral surgery, and periodontal treatment. Referrals are confirmed for 90 days from the approval date. Specialty referrals are not required for orthodontic treatment or pediatric care for children up to seven years old, as long as members visit network specialists. The network dentist may submit a request for preauthorization to Cigna for oral surgery, endodontic and periodontal services. Members are responsible for the applicable patient charges listed on the patient charge schedule (PCS) for covered procedures. After specialty treatment is finished, the member should return to the network general dentist for care. If a network specialist is not available, the general dentist will refer the member to an out-of-network specialist, and the member will only be responsible for charges listed on the PCS; however, Cigna Dental Care (DHMO) network general dentists render the range of services that are required for graduation from dental school, including diagnostic treatment, preventive treatment, operative dentistry, crown and bridge, partial and complete dentures, root canal therapy, minor oral surgery, preliminary periodontal therapy, and pediatric dentistry. DPPO – There is no need for a referral by a primary care dentist to obtain services from a specialist with the Cigna DPPO plan. Members may choose to seek service from any in- or out-of-network specialist or general dentist at any time. Of course, network dentists have agreed to our reduced fee schedules, which lower out-of-pocket expenses. DEPO – There is no need for a referral by a primary care dentist to obtain services from a specialist with the Cigna DEPO plan. Members can visit any network specialist or general dentist at any time to receive coverage. INDEMNITY – Cigna Traditional indemnity members are always free to seek care from any licensed dentist at any time. Delta Dental: Fee-for-service enrollees can self-refer; referral by the general dentist isn’t required. For DHMO enrollees, the primary care dentist is responsible for submitting the predetermination request and directing the enrollee to the appropriate specialist once authorization is received. Dental Health Services: The participating general dental office sends Dental Health Services a specialist referral authorization. Upon approval, the authorization is sent back to the general dentist who informs the patient that they are now eligible to get appropriate care from a specialist. Guardian: For the DHMO plan, any complex treatment requiring the skills of a dental specialist may be referred to a participating specialist dentist. Our DHMO plans offer direct referral in which the member may be referred directly by their primary care dentist to a participating specialist without pre-authorization. Health Net Dental: For DHMO plans that require pre-authorization, the contracting primary care dentist completes a specialty referral form and submits to Health Net Dental. Approvals are returned to the primary care dentist, member and specialist. Upon receiving the approval, the member contacts the specialty office to schedule an appointment for completion of treatment. For plans that have direct referral, the primary care dentist may directly refer the member to a participating specialist by visiting our website or by contacting our customer service. Our PPO dental plans allow self-referrals to participating or non-participating specialists as needed. HumanaDental: General dentists are encouraged to refer members to participating specialists to provide the highest level of benefit to the member. The general dentist can refer out-of-network if there are no specialists within a reasonable distance. Principal Financial Group: Patients can choose any provider in the network; referrals are not required. Securian Dental: No referral is required. United Concordia: If a general dentist determines that a patient requires referral to a specialist, all care must be coordinated through the primary dental office. The primary dental office should refer the patient to a participating specialist located in our Concordia Plus Specialist Directory and also complete the specialty care referral Form. The patient should be given a copy of the referral form to give to the specialist at the time of their appointment. The specialist will then be responsible to submit the claim, corresponding documentation and referral form to United Concordia for reimbursement. There is no requirement for United Concordia to pre-authorize the referral, thus providing better access to care when it is needed. Western Dental: Once the general dentist determines that the necessary procedure is out of his or her scope of practice, the office will submit a written referral request to our plan. Western Dental’s dental director then determines whether the referral is medically necessary and whether the procedure is covered under the benefit plan. 20. Are any of your specialists board eligible/certified? Aetna: Yes Ameritas PPO: Yes, all are board-eligible or certified and are monitored during the PPO credentialing process. Anthem Blue Cross: All contracted specialists with Anthem Blue Cross must be board certified/board eligible. Aflac: Aflac Group Dental has no provider networks, however, for benefits to be payable, the specialist must be licensed by his or her state to perform the required treatment. Assurant Dental Network: Yes. BEN-E-LECT: Yes. BEN-E-LECT requires that all participating specialists be board certified. BEST Life: All of our specialists are certified and must meet a rigorous credentialing process to be admitted into the network. DenteMax credentials its specialists using the following elements: • License to Practice • DEA/CDS Certificates • Education/Board Certification • Work History • Malpractice Claims History • Malpractice Insurance • Application and Attestation Content • Sanctions Against Licensure • Medicare / Medicaid Sanctions • Medicare Opt Out Blue Shield: Yes, but certification varies by specialist. Dental specialists may be certified, but it is not an industry requirement. Therefore we do not track board certification. We ensure that members receive the best possible care by credentialing and re-credentialing dentists following NCQA guidelines. BRIGHTER: All Brighter dentists go through a rigorous certification process that includes validation of industry eligibility and certifications. Cigna: DHMO/DEPO/DPPO – Network dentists contracted to provide specialty care have successfully completed postgraduate dental specialty programs in their fields. Our networks include specialists in periodontics, orthodontics, endodontics, pediatric dentistry, and oral surgery. We accept dentists who are recognized specialists, including those that are board certified or board eligible. INDEMNITY – Network related issues are not applicable to the Cigna traditional indemnity plan. Members may choose any licensed dentist to provide care. Delta Dental: Delta Dental requires board certification where it is required by state law. Under the fee-for-service plans, Delta Dental credentials all of its participating specialists in the same manner, whether they are board eligible or board-certified. Under the DHMO plans, Delta Dental requires all DeltaCare USA network specialists to be board-qualified. Dental Health Services: Yes. Majority of Dental Health Services’ dental specialists are board certified. Guardian: Many of our PPO specialists are board certified or eligible and all of the DHMO specialists are board eligible. Health Net Dental: Yes. HumanaDental: All participating specialists must provide copies of their specialty licenses or residency certificates. Principal Financial Group: Yes. All specialists are required to be board eligible, board certified or be a designated specialist by the ADA. Securian Dental: 100% of the specialists in our network are board certified or board eligible. United Concordia: Yes, as part of our credentialing process, we verify each dentist’s education, license and certifications. Western Dental: All contracted specialists are board-eligible/certified. 21. How do you fund your specialty care? Aetna: Specialty services are paid on a fee-for-service basis. Aflac: Aflac Group Dental insurance pays a set amount per procedure based on a table of allowances. Additionally, insureds have the freedom to choose their own providers without precertification. Ameritas PPO and the FDH Networks: Specialty care claims are paid out of the same claims reserve that is established for the group’s general dentist claims. If employers are fully insured, all are funded out of the premiumcharged to each group. If employers are self-funded, the specialist claims would be included in the claim funding bill provided to the employer. Anthem Blue Cross: Claims for specialty care for both Dental PPO and DHMO plans are paid according to the provider’s fee schedule. Assurant Dental Network: Proprietary BEST Life: Specialty care is built into the premium. Specialty care received by a network provider is reimbursed at a discounted fixed fee schedule. Specialty care received by a non-network provider is reimbursed on what is usual and customary for that area, procedure and specialty. Blue Shield: Specialty care is paid on a discounted fee for service basis for dental HMO, INO and PPO plan designs. Member and plan copayments vary, depending on the plan design. BRIGHTER: The employer sets its own funding & specialty amounts. Cigna: DHMO –We contract with an extensive network of specialists to ensure that we provide our members with the needed services at negotiated fee levels. We pay specialists based on a reduced fee schedule. Patient charges listed on the patient charge schedule (PCS) apply at the specialist’s office once we have authorized payment. We review referrals to specialists for eligibility and coverage. DEPO – The DEPO plan uses our national DPPO network. Specialists are part of the Cigna DPPO network, and members can seek care from any network specialist without a referral. Like network general dentists, network specialists are contracted on a discounted fee-for-service (FFS) schedule based on average charges in a geographic area. DPPO – Specialists are part of the Cigna DPPO network; members can seek care from an in-network or out-of-network specialist without a referral. Like network general dentists, we contract with network specialists on a discounted fee-for-service schedule based on average charges in a geographic area. We pay out-of-network dentists according to maximum reimbursable charge levels or fixed schedules, depending on the plan design. INDEMNITY – The Cigna Traditional indemnity plan is not a network-based plan. Delta Dental: Specialty care is built into the premium. Under the fee-forservice plans, specialists are reimbursed by a combination of maximum plan allowances by procedure (contracted fees between Delta Dental and dentists) and coinsurance paid by the covered enrollee. Under the DHMO plan, network specialists are reimbursed for preauthorized services on a per-claim basis according to contracted fee schedule and copayment paid by the enrollee. Dental Health Services: Specialty care and treatment are paid for on a contracted basis and payment varies by procedure. These costs are built into each plan’s monthly premium rate. Guardian: Our PPO specialists are paid on a fee-for-service basis. For our DHMO plans, specialty care is funded through a portion of premium. Health Net Dental: For both our DHMO and DPPO plans, we underwrite and rate dental plans based on an assumed specialty care claims liability and build an allowance into our dental premiums. HumanaDental: Specialists are paid on a fee-for-service basis according to a contracted fee-schedule amount or by reimbursement limit. Principal Financial Group: Through normal plan provisions. Securian Dental: Network dentists (general and specialty dentists) are reimbursed on the basis of a discounted fixed fee schedule. Network dentists agree to accept the fee schedule amount as full consideration, less applicable deductibles, coinsurance and amounts exceeding the benefit maximums and will not balance bill the member. United Concordia: Both PPO and DHMO specialists are paid on a negotiated fee-for-service basis. Western Dental: We incorporate into our premiums what we expect specialty care claims to be. We then pay the claims based on dental necessity and plan guidelines. 22. Does the member have to be referred by the primary dentist to the orthodontist or can he or she self-refer? Aetna: Member can self-refer. Aflac: The Aflac Group Dental plan does not require referrals. Insureds may self-refer. Ameritas PPO and the FDH Networks: No, every member can self-refer. Anthem Blue Cross: We do not require referrals in our PPO plans, including Dental Prime and Dental Complete. Members enrolled in the Anthem Blue Cross Dental Net DHMO program must be referred by their primary dentist to an orthodontist. Using our direct referral program, the participating general dentist can refer the patient directly to the specialist without prior authorization. Assurant Dental Network: They can self-refer. BEN-E-LECT: Members may self-refer to any orthodontist they prefer. In-network versus out-of-network and plan selection will determine coverage provided. BEST Life: No referral is necessary. Blue Shield: For dental HMO plans, the general dentist completes a specialty care referral form and provides a copy to the member, who brings this to the participating specialist at the time of the appointment. Dental PPO/INO plan members may self-refer. Brighter: Self-refer Delta Dental: Under the fee-for-service plans, enrollees can self-refer. For DHMO plans, the assigned network dentist submits a referral request for orthodontic treatment to Delta Dental. The network dentist is notified upon approval and is responsible for advising the DeltaCare USA enrollee who then contacts the assigned network orthodontist for an appointment. Cigna: None of our plans require a referral for orthodontic care. Dental Health Services: Yes. Members must get a referral from a participating Dental Health Services dentist before visiting a participating orthodontist. Guardian: PPO members can self-refer to all types of specialty care, including orthodontia. General Dentists in our DHMO network will refer the member to a participating orthodontist. The referral does not require plan authorization. Health Net Dental: Our DPPO product does not require referrals for specialty or orthodontic care, so participants may self-refer. For DHMO, there are three types of specialty referral processes based on the member’s schedule of benefits. For plans that require pre-authorization, a specialty referral form must be submitted by the primary care dentist. For plans that have direct referral, the primary care dentist may directly refer the member to a participating orthodontist by visiting our website or by contacting our customer service. For plans that allow self-referral, the member may go directly to a contracted specialist by visiting our website or by contacting our customer service. HumanaDental: In our PPO, the member can self-refer to an orthodontist. HumanaDental encourages members to ensure any dental provider is in network. Humana has a provider directory available on our website, www. Members can also call the customer service number on the back of their insurance card. Principal Financial Group: A member can choose to seek services from any provider. Securian Dental: The member can self-refer. United Concordia: Our PPO plans allow members to self-refer. Under our DHMO plans, the primary dental office determines if a specialty referral is required, regardless of the specialty. Western Dental: The member has to be referred by the primary dentist to the orthodontist for our IPA Dental Plan. Our Western Centers-only plan allows the member to self-refer. 23. What is the time frame for processing a referral in terms of member notification and payment to the specialist? Aetna: DMO general practitioners usually provide a member with an immediate referral. Specialty payments are made on receipt and adjudication of the claim. Aflac: Aflac Group Dental doesn’t require referrals because insureds have the freedom to choose their own dentist without restriction. Ameritas: Since this is a self-referring process, this question is not applicable. Anthem Blue Cross: With our PPO plans, there is no need for a referral. With Anthem Blue Cross Dental Net DHMO plans, referrals are usually processed within 48 hours through the use of our Direct Referral program. Referrals for emergency reasons are usually processed within the same day. Assurant Dental Network: N/A BEN-E-LECT: Referral is not necessary. Members may call and schedule the appointment as desired. BEST Life: No referrals are required. Members may self-refer to any specialist they choose. Blue Shield: For dental HMO plans, the general dentist completes a specialty care referral form and provides a copy to the member, who brings this to the participating specialist at the time of the appointment. Our average turnaround time for claims payment to the specialist after receipt of the claim is approximately six days. Our dental PPO plans do not require referrals. Brighter: N/A Delta Dental: For PPO and Premier patients, specialty care referrals are not required, and payments to specialists are processed the same as for general dentists. For DHMO enrollees, preauthorizations for specialty care processed within five business days. Dental Health Services: Emergency referrals are processed immediately. In a non-emergency situation, referrals are processed within one to two weeks. Claims are paid within two to three weeks. Guardian: Referrals are not required under our PPO plans. For our DHMO plans, payment to the specialist is within 30 days of receipt of the claim. Health Net Dental: The average turnaround time in processing a nonemergency referral is 48 hours and then 7-10 business days for the EOB to be received by the member. Once the claim is submitted by the specialist, our average turnaround time in processing is 10 business days of receipt and then 7-10 business days for specialists to receive payment in the mail. If claim was sent electronically, it will be sooner. HumanaDental: Most HumanaDental plans do not require a referral from a general dentist to a specialist. The member gets a higher benefit when seeing a participating dentist and specialist. In 2013, 97% of claims were processed within 14 calendar days Securian Dental: No referral is required. United Concordia: All referrals are immediately effective. There is no requirement for specialty referrals to be pre-authorized by United Concordia. The member is instructed to provide the referral to the specialist at the time of service and the specialist files the referral with the claim. All claims, including specialist claims, mailed to United Concordia are usually processed within 14 days. Claims filed electronically are processed during the weekly cycle. Western Dental: Emergency referrals are handled within 24-hours. The turnaround for non-emergency referrals is three business days. Specialists can expect payment in 10 business days for clean claims. 24. If you limit services with an annual or lifetime maximum, what does the maximum dollar amount allowed refer to? Aetna: The maximum dollar amount refers to the total amount Aetna will pay for covered benefits. Aflac: The annual maximum refers to the maximum amount of benefits that may be received within a policy year per covered person. Annual maximums do not apply to wellness and X-ray benefits. Ameritas: The maximum is the total amount of dollars payable to a member under their policy during the specified plan year. Anthem Blue Cross: Our Dental PPO plans have an annual maximum, which refers to the maximum dollar amount that will be paid by the plan in a calendar year. With Anthem Blue Cross Dental Net and Dental Select DHMO plans, there are no annual or lifetime maximums. Assurant Dental Network: Our PPO plans have a variety of annual maximums. BEN-E-LECT: The maximum dollar and lifetime maximum refers to all services and procedures unless specified otherwise by benefit. BEST Life: Lifetime maximum applies to orthodontia benefits. We offer multiple choices of calendar year maximums for preventive, basic and major procedures. Blue Shield: The “maximum” is the maximum amount paid for covered benefits under the plan. The dental HMO plans have no annual maximum or lifetime maximum. Dental PPO annual plan maximums range from $1,000 to $2,000 and encompass all dental services received except orthodontics. Dental INO plans have a $2500 annual maximum. There are no lifetime maximums for dental PPO/INO plans. Orthodontia is offered to adults and children in many dental PPO plans as an additional benefit, which does not apply to the plan annual maximum. Group dental PPO/INO plans provide a generous calendar year orthodontic maximum of $1,000; there is no lifetime orthodontic maximum. Individual and family dental PPO plans offer low copayment and a two-year lifetime orthodonture benefit. Dental HMO plans have no annual maximum. BRIGHTER: Services & claims payments actually utilized. Cigna: DHMO – There is no annual or lifetime maximum. DPPO/DEPO/Dental indemnity – The maximum dollar amount refers to the maximum amount payable by Cigna for covered services rendered. Delta Dental: Under the fee-for-service plans, the maximum dollar amount refers to the maximum dollar amount paid by the plan. Our DHMO plans do not have annual or lifetime maximums. Dental Health Services: The majority of Dental Health Services’ prepaid (D-HMO) plan offerings have no annual dollar maximums, although this option isavailable by client request. PPO plan annual maximums range from $500 to $2000. Please call or email your broker advocate, and a client service manager will help you and your clients receive excellent, innovative and custom benefit programs that fit their needs. Guardian: The maximum refers to the total of benefit dollars actually paidfor covered services incurred within the annual period, or the member’s lifetime in the case of orthodontia. With Preventive Advantage, only Basic and Major services count toward the annual maximum. We also offer an option to cover cleaning after the maximum is reached. Health Net Dental: The maximum dollar amount is the total amount the plan will pay for covered benefits. Humana Dental: Annual maximum refers to the maximum amount paid annually for services, excluding orthodontia. Orthodontic treatment has a lifetime maximum. Principal Financial Group: The maximum dollar amount refers to benefits paid. Securian Dental: The annual and lifetime maximum refer to the maximum dollar amounts we will pay for covered services in a calendar year (annual maximum) or over the coverage lifetime (lifetime maximum). Our plans generally include an annual maximum for non-orthodontic covered services and a separate lifetime maximum for orthodontia. United Concordia: DHMO plans do not have annual or lifetime maximums. PPO plan annual and lifetime maximums vary by benefit plan and refer to the total amount paid in benefits by United Concordia annually or over the member’s lifetime. Western Dental: The Series 7 DMO plans do not have an annual or lifetime maximum. 25. How and when do you provide eligibility information to your dental offices? How can you ensure that your offices will provide services to a member if they are not on the eligibility listing and it is after regular plan hours? Aetna: Eligibility is available to our providers 24/7 by calling our automated telephone inquiry system or by accessing the online eligibility roster. DMO providers receive eligibility rosters the first week of each month. Aflac: Providers may verify eligibility online — — or by calling Aflac’s customer service center at 1.800.99.AFLAC. Aflac Group does not require prequalification for treatment. Ameritas: They will want to verify eligibility through our real time system. Our plans do not require preauthorization or mandated PPO network usage. Anthem Blue Cross: Participating providers can confirm eligibility via our secure website 24/7. Also, our customer service representatives are available toll-free Monday through Friday from 5:00 a.m. to 5:00 p.m. (PST) to help members with locating network providers, verifying provider status, member eligibility, answering claim questions, quoting plan benefits, and receiving member complaints. An interactive voice response (IVR) system is also available to answer calls and provide information 24 hours a day, seven days a week. Assurant Dental Network: Prepaid/DHMO eligibility is provided on a monthly basis. A call center is available during regular business hours for eligibility issues. BEN-E-LECT: BEN-E-LECT provides electronic eligibility 24/7 through our Empowr web portal for providers and members. The Pre-Paid product will provide services upon collecting information from the member. This information will be transferred to BEN-E-LECT’s system electronically. BEST Life: Providers can use our fax back eligibility system to determine if a member is eligible, outside of normal business hours. Offices routinely check eligibility prior to appointments and have a process in place for dealing with emergency situations. Blue Shield: Eligibility lists for dental HMO plans are distributed to the dental HMO dental center during the 1st week of each month. Providers are responsible for contacting our customer service department to verify eligibility, if a member is not on their list. Our Interactive Voice Response (IVR) is available 24 hours, seven days a week and has the capability to verify eligibility and assign members. Brighter: For every appointment scheduled via our online platform we are able to provide real-time eligibility information to the dental office prior to treating the patient. Cigna: Our dental health care professionals’ website,, allows dentists to: • verify members’ network participation and eligibility • check members’ benefit information and details on their YTD accumulation toward maximums and deductibles • view claim status • enroll in EFT and receive payments faster • access and download payment reports, office management reports and financial reports in a printable PDF format (DHMO) • print forms – American Dental Association (ADA) claim, referral, and more • download policy manuals including the general dentist dental office reference guide • access patient charge schedule at-a-glance booklet (DHMO only) • take continuing education courses at no charge (contracted health care professionals only) • access information about the Cigna Network Rewards Program® Delta Dental: Dental offices can verify eligibility by contacting Delta Dental via our website, calling our automated information line or speaking with a customer service representative. Under the fee-for-service plans, a patient who is not shown as eligible may be asked to pay the entire amount of the bill up front. The dental office would be responsible for refunding the patient their overpayment after receiving Delta Dental payment. Under the DHMO plans, in addition to verifying eligibility as listed above, network dentists also receive eligibility lists at the beginning of each month. If an enrollee is not contained in Delta Dental’s eligibility database and claims to be eligible for benefits, Delta Dental contacts the client or the client’s benefit administrator to verify eligibility. If the eligibility verification is for an enrollee who has urgent or emergency needs, our customer service representatives will extend an urgent care authorization. Dental Health Services: Participating dental offices receive eligibility rosters twice a month. If immediate eligibility is needed at any time, the dental office can call Dental Health Services’ 24-hour automated eligibility verification system or check eligibility online through the company’s website. Guardian: Dentists can use our online self-service website, or call our toll-free line and receive a faxed verification of benefits from 3:00 a.m. to 8:00 p.m., Monday through Friday and from 3:00 a.m. to 1:00 p.m. on Saturday, Pacific Time. Eligibility rosters for the DHMO plan are provided to the offices twice a month, at the first of the month and the 10th of the month. Dental Offices may also call our Member Services Department from 8:00 a.m. to 5:00 p.m. Monday through Friday. Health Net Dental: Our DHMO dentists receive a monthly updated eligibility list that includes member name, member status (active, dropped, suspended or transferred), member ID number, dependent names and eligibility status, fee schedule code, group number and capitation amount, if applicable. DPPO dentists do not receive an eligibility roster as members are not required to select a primary care general dentist. Members would simply choose any network dentist (or non-participating dentist, if they desire) and schedule an appointment. DPPO and DHMO dentists can verify eligibility information via our interactive voice response system and Web site, which are both accessible 24-hours a day, seven days a week. Because the IVR and Web site are available 24/7, eligibility can be verified anytime of the day regardless of whether the need occurs during business hours. HumanaDental: Participating offices are encouraged to check eligibility before providing treatment. They can verify members and benefits by calling our toll-free customer service line or through our automated information line to get 24 hour-a-day, seven-day-a week eligibility verification. There are no eligibility rosters for PPO business. Securian Dental: Dental offices can use a toll free number to call customer service to verify eligibility and benefits. Dental offices can also access to verify eligibility. United Concordia: PPO dentists can verify eligibility at any time via our Dental Customer Service toll free number, or by using our online system, My Patients’ Benefits. Primary dental offices can verify DHMO members’ eligibility and benefit information 24 hours a day, 7 days a week through My Patients’ Benefits available online at or by using United Concordia’s IVR system, which can be accessed by dialing our toll free Dental Customer Service phone number at (866) 357-3304. Western Dental: Western Dental provides eligibility listings to our staff model offices electronically and printed eligibility listings to our IPA Providers. This information is updated on the 1st and 15th of each month. For members who are not on the eligibility listing, we offer guaranteed capitation to our network of providers. 26. How do you handle early termination of coverage when a member is still in the middle of orthodontic treatment? Aetna: We stop issuing our quarterly payments when the member is no longer covered. Aflac: Benefits will cease upon termination of coverage. Ameritas PPO: PPO provider discounts are determined using the treatment start date. Our PPO providers are contractually obligated to honor those discounts for any ongoing covered treatment under their plan. Anthem Blue Cross: While details vary by plan, with our Dental Prime and Dental Complete programs, benefit payment is pro-rated based on the services completed. Assurant Dental Network: Benefits are calculated to pay out through the period in which they will be banded, as long as they are still active members. If coverage terms in the middle of treatment, no additional benefits will be paid. BEN-E-LECT: Payment for benefits will cease at the end of the month for which the termination became effective. BEST Life: Coverage terminates at the end of the month in which a member is no longer eligible. Blue Shield: Once the member’s coverage is terminated, the cost of treatment is the responsibility of the member. BRIGHTER: We empower the employer, and their broker, to set their own policy for such situations and we pay claims accordingly. Cigna: Coverage for a dental procedure that was started before disenrollment from the plan (crowns, root canal treatment, bridges, dentures, and partials if the teeth were fully prepared or the final impressions) will be extended for 90 days after disenrollment unless it was due to nonpayment of premiums. Coverage for orthodontic treatment which was started before disenrollment from the dental plan will be extended to the end of the quarter or for 60 days after disenrollment, unless it was due to nonpayment of premiums. Our standard DEPO/DPPO/Indemnity extension of coverage is 90 days; however, other arrangements can be made. Delta Dental: Delta Dental’s obligation to pay toward orthodontic treatment terminates following the date the enrollee loses eligibility or upon termination of the client’s contract. Dental Health Services: If a member’s coverage is terminated in the midst of orthodontic treatment, members are encouraged to participate in a COBRA individual plan that will allow them to retain orthodontic benefits. If the member chooses not to maintain his or her coverage, the dental office can prorate any additional treatment fees. The member would then only be responsible for the prorated amount of the full treatment cost. Guardian: When an orthodontic appliance is inserted prior to the PPO member’s effective date, we will cover a portion of treatment. Based on the original treatment plan, we determine the portion of charges incurred by the member prior to being covered by our plan and deduct them from the total charges. Our payment is based on the remaining charges. We limit what we consider of the proposed treatment plan to the shorter of the proposed length of treatment, or two years from the date the orthodontic treatment started. Also, we enforce the plan’s orthodontic benefit maximum by reducing the total benefit that Guardian would pay by the amount paid by the prior carrier, if applicable. If a member is undergoing orthodontic treatment and his or her Guardian coverage terminates, we pro-rate the benefit to cover only the time period during which coverage was in force. We do not extend benefits. Our DHMO agreement provides for the contracted orthodontist to complete treatment at the contracted patient charge on a number of our plans. As an additional contract rider we can allow for supplemental transfer coverage for Orthodontia under our DHMO. Health Net Dental: Upon termination of coverage, we will pay for orthodontic cases in progress on a prorated basis up to the last effective date of coverage. Benefits are no longer payable after the member terminates and are the responsibility of the member and/or the new dental carrier. HumanaDental: HumanaDental will prorate to provide the appropriate amount given during the time the member was in the plan. Principal Financial Group: On individual terminations, most of our plans allow for extended benefits that provide one month of additional coverage. Securian Dental: Benefits are paid based on the services received while the member was covered by Securian Dental. United Concordia: The extension of orthodontic coverage for PPO plans is 60 days if payments are being made monthly. However, if payments are being made on a quarterly basis, coverage will be extended to the end of the quarter in progress or 60 days, whichever is later. Western Dental: Western Dental has designed a termination clause to protect the member. The member does not incur any additional fees for the early termination of a provider. 27. How do you handle the additional cost of OSHA required infection control in your participating offices? Aetna: These costs are a part of doing business. Aflac: Since Aflac Group Dental doesn’t have network requirements, insureds can choose any dentist without restriction. It is the responsibility of ... Continue Reading →

Insurance Insider News
Brokers Are Failing Their Clients
by Leila Morris

There is a disconnect between what brokers are providing clients and what clients want, according to a survey by Zywave. The survey reveals the following: • 65% of employers want their broker to help create or maintain an employee handbook, but 85% say their broker is not doing a satisfactory job in this area. • 92% want their broker to provide regulatory and legislative updates, yet 53% say their broker is not doing a satisfactory job in this area. • 88% of employers want help with their workplace wellness program, but 56% say their broker is not doing a satisfactory job in this area. • 92% want information on reducing the frequency and expense of claims, but 59% say their broker is not doing a satisfactory job in this area. • 90% of employers expect brokers to help create benefit statements, yet 63% say their broker is not doing a satisfactory job in this area. Dave O’Brien, CEO at Zywave said, “Clients are expecting services from their brokers beyond just the placement of insurance. Most of us will agree this is positive, as it moves the broker to more of an adviser role, supporting business issues, such as compliance, HR, risk management, wellness, etc. Agencies and brokers who excel at positioning themselves this way have enjoyed significant growth in recent years. In my eyes, it means opportunity for the brokers who are willing to fulfill these unmet client needs and differentiate themselves in their market.” Employers say that their top three risk management challenges are keeping up to date on regulatory changes, controlling workers’ compensation costs, and educating employees on safety. Their top three employee benefit challenges are managing health care costs, keeping compliant, and performing benefit administration and employee benefit education. To view the white paper, visit Insurance Companies Are Staffing Up Fifty-eight percent of insurance companies plan to increase staff in 2014, according to a study by The Jacobson Group and Ward Group. This is the second highest rate in the history of the survey. In addition, the Bureau of Labor Statistics says that unemployment rate for the insurance industry is only 3.4%. Technology, underwriting, and claims positions are most in demand and are expected to grow the most in the next 12 months. Companies are having a hard time recruiting for most positions, but technology, actuarial, and analytics positions are the hardest to fill. Gregory P. Jacobson, co-chief executive officer of Jacobson said, “The industry is settling into its return to pre-recession rates, resulting in growing confidence and the leveling-off of staffing and revenue forecasts. The market is stabilizing and organizational predictions are following suit.”  Nearly 85% of companies expect an increase in revenue throughout the upcoming year, the third highest level since the beginning of the survey. If the industry follows through on its plans, there will be a 1% increase in industry employment through the final half of 2014. For more information, visit IN CALIFORNIA Covered California Offers New Dental Plans Covered California is offering new family dental plans to consumers who enroll in health insurance coverage in 2015. All individual health insurance plans sold through the Covered California exchange will include pediatric dental benefits for members younger than 19. All children enrolled in Covered California will have dental coverage embedded in their comprehensive health plan, Covered California Executive Director Peter V. Lee said. They will be getting better coverage and more for their money. The family dental plan will offer adults the option of receiving dental coverage outside the general health plans at an additional cost. Some consumers also may be drawn to family dental plans if a provider they prefer for their child is not offered in their embedded coverage. The optional stand-alone family dental plans, which offer coverage for adults will be added in early 2015. Covered California will offer dental health maintenance organization (DHMO) and dental preferred provider organization (DPPO) plans, giving consumers a choice in the type of plan that will work best for them. There is no financial help available for the optional adult dental benefits. There is no requirement to enroll children in a family dental plan. The family dental plan, which is optional, is primarily for adults who did not have coverage in 2014. Families should keep in mind that adding their children to a family dental plan will be more expensive than the same dental services they already get in their standard health insurance plan. The most likely reason to enroll a child in the family dental plan is to use a dental provider who is not offered through their embedded coverage. For more information, visit State Backs Reproductive Rights California’s executive and legislative branches have thrown their support behind reproductive rights. First, the California Dept. of Managed Health care sent letters to carriers and colleges reminding them that insurance companies in the state can’t refuse to cover abortion. The announcement came after two Catholic institutions, Santa Clara University and Loyola Marymount University, decided to drop coverage for elective abortions for more than 2,000 employees. Second, the California legislature passed the Contraceptive Coverage Equity Act, which strengthens the coverage for FDA-approved birth control methods under Obamacare. It now heads to the governor, who is expected to sign it. Senate Bill (SB) 1053 would expand access to the full range of FDA approved methods of birth control without restrictions or co-pays.  The measure was introduced by Senator Holly J. Mitchell (D-26) of Los Angeles and co-sponsored by California Family Health Council and the National Health Education Law Program. California has had a law on the books since 1999 that requires health insurers to cover contraception along with other prescription drugs. The new measure goes even further to ensure that women can select their birth control method without being required to try other methods first. “We continue to see an alarming national trend of restricting access to women’s health care. In the aftermath of the disappointing Hobby Lobby decision, California, once again, has the opportunity to lead the nation with a legislative model to help women more effectively plan their families and futures with fair and consistent contraceptive coverage,” said Julie Rabinovitz, President and CEO of California Family Health Council. HEALTHCARE Tops Trends in Employer Based Plans Employers expect a 4% increase in 2015 health care costs for active employees, according to Towers Watson. If no health plan adjustments are made, employers project a 5.2% growth rate, putting absolute cost per person for health care benefits at an all-time high. Despite this cost trend, 83% of employers plan to continue subsidizing and managing health benefits for full-time and part-time active employees, according to a Towers Watson Health survey. However, employers are rethinking company subsidies for spouses and dependents. Seventy-three percent of employers are concerned about triggering the tax excise tax based on their plans. Forty-three percent say that avoiding the tax is their top priority health care strategy in 2015. CEOs and CFOs are more engaged in health plan strategy discussions as a result of the excise tax and other provisions of the health care reform law. Randall Abbott, senior consultant at Towers Watson said, “CFOs are now focused on a new gold standard: managing health cost increases to the Consumer Price Index. This requires acute attention to improving program performance.” Eighty-one percent of employers plan moderate to significant changes to their health care plans over the next three years, up from 72% a year ago. One tactic is specialty pharmacy management. Companies project that the pharmacy-only cost trend will be 5.3% after plan changes (6% before changes). Employers will also embrace telemedicine. Another key tactic is new payment approaches that hold providers accountable for the cost and outcomes of an episode of care. For 2016 and 2017, 48% of employers are considering tying incentives to health outcomes, compared to just 10% in 2015; 37% are considering offering plans with a higher level of benefits based on the use of high-performance or narrow networks of medical providers, compared to just 7% in 2015. Thirty-four percent are considering telemedicine, compared to 15% in 2015. Thirty-three percent of employers are considering significantly reducing company subsidies for spouses and dependents; 10% have already implemented such reductions, and 9% intend to do so in 2015. In addition, 26% are considering spouse exclusions or surcharges if coverage is available elsewhere; 30% have that tactic in place now, and another 7% expect to add it in 2015. Employers are also examining caps on health care coverage subsidies for active employees, using defined contribution approaches, with 30% of employers considering them for 2016 and 2017, 13% having them in place and another 3% planning them for 2015. Twenty-eight percent of employers have extensively evaluated private exchanges. Twenty-four percent say private exchanges could provide a viable alternative for their active full-time employees in 2016. The following are the top three factors that would cause employers to consider a private exchange for full-time active employees: 64% — a private exchange can deliver greater value; 34% — other companies in their industry are adopting private exchanges; and 26% — the employer is unable  to stay below the excise tax ceiling as 2018 approaches. Nearly all employers say they have no plan to stop offering health benefits and direct active employees to public exchanges. Seventy-seven percent are confident that public exchanges offer a viable alternative for their active full-time employees in 2015 or 2016. Abbot said that the most effective employers are continually evaluating new strategies to improve health plan performance. Examples include a steady migration to consumer driven health plans (CDHPs), action-based incentives, value-based payment methods with health plan partners, and plan designs that drive efficiencies. Other options are technology-based solutions, such as telemedicine, fitness devices or trackers, and social media. Sixty percent of employers plan to look at data to gauge the performance of their health plan. Seventy-six percent are looking at encouraging greater physical activity among their employees by using technologies, such as mobile health applications, fitness wearables, and social media. Full-replacement CDHPS could be in place at 50% of companies by 2017: 17% offer only a CDHP; 4% intend to do so in 2015, and another 28% are considering it for 2016 or 2017. For more information, visit Special Enrollment Period to Boost Insured Rate Nationally, almost 7 million adults are likely to experience a qualifying event that triggers a special enrollment period, according to a report by Those who missed the March 31 enrollment deadline and are not eligible for Medicaid or the Children’s Health Insurance Program (CHIP) can still enroll in health insurance if they experience a qualifying event that triggers a Special Enrollment Period (SEP). Examples of qualifying life events include permanently moving to an area where different plans are available on the marketplace, getting married, having or adopting a child, and becoming a citizen, national, or “lawfully present individual.” Young Uninsureds — It Won’t Happen to Me Twenty-four percent of Millennials (age 18 to 29) have no health insurance, according to a report by That compares to 16% of all adults without health insurance. Millenials are not just ignoring health insurance. They are also less likely  to have auto, life, homeowner’s, renter’s, and disability insurance compared to all other age groups. Only 12% have renter’s insurance, which costs only around $10 per month, in many cases, while providing valuable protection. Sixty-four percent of 18- to 29 year-olds have no life insurance. The most common explanation was that it costs too much, but $500,000 of 20-year level term life insurance can cost less than $20 per month for a young adult. The second-most common response objection is, “I’m healthy and don’t need life insurance.” Even car insurance is not particularly popular among Millennials. Even though car insurance is mandatory in all states except for New Hampshire, 36% of Millennials don’t have it. This might be because the number of young adult drivers has fallen in recent years. Despite evidence to the contrary, Millennials say they are prepared for the financial consequences of getting into car accidents, having their belongings stolen, incurring substantial medical bills, or becoming disabled. For more information, visit When a Platinum Plan Is a Better Buy Platinum plans may have the highest premiums among the Obamacare health plans. But they may save money for people taking specialty drugs because of their reduced co-payments and lower caps on annual out-of-pocket costs, according to a study by HealthPocket. Platinum plans have the lowest average out-of-pocket costs for the five common specialty drugs. HealthPocket looked at 2015 Obamacare metal plans whose rate filings have been made public. The average out-of-pocket specialty drug costs for platinum plans were 64% lower than gold plans, 74% lower than silver plans, and 78% lower than bronze plans. The difference in out-of-pocket costs is dramatic. For example, taking the specialty drug Humira (used to treat inflammation) could result in annual out-of-pocket costs of $6,381.38 for 2015 bronze plans compared to only $1,416.67 for 2015 platinum plans. However, not every Obamacare health plan covers the same drugs; and caps on annual out-of-pocket costs can vary within the same metal tier. Consumers who take expensive specialty drugs need to make sure that their drugs are included in the list of covered medications on the Obamacare plans they are comparing. “Specialty drugs represent an increasing percentage of insurance spending for prescription medications. In coming years, they’ll become the largest single cost category despite the fact that specialty drugs serve a minority of the population,” said Kev Coleman, Head of Research & Data at HealthPocket. For those who depend on these drugs, comparing premiums and annual caps on out-of-pocket costs is often more important than comparing health plans’ copayments and co-insurance fees for drugs, he added. For more information, visit FINANCIAL PLANNING One Size Does Not Fit All for the Middle Market Segments of the middle market have very different attitudes about financial decisions, according to a LIMRA study.  For example, younger families with children under 18 say life insurance is important, and are likely to have incurred debt that affects their financial decisions.  The study says that that low-cost product like term life insurance would resonate best with this group.  In contrast, very young or older consumers who are risk takers and have little desire for insurance products.  Researchers say that investment products, such as mutual funds and annuities, would be better for these consumers. The factors that most influential to decision making are: 1. Risk tolerance 2. Current impact of debt on household 3. Financial situation/life stage 4. Household composition (since this drives values and lifestyle attitudes) 5. Attitudes toward spending/saving, importance of reputation/brand vs. price in purchase decisions in general For more information, visit or NEW PRODUCTS Private Healthcare Exchange CieloStar has partnered with HCC Life Insurance to offer the private healthcare exchange concept to the self-funded market. The HCC self-funded private exchange will offer an exclusive pricing arrangement. The HCC Private Exchange offers employers and TPAs an integrated employer administration and reporting system as well as comprehensive administrative tools. For more information, visit Wellness Tracker Insignia Health updated its Flourish e-health platform. Flourish offers personalized services and resources including articles, tip sheets, videos, quizzes, journaling opportunities, coaching, and health tracking activities. Flourish supports wellness and disease prevention, as well as select conditions including asthma, chronic pain, depression, diabetes/pre-diabetes, heart disease, high cholesterol, hypertension, and multiple sclerosis. For more information, visit Health Insurance Guide for Veterans The non-profit, Transamerica Center for Health Studies, has developed the “Veterans Health Coverage Guide,” which explains the types of insurance available and how they interact. Recent changes in healthcare legislation offer more overage options for veterans and their families. For more information, visit Life Insurance Colonial Life is offering a new employer-paid group term life plan and a long-term care benefit rider on whole life insurance policies. The employer-paid option uses a composite rate structure, which means the same rate applies to all employees, regardless of age or tobacco use. Group term life insurance coverage, which can be offered on an employee-paid basis, provides options tailored for large and small accounts. For small accounts, program administration is simple. For larger accounts, employers can customize additional options to fit the needs of their employees. Colonial Life’s new long-term care rider option on a whole life policy offers a living benefit if long-term care becomes a necessity. For more information visit Ancillary Benefit Exchange Choice Builder is offering an exchange with dental, vision, chiropractic, and life insurance coverage to businesses with two to 199 employees. The expansion from the group size limit of 99 employees to 199 employees is available for coverage effective October 1, 2014 or later. Choice Builder offers coverage to small and mid-sized companies, including dental insurance from Delta Dental, Ameritas Group, and Madison National Life; vision benefits from VSP and EyeMed; chiropractic and acupuncture benefits from Landmark Healthcare; and life insurance protection from Assurity Life. Coverage is available to employers on a voluntary basis (with employees paying all of the cost) or as employer-sponsored benefits (with the employer and employees sharing the cost). For more information, visit Life Insurance Video Series Guardian  Life is launching an online video series on YouTube depicting actual customers whose life insurance policies have had a powerful effect on their financial well-being. The three-minute videos provide real-life examples of financial professionals using various life insurance strategies to meet their clients’ goals. ... Continue Reading →

Voluntary Benefits Survey

Voluntary employee-paid benefits are becoming more and more popular as employers struggle to offer employee benefits amid rising costs and shrinking budgets. These benefits offer employees the convenience and the discounted rates that they would not have access to on the individual market. But how does a benefit broker choose which voluntary benefits to present to clients? This survey of insurance carriers helps California insurance agents and brokers stay on top of plan changes from year to year. Many of the survey questions came directly from insurance agents in the state. 1. Please list the voluntary/employee-paid benefits that you offer along with the minimum group size for each offering:  Aflac: Aflac’s policies, from accident/disability to vision, offer direct-to-the-policyholder cash benefits, unless otherwise assigned, to help cover what other insurance does not. Following is a list of individual policies available through Aflac: • Accident • Cancer/Specified-Disease • Critical Care & Recovery • Dental • Hospital Confinement Indemnity • Hospital Confinement Sickness Indemnity • Hospital Intensive Care • Juvenile Life • Life • Lump Sum Cancer • Lump Sum Critical Illness • Short-Term Disability • Vision *Certain policies may not be available in all states. The following is a list of group plans available through Aflac Group: • Accident • Critical Illness • Dental • Life • Hospital Indemnity • Disability There is no minimum participation requirement for our individual policies available through Aflac. We only ask that the client establish an account with us by completing and signing a Payroll Account Acknowledgement form and allowing three separate W-2 employees to apply for at least one of our policies. Aflac Group requires a minimum of 25 payors to establish group billing. Ameritas: Ameritas Group offers dental, vision and hearing on a voluntary basis. Dental and vision begin at two enrolled lives and hearing at 50; we also offer individual plans. Colonial Life: Colonial Life offers voluntary benefits to businesses with as few as three employees up to thousands of employees. Our product portfolio includes individual and group voluntary products for short-term disability, accident, hospital confinement, cancer, critical illness, and term, whole and universal life. Delta Dental: Delta Dental of California’s voluntary dental plans are for employers, associations, affinity groups and other trust organizations that wish to offer employee-paid comprehensive dental coverage. Delta Dental offers a variety of features and benefit plan designs that allow employers to offer our Delta Dental PPOSM, Delta Dental Premier and/or DeltaCare USA products to meet their needs. These dental plans have the same quality standards, cost savings and ease of administration as our employer-financed products. Plans are available based on a variety of premium contribution levels from fully employee paid to some level of employer contribution. Voluntary plans require a minimum participation of five primary enrollees. Guardian: Voluntary LTD – minimum group size: 3 (depends on state) Voluntary STD – minimum group size: 10 Voluntary AD&D – minimum group size: 10 Voluntary Life – minimum group size: 3 (depends on state) Voluntary Critical Illness – minimum group size: 10 Voluntary Dental – minimum group size: 5 Voluntary Vision — minimum group size: 50 Health Net: Health Net offers voluntary dental, voluntary vision, and voluntary term supplemental coverage to groups of two or more. Voluntary supplemental is offered as a buy-up option to basic group term life coverage. Humana: When your clients work with Humana, they partner with a team of experts who provide a benefits package that attracts top talent and helps keep existing employees for a long time. We excel in the following products: • Workplace Voluntary Critical Illness Advantage offers benefits for vascular coverage and other critical illnesses – with some funds payable at initial diagnosis. All benefit payments are made directly to members, unless they specify other arrangements. Benefits are payable in addition to any other coverage they may have. • Workplace Voluntary Cancer Plan/Lump Sum Benefit plans provide cash payments to assist in covering a variety of expenses associated with critical illness. Humana’s Cancer Plan/Lump Sum Benefit is designed to help members cope with today’s economic realities by helping protect their finances in the event of a cancer diagnosis. • Workplace Voluntary Cancer Plus plans offer peace of mind when specialized healthcare, which often is not covered by health insurance plans, is needed. Cancer Plus benefits are reinstated each year to help offset the long-term costs associated with cancer. • Workplace Voluntary Supplemental Health plan offers additional coverage for everyday medical costs such as physician’s office visits and emergency room treatment. Humana’s Supplemental Health is designed to enhance existing medical coverage, and members are able to use their benefits right away. • Workplace Accident (Accident Plus) plans are flexible plans offering four levels of coverage, and provides members with off-the-job or 24-hour coverage for accident-related expenses such as ambulance services, hospital confinement, and medical treatment. Members receive benefits regardless of other in-force coverage, including primary medical insurance. Coverage also is available to the member’s spouse and children. This plan protects the whole family and has no calendar year maximums. • Workplace Voluntary Term Life/CriticaLife is a combination of life insurance and living benefits in one affordable policy. By accelerating all or part of the life benefit, members can use the money to help pay for treatment and coping with cancer, heart attack, stroke, or other conditions. Members can enroll at work with just a few simple questions; there’s no medical exam. • Workplace Voluntary Whole Life (Secure Life) offers permanent protection while living and a solid foundation to build a long-term financial plan on because it guarantees lifetime protection for members’ families. Whole life insurance can have a positive influence on current and future financial requirements. • Workplace Voluntary Disability Income Advantage plans provide non-occupational (off the job) coverage for disability resulting from injury or illness. The benefit can cover every day costs such as housing, food, car payments, and even additional medical costs. Disability Income Advantage gives members extra reassurance by providing coverage with cash benefits paid directly to members when they suddenly become disabled. • Workplace Voluntary Disability Income Plus plans provide a monthly disability income benefit due to a non-occupational “off-the-job” accident or sickness. Members can obtain this important coverage without a medical exam, at affordable group rates that can be paid through simple payroll deductions. • Participation requirements vary depending on the group and its size. MetLife: MetLife offers a comprehensive suite of complementary employer-paid and employee-paid employee benefits products. In addition to traditional voluntary, employee-paid options for life, dental, disability and vision insurance for employers with 10+ employees, MetLife and its affiliates offer the following voluntary/employee-paid benefits: • Auto & Home (employers with 500 or more employees); underwritten by Metropolitan Property and Casualty Insurance Company and its affiliates: Metropolitan Casualty Insurance Company, Metropolitan Direct Property and Casualty Insurance Company, Metropolitan General Insurance Company, Metropolitan Group Property and Casualty Insurance Company, and Metropolitan Lloyds Insurance Company of Texas, all with administrative home offices in Warwick, RI. • Group Legal (employers with approximately 10 or more employees) through Hyatt Legal Plans, Inc., Cleveland, Ohio, or, in certain states, underwritten by Metropolitan Property and Casualty Insurance Company, Warwick, RI and in Florida provided by Hyatt Legal Plans of Florida, Inc.  • Critical Illness (employers with 500 or more employees). Transamerica: We offer the following: • AccidentAdvance, 2 • Accident Select, 2 • CancerSelect Plus, 2 • CriticalAssistance Plus, 2 • CriticalAssistance Select, 2 • CriticalAssistance Advance, 2 • TransSmile, 10 • Family Legal, 10 • MyPack, 5 • HealthPakm 2 • Trans Select 5, 10, 20, 2 • TransConnect, 2 • TransChoice Plus, 50 • TransDI Plus, 2 • TransLegacy, 2 • TransSure, 2 • Sight Select, 10 • TransSmile, 50 • Stop Loss, 51 • LifeLock, 2 (Dependent on offering and enrolling another TEB product) Unum: We offer the following: • Accident, 10+ • Specified critical illness, 10+ • Group critical illness, 250+ • MedSupport, 10+ • Term life, 10+ • Interest-sensitive whole life, 10+ • Universal life, 10+ • Group voluntary short term disability, 10+ • Voluntary individual short term disability, 10+ • Group voluntary long term disability, 10+ • Individual disability, 3+ • Group voluntary long term care, 15+ • Individual long term care, 3+ • AD&D, 25+  VSP: We offer vision benefits for small (2-9), medium (10-499) and large (500+) companies. We also provide individual plan options directly to consumers, so we are available to anyone. 2. Do you have any benefit offerings for employees that work fewer than 40 hours a week?  Aflac: Yes. All of our individual policies and group plans are available to all full-time employees (as defined by your client) that work less than 40 hours per week. Please note the following: • Individual accident and short-term disability policies — Employees must work a minimum of 19 hours per week. • Group plans (all except disability) — Employees must work a minimum of 16 hours per week. Seasonal and temporary employees are not eligible for coverage. • Employees must work a minimum of 19 hours per week for group disability advantage. Ameritas: All our benefits can be reviewed and customized to accommodate work hours less than 40 per week. Colonial Life: Yes. All of our products are available to employees who work a minimum of 20 hours a week. Employees must be actively at work and permanent employees of the employer group. Delta Dental: Yes. The client specifies eligibility rules. Our voluntary plans are a solution to the benefit needs of part-time employees, retirees, association members and cafeteria plan participants. Guardian: Yes. Guardian benefits can be offered to employees that work less than 40 hours a week. Health Net: Yes. Health Net allows coverage for full-time employees working 30 or more hours per week. Humana: Yes. Many of our groups have associates who work 20 hours a week. We also offer solutions for various groups and classes within one employer group including long-term care (employers with approximately 10 or more employees) and vision (employers with 500 or more employees), through EyeMed Vision Care. MetLife: Yes, MetLife and its affiliates work with each employer to determine the eligibility requirements for the employee population. However, we also adhere to all applicable laws and regulations concerning eligibility, which, in some states, exclude those not working more than 24 or 30 hours a week. Transamerica: Yes. Unum: Yes, our offerings are available to employees who work 20 hours. VSP: Yes. Our plan does not have minimum participation or minimum enrollment requirements. In fact, with our support of enrollment through online tools and member communications, our voluntary enrollment trends higher than the industry average. For those clients with limiting eligibility we offer an individual plan that an employee can purchase directly. 3. Do you offer flexible enrollment data, billing capabilities and processes that work with the employers’ systems instead of the other way around?  Aflac: Yes. Aflac Wingspan Enrollment Solutions help remove enrollment obstacles by streamlining the benefit enrollment process for your client and their employees. Our technology-based services can help simplify the enrollment process. We offer the following enrollment methods: • One-on-one laptop • Call center • Web self-service • A combination of the above These services are provided to your clients at no direct cost to them. Through our SmartApp Next Generation software, we can process a large number of policies quickly and accurately. Business submitted through our software, located on our agents’ laptop systems, can be issued without human intervention (resulting in a 24-hour turnaround time). These services apply to our individual policies only. Aflac has the capability to transmit billing data to an account in a variety of different ways. Aflac agents will work with your client to discuss available enrollment and billing options and determine which options will best meet their needs. Ameritas: Yes. Our goal is to keep the difficulties of administration behind our walls. We offer many flexible solutions that work with our customers’ systems. Colonial Life: Yes. Colonial Life’s Harmony enrollment system is built to accommodate the many specialized needs businesses have for enrollments and data reporting. We can provide face-to-face enrollments at any business location and during any work shift. We can also provide employers with daily enrollment reporting, such as which employees have been seen and what they’re buying. This reporting capability allows employers to assess the enrollment’s progress daily and make any necessary adjustments. Colonial Life also has several convenient electronic services for businesses that allow them to receive their bills, make payments and adjust their bills, as necessary, online. Colonial Life also offers additional flexible enrollment solutions, including the ability to integrate real time with other benefit administration and HRIS systems. This allows users to enroll in their core benefits on a vendor’s platform and seamlessly bridge to our Harmony enrollment system and elect their voluntary benefits. We also offer the option to build out our group products on another benefit administration or HRIS system for qualified cases. Delta Dental: Delta Dental has extensive experience working with a wide variety of employers’ systems and third-party administrators for the purposes of eligibility, enrollment and billing. We can accept eligibility transmission in the following formats: • Secure File Transfer Protocol (SFTP) • FTP with PGP encryption • Email with PGP encryption • Secure email monitoring system • Secure website (Delta Dental pick up or customer drop off) • Web enrollment (directly online) • Enrollment cards Guardian: Yes. Guardian offers a wide range of enrollment options including electronic eligibility files, online and paper enrollment, as well as different billing options including online, paper and electronic fund transfer to meet the varied needs of employers and ensure ease of administration. Users make all of their enrollment selections, access information, and update accounts all in one place. We offer access that gives employees the ability to do the following: • Access their portfolio of benefits online, regardless of carrier, from any location • Enroll in benefits and make life events changes online • Support employee decision-making with helpful tools (e.g., compare benefits, view plan summaries) • View detailed employee information and access a full record of employee changes • Provide electronic data feeds to carriers • View and edit bills • Export files in common formats for COBRA, FSA and payroll • Produce a current census and other useful reports Guardian’s online enrollment platform provides 24/7 online access, provider directories, a nationwide team of benefits counselors, a 24-hour employee benefits hotline, personalized enrollment kits and post enrollment support tools. Health Net: Health Net has a variety of enrollment and billing options, including electronic eligibility data transmission and Web-based tools. The company also offers a standard format for electronic eligibility transmission. If a client has a preferred format, Health Net will accommodate employers’ preferred formats whenever possible. For Medicare beneficiaries, Health Net uses paper enrollment applications. Humana: Our goal is always to put the customers’ needs first. Enrollment is accepted daily, weekly, biweekly, and monthly. Humana can accept electronic transmissions via the Internet, EDI, list enrollment spreadsheet, or via its hard copy enrollment form, which is scannable for loading into the system. The Internet, scannable application, EDI, or list enrollment spreadsheet are the most common vehicles for receiving eligibility information. The enrollment spreadsheet is an option for new and renewing groups, but it would not be utilized for ongoing enrollment. Ongoing enrollment can be supported by an EDI file, Web enrollment, or paper applications. Billing can be set up as a self bill or list bill and the client can remit payment via check or electronically online. MetLife: Yes, MetLife, for itself, and as the billing service provider for its affiliates, is able to work with virtually all types of payroll systems. Transamerica: Yes. We have paper and electronic enrollment. The latter consists of Translink, Common Census or Excel spreadsheeting of enrollment data. We also have Web bill, self-bill and paper bill. TransApp is our proprietary web-based platform designed to make enrollments easier for producers and employers. Unum: Yes VSP: Yes. We support several types of electronic eligibility submission including File Transfer Protocol (FTP) and SFTP over SSH, with or without PGP encryption. Our preferred membership file format is ANSI 834 “changes only.” You can also make real-time updates to your eligibility data online through the Manage Your Plan section on the Benefit Managers tab on, or by phone. 4. Do you offer the flexibility to conduct enrollments through one-on-one benefit sessions, group meetings, call centers, and online self-enrollments?  Aflac: Yes. We have the flexibility to conduct enrollments through each of the methods listed. However, the availability of each method is determined by the number of eligible employees. Ameritas: Yes. Ameritas Group offers many different ways to enroll depending on the needs of the customer. All options above are involved depending on the number of lives being enrolled. Colonial Life: Yes. Colonial Life offers a full spectrum of benefits communication and enrollment options, including group meetings, one-to-one meetings, call centers, co-browsing and online self-enrollments. Our national team of local, professional benefit counselors uses the Harmony enrollment system to educate and communicate benefits to employees face-to-face so they can make better benefits decisions. For hard-to-reach employees, we can offer the same benefit communication and education experience by co-browsing with employees on the Internet, meeting through a call center or setting up online self-enrollments. Delta Dental: For groups over 100, Delta Dental representatives are available to participate at open enrollment meetings and health fairs to provide information about our dental plans. We provide open enrollment support at no additional cost. Customized videos are also available in a variety of formats that explain the client’s benefit information and can be played at open enrollments or new hire orientations. Customer service is available to support questions about a plan’s coverage, but cannot accept enrollments. Enrollment is facilitated by the benefit administrator. Delta Dental gives benefit administrators access to an application that allows enrollees to select a benefit package online during open enrollment and update personal information online year-round. Guardian: Guardian offers the flexibility for employers to deliver a range of enrollment options to employees, including online self-enrollment and paper enrollment kits that can be personalized to each employee (in English & Spanish). In addition, Guardian offers additional support services, such as group meetings conducted by a certified enrollment specialist, toll-free benefit hotline in over 50 languages and turnkey employee communications at no additional cost to ensure the enrollment process is simple and easy for employers and their employees. Health Net: Health Net provides on-site support, including bilingual representatives, if needed, to help employer groups with new case and renewal enrollment meetings. Additionally, our Customer Contact Center is available to answer any questions from and prospective members and clients. Humana: One of our key selling points is the ability to offer comprehensive enrollment solutions. As part of Humana’s consumerism philosophy, our goal is to educate the employees about the products and services available to them and their families. A typical enrollment scenario may include payroll stuffers, enrollment posters, email blasts, then a face-to-face enrollment with the ability to capture any other associates through our call center or online enrollment capabilities. MetLife: Yes. MetLife’s simplified approach to enrollment leverages easy-to-use materials that help make the process smooth and drive employee engagement and participation. MetLife and its affiliates conduct enrollments/application processes through group meetings, our call center, and online. We work with the broker and employer to determine which enrollment/application channels will provide the best experience for a particular employee population. Transamerica: Yes. We offer all of these options. Unum: Yes VSP: Yes. VSP will process the eligibility information provided by clients. Our Customer Service staff, IVR, and website are available to assist employees during the enrollment period. Here are some options employers can choose from to fit their needs: • Member benefit summary customized with plan coverage and explanation on how to use the benefit, • Robust social media support across numerous channels including the opportunity for one-on-one interaction. • Collateral that educates on the importance of annual eye exams and how eyecare can affect your overall wellness. • Promotional giveaway items for employee benefit fairs, • Special activities to educate employees about eye health and protection. 5. Do you honor broker-of-record letters?  Aflac: Yes. Ameritas: Depending on the situation, we can honor them. Blue Shield: Yes. Colonial Life: Yes. Delta Dental: Yes. Guardian: Yes, Guardian honors broker-of-record letters. Health Net: Yes. Humana: Yes. Additionally, all of our broker contracts are vested. MetLife: Yes, MetLife will honor any written request from an authorized officer of a policyholder to recognize a broker or other intermediary as”broker-of-record” for purposes of providing such broker or other intermediary with information and/or paying commissions, provided of course that such request is not inconsistent with law or any in-force compensation agreement. Transamerica: Yes. Unum: Broker-of-record letters apply to voluntary at a case level (while the individual policies remain vested) VSP: Yes. We do honor broker-of-record letters from the client. 6. Do you offer simple and hassle-free account billing and payment processes?  Aflac: Yes. Our goal is to make billing and payment of premiums simple and hassle-free for your client. Aflac’s systems are flexible enough to accommodate a variety of billing methods and handle almost any type of billing layout. Your client can be billed electronically, via paper, or your client can participate in Aflac Wingspan Online Services for accounts. Depending upon the billing method selected, your client will receive an invoice containing the premium amounts due for the policies of the employees participating in our plans. The payroll-deducted premiums for the employees may then be remitted to Aflac via check, wire transfer, or through an automated clearinghouse. Ameritas: Absolutely, our goal is to take the burden off of our customers. We listen to their needs, then enhance our billing and payment processes whenever necessary to make sure we’re meeting those needs. Colonial Life: Yes. Colonial Life offers many electronic services for businesses that allow them to conduct transactions online such as receiving their bills, making payments and making any necessary billing adjustments. Delta Dental: Yes. Delta Dental offers its clients ease of administration with our online billing and reconciliation application that allows benefit administrators to view, pay and reconcile enrollment online. Online features include the following: • Invoice Presentment — It shows the details of a selected invoice. The benefit administrator can do the following: attach a note to an invoice and submit back to Delta Dental’s Enrollment & Billing department, download an invoice and save it as an Excel spreadsheet, and have easy access to current and historical invoices and their associated notes • Payment — It provides a convenient and secure method for invoice payments with the option of paying invoices online or printing or mailing the remittance statement with payment. The benefit administrator can view and track payment history. • Group reconciliation — Benefit administrators can submit enrollee additions, changes, and terminations. Tools automatically compare a Delta Dental invoice to client’s remittance file. The administrator can view and/or download results and view of the line-item adjustment summary.  Guardian: Yes. Guardian offers a range of billing and payment options from online to paper to electronic fund transfer to help meet the varied needs of employers and ensure ease of administration. Health Net: Yes, Health Net offers simple, hassle-free account billing and payment processes including Web-based tools to help our clients and their brokers. Humana: Once a case is sold, a dedicated account installation manager will implement it. Each case will also be assigned a dedicated billing representative who will ensure that the monthly bill is timely and accurate. MetLife: Yes. A single bill file platform is available for all voluntary benefit group products, which allows a single customer payment on a per- pay period or monthly basis. Unlike the other group products, MetLife Auto & Home enrolls employees individually Transamerica: Yes. Unum: Yes. VSP: Yes. A binder check is not required with VSP. We can provide monthly online billing as an option through the Manage Your Plan section on the Benefit Managers tab of Online billing will allow clients the option to view and/or pay monthly administrative statements. 7. Does your billing system allow plan administrators to make online deletions and changes to their plan account?  Aflac: Through Wingspan Online Services for Accounts and Online Billing your clients can safely update, reconcile, and pay their Aflac invoice electronically. This automated service enhances accuracy, speeds transactions, and minimizes paperwork. Your client will save time and money as their electronically remitted payments and changes are processed faster. Ameritas: Yes Colonial Life: Yes, Colonial Life offers online billing capabilities. A plan administrator also has the ability to make changes online, as well as update employees’ coverage and general information through our secure website. Delta Dental: Yes. Delta Dental’s online eligibility management system allows the clients’ representatives to add or terminate enrollees and dependents and modify enrollee information through a secure website in real time. Guardian: Yes. Guardian’s benefit Website offers a one-stop source for plan administrators to manage their account and request plan changes online, including submitting eligibility changes that affect their bill. Plan administrators have the flexibility to recalculate their bill online to take any eligibility changes into account so they can adjust payments accordingly. Health Net: Yes. Plan administrators can make most enrollment changes online. Humana: Humana does not currently have online administration for the proposed products. MetLife: Yes. Through our online billing system per pay period deduction amounts can be changed in accordance with each payroll run. Unlike the other group products, MetLife Auto & Home enrolls employees individually. Transamerica: Yes. Unum: Yes. VSP: Yes. Clients have access to various online eligibility tools through the Manage Your Plan section on the Benefit Managers tab on These online tools will empower clients to: • Make real-time updates online • Add or terminate members • Download member lists • Change member data The eligibility management tools also give clients control of the accuracy and timeliness of membership changes, which in turn helps ensure the accuracy of billing statements. 8. Does your billing/payroll deduction process make it easy for the employer to offer multiple products?  Aflac: Employers are looking for voluntary benefit options that are easy to administer. Aflac offers many billing options designed to meet a variety of needs. Aflac provides invoices for payroll deductions after an employer makes them, which means they will never have to pay premiums out-of-pocket. Additionally, employers have access to Aflac Benefit Services, which allows them to manage their billing information faster and easier. They can view and update information, reconcile invoices, and submit service requests online, anytime. Aflac has also built flexibility into our systems so that we can handle almost any type of billing layout and accommodate several billing methods. Aflac can bill an employer electronically, online or paper. Payroll deducted premiums will then be remitted to Aflac via check, wire transfer, or through an automated clearing house. Ameritas: Yes. Making it easy to offer multiple plans is our expertise. Colonial Life: Yes. Colonial Life can enroll an employer’s core and voluntary benefits and provide the account with enrollment data on all employee elections in an easy-to-use spreadsheet. Employers can electronically submit this information through our secure website, and Colonial Life reconciles the bill to eliminate any additional work for the employer. Delta Dental: Yes. Delta Dental has several billing and payment formats available depending on the client’s plans and preference and will work with the client to determine the best process to meet their needs. The group sponsor is responsible for collecting the monthly premiums from enrollees and submitting eligibility data and payment to Delta Dental. Guardian: Yes. Guardian offers a single bill (online or in the mail) for all Guardian coverages a client has in order to ensure the payment process is easy to manage. Health Net: Yes, Health Net offers consolidated billing for medical, dental, and vision products so that they appear on a single statement. Life Supplemental insurance is billed separately. Humana: Humana supports most payroll deduction methods, combined with a variety of invoicing options. Currently, we support the following deduction frequencies: biweekly, every four weeks, semi-monthly, and monthly. Our current invoicing methods are monthly, every four weeks, semi-monthly, and 9 or 10 invoices a year. (This option, which is also known as “skip billing,” is typically used by school districts.) MetLife: Yes. MetLife can allow for a single voluntary benefit deduction for numerous benefits or separate deductions for each benefit on one single bill. Transamerica: Yes. We offer list billing. Unum: Yes. VSP: Yes, We can tailor payroll deductions to meet a client’s needs.  9. Does your system offer online searches for employee policy status, coverage effective dates and policy/coverage type?  Aflac: We offer online services for policyholders — the fastest most convenient way to access and update their account information. Policyholders can log on to 24/7 to do the following: • Download claim forms and check claim status • Access policy information • Update personal profiles • Request forms or copies of their policies • Obtain contact information of their Aflac agent • File claims quickly using Aflac SmartClaim Ameritas: Yes Colonial Life: Yes. The plan administration section of our website offers online searches for employee policy status, coverage effective dates and policy/coverage type.  Delta Dental: Yes. Delta Dental’s online eligibility application allows benefit administrators to view and maintain coverage effective dates and coverage types, make real-time updates to eligibility data and improve the efficiency, accuracy and security of eligibility reporting. In addition, Delta Dental’s website,, provides useful features to registered enrollees behind a secure sign-on, including the ability to view benefits and eligibility information, print ID cards, verify plan deductible and maximum information, and view claims status and claims history. Health Net: Employees/members can confirm their coverage effective date and policy/coverage type online or by calling Health Net’s Customer Contact Center. Humana: The employee can go online to view any EOBs about any of the health-based products. Guardian: Yes, Guardian’s benefit Website offers a one-stop source for plan administrators to manage their account online, including look ups for an employee’s policy status, coverage effective date and policy/coverage type. MetLife: Our online billing system allows the employer to sort the bill by different criteria for group products. MetLife Auto & Home enrolls employees individually. Transamerica: Yes. Unum: No VSP: Yes. Clients have access to various online eligibility tools through the Manage Your Plan section on the Benefit Managers tab on These online tools will empower clients to: • Make real-time updates online • Add or terminate members • Download member lists • Change member data The eligibility management tools also puts clients in control of the accuracy and timeliness of membership changes, which in turn helps ensure the accuracy of billing statements. 10. Do you offer downloadable claim forms?  Aflac: Yes. Policyholders may download claim forms from They also get tips on expediting forms and a direct link for sending a message to our Claims Department. Aflac also offers SmartClaim, an online claim filing process. Ameritas: Yes Colonial Life: Yes. Policyholders and plan administrators can download and print Colonial Life claim forms on the company’s website at Delta Dental: Yes. However, our network dentists agree to submit claims on behalf of the enrollee and to accept payment directly from Delta Dental. The only time enrollees may be responsible for submitting a claim form to Delta Dental is when non-network dentists do not submit on the patient’s behalf. In these rare instances, the enrollee may download and print a claim form directly from our website. Guardian: Yes, Guardian’s benefit Website offers a one-stop source for plan administrators to manage their account online, including the ability to download claim forms or e-mail a claim form directly to someone. Health Net: Yes. Employees/members can find claims forms on Humana: Yes. PDFs of all claim forms can be downloaded from the Website. MetLife: Yes, for several product offerings that require claim forms. In addition, MetLife Auto & Home accepts towing claims online in many states. Transamerica: Yes. Unum: Yes. VSP: Yes. 11. Do you require carrier reps. to have a comprehensive knowledge of all of the products they deal with? Aflac: Yes. Training for Aflac agents hits every facet of Aflac’s plans and sales cycle, such as field-tested scripts, brochures, one-on-one mentoring and online courses. Here are a few of the resources available to our agents: • New Associate Sales School (features comprehensive training sessions for new sales agents) • Ongoing training on new plans, services, and technology led by experienced trainers in a classroom setting • Coaching and mentoring from sales managers and veteran agents • Specialized training. Ameritas: Yes. Our reps are subject matter experts on all products they sell. • Continuing education via Aflac University courses online (provides product, leadership, and industry training for agents at their convenience) • Webinars and other online training materials available through Aflac’s Web site With the years of experience of Aflac’s District, Regional, and State Sales Coordinator and our extensive training, agents have the knowledge to provide the best service to your client and their employees Colonial Life: Yes. Colonial Life has a 10,000-member national organization of benefits professionals. These individuals receive comprehensive product training through Colonial Life College on both voluntary products and the employer’s core benefits, at the employer’s discretion. One of our areas of expertise is helping employees better understand their benefits programs, uncover their unique insurance needs and select the coverage they need to protect themselves and their families from financial risk. Delta Dental: Yes. Throughout the year, we provide support through continuing education for consultants and brokers, such as lunch-and-learn presentations, CE courses and personalized support from our sales staff. Guardian: Yes. Guardian sales representatives achieve a high level of comprehensive knowledge of the Guardian products they present through intensive and ongoing training. Health Net: Yes. Health Net’s Sales and Account Management teams must have a comprehensive knowledge of all Health Net products that they offer and support. Humana: Yes. Each sales representative must go through an extensive sales learning academy, pass multiple tests, and continue to be accredited each year. MetLife: Yes. Our licensed representatives specialize in voluntary benefits and have extensive experience in designing benefit programs. Transamerica: Yes. We require study of all Producer Guides and signed acknowledgments from producers. Unum: Yes, we have an extensive training process. Sales reps are expected to have an extensive and comprehensive knowledge of our group and VB products. Their first year is dedicated to development, with a nine-month self-directed process of activities and testing. VSP: Yes. VSP expects our sales and service reps to be subject matter experts in vision care. We provide on-going training and support tools to ensure our reps have all the information they need. 12. How does your company support a good working relationships between brokers and carrier reps?  Aflac: Aflac offers complete insurance broker training, personalized support, sales materials, industry leading tools, and competitive compensation. Aflac is not about ìonce and done.î We are committed to providing continuous training, to our brokers, on the latest news and information, and presentations on industry topics and continuing education. In addition, our internal insurance broker team is always available to answer questions and provide personalized support. Ameritas: Relationships are key with our brokers/producers. Our goal is to provide solutions they can offer our customers throughout the life of our relationship. Our service is not just at the beginning of a sale; it remains throughout the process and for the life of the case. This takes great relationship skills among all partners. Colonial Life: Colonial Life places a high priority on working with brokers to help solve their clients’ benefit challenges. Colonial Life has regional broker marketing managers who are dedicated to strengthening broker relationships nationally and regionally, supporting national alliance partners and interacting with worksite specialist brokers. Because of our dedication to broker marketing, brokers have named Colonial Life their top choice eight years in a row in a nationwide readers’ survey conducted by Benefits Selling magazine. Delta Dental: Delta Dental focuses on providing brokers and consultants easy access to their client’s data during the RFP and renewal process. We believe that we provide more hands-on service than any other dental carrier — both before and after the sale. Guardian: With one of the longest-tenured sales forces in the employee benefit industry, Guardian has a history of understanding the needs of growing businesses, which strengthens good working relationships. Guardian works to give brokers more ways to take good care of their clients. Our flexible and comprehensive product portfolio and responsive, personalized service give support to local relationships and help ensure client needs are met. Health Net: To support the needs of our brokers and reps, Health Net has a dedicated account management team. We give small business group brokers direct access to account management teams responsible for territory and broker assignment/relationships. Brokers also have immediate, toll-free access to the Account Management team during business hours. In addition, our Account Service Unit within Health Net’s Customer Contact Center can provide claim and benefit information quickly. Humana: Humana has a long history of strong relationships among brokers and our internal representatives. Brokers are integral to the success of our business and we provide opportunities, such as field advisory counsels, as a way for brokers to help develop the framework for developing new products and services that they believe are important to our employer groups. It is through these continued initiatives that we create a partnership between our sales associates, our brokers, employer groups, and the employees.  MetLife: Our representatives work closely with brokers and consultants to help provide solutions that meet the needs of their clients. Transamerica: Corporate home office visits are regularly scheduled along with continuing education seminars, and sponsorship of educational workshops. Unum: Yes, Unum has strong relationships with its sales partners throughout the United States, with 40 field offices that provide local sales and service support. Unum provides broker training opportunities throughout the year, including CE course offerings; publishes a quarterly newsletter for brokers; and welcomes brokerage firms to its home offices for information sessions and tours of its claims and service operations. VSP: Strong communication between brokers and sales and service reps is key. We provide newsletters to keep brokers informed of changes and have frequent touch points with them to ensure their familiarity with our resources and training. We also keep brokers in the loop on client issues. 13. Do you offer marketing materials that are easy to present and simple for clients to understand?  Aflac: Your client’s Aflac service team is dedicated to working with them to ensure that the marketing campaign they select best suits their employees’ needs. All benefit education material is provided at no direct cost to your client. Here are a few ways we can educate your client’s employees about our plans and services: posters, flyers, brochures, payroll stuffers, flash presentations, an account specific website, employer Website information, newsletter articles, and e-mails. Ameritas: Yes. Ameritas Group insists on providing marketing material that is easy to understand. This is maintained throughout all our material, including correspondence. As far as we’re concerned, insurance does not need to be complicated. Colonial Life: Yes. Colonial Life realizes benefits and insurance terms can be complicated. That’s why the company’s marketing materials are easy to understand. Simplified enrollment materials help employees better understand their insurance needs so they can make better decisions to meet their needs. Delta Dental: Yes. We have a strong commitment to educating all of our customers. For brokers, consultants and benefit administrators, Delta Dental sends regular email newsletters with dental benefit news and updates. Delta Dental also offers information online covering our products, dental benefit pricing and sales, an RFP submission checklist and a benefit administrator support guide. Guardian: Yes. From marketing materials shared with brokers to bound enrollment kits personalized to each employee and beyond, the foundation of Guardian’s communications are centered on being easy to present and simple for clients to understand. Health Net: Yes, Health Net takes great pride in the ease of use of our marketing materials. For example, Health Net has received tremendous positive feedback from brokers on “The Desk Topper,” a visual aid that helps small business group brokers better understand our full portfolio of plans. Humana: Yes. We have a comprehensive suite of materials that brokers can present to employers and another set of materials that are designed for the employees. Our research has shown that employees want benefits that are concise and easy to understand and our marketing materials reflect their needs. MetLife: Yes. We offer a broad range of materials that are easy to understand and demonstrate the value of voluntary benefits to employees. MetLife will work closely with brokers and their clients to understand an employer’s workplace culture, communications style and preferences. This approach, coupled with our experience and knowledge of proven communications practices, will help to ensure that the simplest and most effective communications are implemented. Transamerica: Yes. Unum: Yes VSP: Yes. We review communication materials annually to ensure they are providing the best resource for brokers. Additionally we are always evaluating new pieces to make sure brokers have all of the tools they need. For example, we have multiple social media sites to help educate clients’ employees on the benefit of vision care. 14. How do you track the quality of the customer service you provide to employers? For example, do you set annual service goals and measure and report results?  Aflac: We constantly measure our customer satisfaction level with policyholders and business accounts in a variety of ways, such as surveys and audits. We monitor satisfaction with the total Aflac experience as well as satisfaction with enrollment, claims and billing. Our customer service quality program is administered by the Administrative Best Practices Quality Department. Each major business function, (i.e. primary, claims, and specialty) is sampled monthly. Additionally, for quality scoring, Administrative Best Practices guarantees a minimum of five audits per month for each customer service center representative. All scoring and error trending are reported weekly, monthly, and quarterly to management. Our Internal Audit Department also conducts audits by line of business in addition to their annual assessment of internal claims controls. Ameritas: All Ameritas Group’s customer service is measured through metrics down to the individual customer service associate. The tracking is done through our own systems and is based on all the major drivers of satisfaction for our customers. All metrics are integrated into our associates’ salaries to assure common drivers of service. Colonial Life: Colonial Life provides superior customer service to all of its customer groups: brokers, employers and policyholders. The company sets internal annual customer service goals and results are measured quarterly. Colonial Life also works with independent research firms to conduct ongoing surveys of plan administrators and policyholders and reports those results through news releases and a quarterly service report card on its website. In addition, all employees who meet with a Colonial Life benefits counselor are asked to rate their one-to-one benefit counseling experience during their enrollment. Every account participating in the post-enrollment survey receives a report card with the survey results. Delta Dental: To ensure we consistently provide quality customer service, Delta Dental records all incoming customer service calls and actively monitors a random sample of calls to identify areas for ongoing training and service improvement. Customer Service management is responsible for evaluating politeness, professionalism, responsiveness and accuracy of information provided. Service goals are tracked daily, measured globally and reported annually. Delta Dental also conducts random surveys of its members to measure, among other things: • Satisfaction with Delta Dental, our benefit plans, the quality of our customer service, our claims processing. • The professionalism of the dentist and dental office staff and satisfaction with the treatment provided. Guardian: Guardian sets service goals, and tracks and reports the results each year. Health Net: Yes, Health Net sets goals and tracks performance against key service metrics. We also conduct customer satisfaction surveys about Health Net’s services and support. Information is also gathered on customers’ perceptions of other health care insurers to provide Health Net with competitive benchmarks. Humana: Humana has established metrics for each division of the company. Our most recent metrics are listed below: • Response time: 70 percent of calls answered within 30 seconds • Abandonment rate: An abandonment rate of 5 percent or less • Hold time: Hold time is encompassed in average handle time (the time is takes to service a call). The goal is to maintain a less than 30-second hold time. MetLife: We provide utilization and participation reports to employers at their request. We also monitor our customer satisfaction levels through our call center on an ongoing basis. Transamerica: We track customer service results according to average answer speed, abandonment rates, average turnaround time, and qualitative analysis. Annual goals are set, monitored and reported for performance improvement. Unum: We certainly set goals around responsiveness and accuracy of service. We also have a quality assurance program that checks to see if we delivered our services in a timely and accurate manner as well. Additionally, we survey customers several times each year to better understand how they view their Unum experience. VSP: Our award-winning and industry-leading customer service team’s goal is to simplify our clients’ administrative work and help our members understand and use their benefits.  We back this goal by quarterly monitoring of call center management guarantees: Every year since 2002, VSP Customer Service has consistently received a wide range of customer service awards from the Service Quality Measurement (SQM) Group Inc. These include: • Call Center of the Year • Call Center World Class Call Certification • Highest Customer Satisfaction by Industry: Insurance • Highest Customer Satisfaction by Industry: Business to Business • Highest Employee Satisfaction for the Call Center Industry • Most Improved Call Center Employee Satisfaction • World Class Certified CSRs • World Class Certified Supervisors SQM is a leading North American call center industry research firm “voice-of-the-customer” expert for improving organizations’ first call resolution, operating costs, employee and customer satisfaction. 15. Do you have an established local sales and service team that can provide critical service in the same cities that the broker’s clients are in?  Aflac: Yes. Aflac is represented by more than 70,000 licensed independent sales agents and brokers throughout the United States. Our certified enrollers are available to service multi-location accounts and we have a national sales coordinator team to manage these relationships. Ameritas: Yes, Ameritas has both local and remote service teams to provide all critical service. If claims information is needed after hours, our customer connections department is open until midnight central standard time. Colonial Life: Yes. Colonial Life has a national team of nearly 12,000 sales professionals who provide local enrollment support and service for its broker partners’ clients. Many of the company’s accounts have thousands of employees in dozens or even hundreds of different locations across the country. Colonial Life’s sales representatives provide employers with valuable services at no direct cost, such as free dependent verification, WellCard discount program, wellness benefits communication and more. Colonial Life benefits counselors can meet with employees at each location and conduct individual counseling sessions with them. Because the benefits counselors are local, they can be on hand to help out with next year’s enrollment and any ongoing service needs. The goal is for the company’s benefits counselors to build strong relationships with employees in the account. Delta Dental: Yes. Every client is assigned a designated account manager who is responsible for overseeing program implementation, participating in information meetings with benefit managers and enrollees, as needed, resolving day-to-day issues, and participating in subsequent renewal activities. Delta Dental of California has sales offices in San Francisco, Sacramento, Cerritos, San Diego and Fresno Guardian: Guardian has local and regional sales offices nationwide to support the needs of brokers and their clients. Health Net: Yes, Health Net has several regional sales and service teams throughout California to support brokers and their clients. Humana: We have account executives in our Northern and Southern California sales offices, which can handle calls as part of our single point of service. Humana also has trained specialists within a central Customer Care team who engage in answering customer questions. We take pride in serving our customers. When a policyholder contacts us, they experience a compassionate specialist who provides accurate information in an efficient manner. Our specialists are empowered to assist callers completely, owning the situation until resolution. If necessary, this includes escalating to a leader or to another department to meet resolution as quickly as possible. Call volumes are tracked and reviewed monthly to ensure we are assisting callers effectively. Customer Care team functions are performed in De Pere, Wisconsin, where Customer Care specialists are available from 8 a.m. to 6 p.m., member time zone, Monday through Friday. The toll-free number for the Customer Care team is 877-378-1505. MetLife: Yes. We have representatives that specialize in voluntary benefits located in major cities throughout the U.S. Transamerica: Not in the same city. We have local representation and a dedicated account manager for service support assigned to each region. Unum: Yes, Unum has 40 local sales and service offices located throughout the U.S. with four locations in California. VSP: Yes, We’re headquartered in California and have an Eastern Operations Center in Ohio. In addition, we have 25 regional sales offices across the country to provide local service. 16. Do you have a sales rep. and a service rep? (The sales rep helps the broker market and position products, manage blocks of business, and develop target markets and the service rep. helps implement and fulfill account enrollments.)   Aflac: Yes. Aflac is represented by more than 70,000 licensed independent sales agents and brokers throughout the United States. Our certified enrollers are available to service multi-location accounts and we have a national sales coordinator team to manage these relationships. Ameritas: Yes. Colonial Life: Yes. Colonial Life’s national team of sales professionals has specialized roles they perform during the enrollment process. Sales professionals work with brokers and their clients to help develop voluntary benefit strategies that will help clients’ solve their benefit challenges. Account coordinators help manage the enrollment logistics and report. And benefits counselors meet individually with all employees to educate them on their benefits, help uncover any unmet needs and select insurance plans to meet those needs. Delta Dental: Yes. To ensure that our clients receive a high level of service, Delta Dental uses a team approach to provide prompt service and rapid response. A client’s team includes a sales account executive and an account manager. Together they are supported by account management associates. Guardian: Yes. Guardian has local sales representatives to help brokers with their marketing efforts, expert teams dedicated to supporting enrollment and administration programs, and customer services representatives available to serve the distinct needs of brokers and their clients. Health Net: Yes. Health Net has sales and service representatives to help brokers and their clients. Humana: Humana provides a dedicated team of account executives, renewal specialists, and account installation managers to each case. We realize that much of the work begins after the case is sold and our goal is to provide dedicated resources for our clients for the duration of the case. MetLife: Yes. Our sales and service teams work closely together to meet the needs of our brokers and customers. Transamerica: Yes. Unum: Yes. Unum has more than 500 sales professionals across the country, backed by a local service force of 1,000 professionals. The service team includes those who support Unum Enroll, our in-house enrollment team tha tsupports voluntary benefits enrollment for employer groups of fewer than 500 lives.  VSP: Yes, we do have both sales and service reps. 17. Do you specialize in voluntary benefits?  Aflac: Yes. Aflac is a leader in guaranteed-renewable insurance policies sold on a voluntary basis that pay cash benefits directly to policyholders, unless assigned. With a broad range of policies and value-added services, Aflac’s offerings suit virtually every business size and type. From three employees to 30,000, Aflac fits easily within any benefits package. Many times in the voluntary insurance business, companies tend to use the same approach to market similar benefits. Aflac is different. We back our unique plans up with the following: • Innovative marketing campaigns. • Strong financial stability. • Brand recognition. • A solid company reputation. • Industry recognized and rewarded claims and customer service. Ameritas: Yes. Ameritas has been providing voluntary benefits since 1990. We consider ourselves specialists in that arena because of our extremely high satisfaction levels from our customers and our constant systems evolutions to accommodate the needs of our customers. To specialize in voluntary benefits, we believe this is critical to achieve a win/win for all. Colonial Life: Yes. When Colonial Life was founded in 1939, it sold accidental death coverage to individuals. In fact, the company pioneered the concept of offering voluntary benefits at the worksite in the 1950s. Colonial Life has always marketed only voluntary benefits, and during the 75 years it has been in business, the company has developed strong expertise and experience in the voluntary benefits industry. Delta Dental: Yes. Delta Dental has more than 55 years’ experience providing non-voluntary, partially voluntary and totally voluntary dental benefits. Guardian: Voluntary benefits are an incredibly important part of our group business. Our insurance products include Dental, Vision, Life, Disability, Absence Management/FMLA, Accident, Cancer and CriticaI Illness that can be funded on a voluntary or employer paid/contributed basis. Health Net: Health Net does not specialize in voluntary benefits. However, Health Net does offer the types of voluntary plans that are most commonly requested by our health plan customers. Humana: Yes. Humana acquired Kanawha Insurance Company in 2007. Kanawha has been providing voluntary benefits for 50 years and is a licensed insurer in 48 jurisdictions. MetLife: Yes. MetLife and its affiliates make it simple, cost-effective and hassle-free to offer and administer voluntary benefit solutions that meet diverse employee needs and enhance benefits programs. Best of all, our expertise and tools streamline the process to deliver information effectively, simplify decision-making, and increase employee engagement and satisfaction. Transamerica: Yes. Unum: Yes. Unum is ranked second in inforce premium in the voluntary benefits market as reported by Eastbridge Consulting Group in 2008. Unum leads the voluntary market in sales of critical illness insurance as well as universal and whole life insurance. VSP: Yes, a significant part of our membership is voluntary. Members sign up because they find the VSP benefit incredibly easy to use and they value the low out-of-pocket costs when compared to other vision plans.   ... Continue Reading →

Insurance Insider News
Employers Shift Health Care Burden to Employees
by Leila Morris

Employer-based healthcare plans are in a state of flux following this year’s implementation of the Affordable Care Act (ACA). Since health care costs in retirement have long been considered a major source of financial stress, changes to coverage are affecting how Americans tackle retirement planning, according to an analysis by Mike Flower and Brad Bofford, managing partners of Financial Principles, LLC in Fairfield, NJ. Until recently, most of the focus of the ACA has been on coverage for the previously uninsured or of those covered through individual health plans. But the conversation is shifting toward how insurance exchanges are affecting employer-based group plans. While information on enrollment and coverage changes will not be available for some time. Principles, LLC has worked with several small businesses that have switched their healthcare coverage this year from group pricing to individual pricing. Traditionally, employees would choose from price-fixed categories such as, married with children, married couple, single parent with children, and single person. By moving to individual pricing, coverage is based on the age of the employee, spouse, and each child — maxing out at three children. What is surprising is the time and effort that are now going into collecting the data needed to administer these plans before and after enrollment since every employee is paying a different price. Some insurance companies are increasing their premiums in order to move employees out of the top-of-the-line Cadillac plans. It forces employers to accept lesser service plans for the same price as what was paid for the Cadillac just two years ago. Increased deductibles, higher co-pays, and more restricted pharmacy benefits are just a few examples of how these changes to employer-base plans are shifting more and more costs to employees. Employees are forced to allocate more of their own money on health and less on retirement vehicles. The authors says that the market trend is moving toward more consumer responsibility and less employer control. The analysis advises employees to ask their employers following: 1. Will there be bigger paycheck deductions for employee and/or dependent coverage? 2. Are there plans to move employees into a private insurance exchange? If so, will it be within a defined contribution framework? 3. Will part-time workers continue to receive coverage? Employees are also advised to do the following: 1. Consider a high deductible health plan with an HSA, and research the federal or state exchanges. 2. While it’s tempting to reallocate money otherwise put into retirement accounts to pay for increasing healthcare costs, don’t do it. Look for other ways to cut back on spending and keep saving to ensure you have enough money to last through your entire retirement years. 3. Work with an independent financial advisor. For more information, visit ACA Hits Health Insurers in the First-Quarter Many health insurers’ first-quarter 2014 results were hurt by that fact that their income statement now includes the annual industry fee assessed under the Affordable Care Act (ACA), according to Best. The fee begins at $8 billion in 2014 and increases gradually until reaching $14.3 billion in 2018. Beginning in 2014, health insurance issuers pay an annual fee based on net written premiums. The fee is imposed on health insurers depending on the amount of the issuer’s net written premium. The Insurer Fee applies broadly to most forms of health insurance. Many insurers have increased premiums to offset the fee. The American Action Forum  estimates that the fee will result in premium increases for the average insured individual of $60 to $160 per person in 2014 and $260 for the average family. The National Association of Insurance Commissioners requires health insurers to expense the 2014 fee, which will be paid in September, in the first-quarter statutory statements rather than accruing the fee quarterly. For more information, visit . Addressing Growing Cost of Diabetes As diabetes cases increase worldwide, curbing the personal and financial toll will become a high priority, according to the American Academy of Actuaries. Diabetes is expected to become more common globally, increasing from 8.3% prevalence in adults in 2011, to 9.9% in 2030, according to data from the International Diabetes Federation. At the same time, spending on diabetes varies widely. In 2010, the United States spent $197.8 billion, accounting for 53% of global spending on diabetes, whereas India, with the largest population of diabetics, spent $2.8 billion, less than 1% of the global total. An issue brief developed by the Academy examines the projected future global prevalence and costs associated with diabetes. It also examines efforts in seven different countries (Australia, Canada, Israel, Singapore, South Africa, the United Kingdom, and the United States) to develop better ways to measure, prevent, treat, and slow the cost of, the disease. The results are cautionary yet hopeful. For more information, visit Medicaid Patients Use, Not Abuse Emergency Rooms Medicaid enrollees visit the emergency department appropriately like most patients, but have more complex health needs and less access to primary care, according to a report from the Medicaid and CHIP Payment and Access Commission (MACPAC).  Non-urgent visits accounted for just 10% of Medicaid visits to the ER, which is very close to that of the general population – about 8%. Most have serious and complex medical problems that can only be addressed in the emergency department. Given Medicaid’s historically low reimbursement rates, the shortage of primary care physicians accepting these patients isn’t surprising. The lack of access to primary care is even more acute for Medicaid patients with disabilities who are disproportionately represented on Medicaid rolls. Alex Rosenau, DO, FACEP, president of the American College of Emergency Physicians  said, “The lack of access to primary care certainly contributes to Medicaid patients’ use of the ER, but for Medicaid patients with serious mental illness, multiple illnesses and homelessness, even having a primary care physician is no bar against appropriate emergency department use. In general, the combination of poverty and illness present challenges with few genuinely simple solutions, despite misplaced beliefs that significant health care costs could be saved by keeping patients out of the ER. Efforts by various states to deny payment for Medicaid visits to emergency departments are dangerous and wrong.” For more information, visit EMPLOYEE BENEFITS Life Insurance Accounts for Almost Half of Inforce Voluntary Premium  Life insurance has the largest share of inforce voluntary premium with term and UL/WL accounting for 47%, according to a report by Eastbridge Consulting. Term insurance accounts for 37% of inforce premium based on the carriers reporting.  Disability (STD and LTD) was a distant second at 17% of inforce premium, and dental insurance was third at 16%. There were a few interesting differences in sales by product compared to the mix of inforce. Some of this reflects the typical persistency of the line (e.g.: life persists better than accident). The following shows the mix of sales and inforce by line of business: Line of Business Mix of Sales  Mix of Inforce Term 37% 22% Dental 16% 13% UL/WL 10% 7% STD 9% 14% LTD 8% 7% Accident 3% 12% Hospital Indemnity/ Supplemental Medical 2% 8% Cancer 2% 5% Vision 2% 5% Critical Illness 2% 5% Other 3% 2% For more information, visit VOLUNTARY BENEFITS Brokers Are Selling More Voluntary, but Use of Private Exchanges and Defined Contribution Is Limited  Most brokers say that the Affordable Care Act has caused them to sell more voluntary benefits, according to a joint survey from Benefits Selling and Eastbridge Consulting Group. In fact, 60% of the brokers surveyed are selling more voluntary, and 18% are selling significantly more. Despite the aggressive promotion of private exchanges (PEX) and defined contribution (DC) strategies, brokers are not rushing their clients to use these approaches. The majority of brokers suggest a PEX less than 5% of the time. Large-case brokers are more likely to recommend PEXs than are smaller-case brokers. When private exchanges are recommended, defined contribution is not often included. In fact, a majority said that DC is included less than 25% of the time. Again, among large case brokers, DC plans seem to be more prevalent. While adoption of PEXs and DC plans may be just a matter of time, the report suggests that time is not now. For more information, visit ANNUITIES Total Annuity Sales Climb 8% In the Second Quarter U.S. annuity sales reached $61.4 billion in the second quarter, rising 8% from the prior year. In the first six months of 2014, total U.S. annuity sales increased 10%, compared with 2013. “This is only the second time we have seen quarterly sales over $60 billion since the third quarter of 2011. Despite declining interest rates during the first six months of this year, fixed annuity sales continue to drive annuity sales growth,” said Todd Giesing of LIMRA. Total fixed annuity sales were $25.2 billion in the second quarter, up 34% versus prior year. Year-to-date (YTD), fixed annuity sales equaled $49.1 billion, a 39% increase from 2013. With a record quarter of index annuity sales driven by product innovation and expansion of distribution, combined with nothing to indicate that sales will drop significantly in the near future, sales may be pushing $50 billion for 2014,  noted Giesing. Sales of fixed rate deferred annuities (Book Value and MVA) grew 30% in the second quarter, compared with prior year. Fixed-rate deferred annuities reached $15.8 billion in the first half of the year, a 42% increase compared to last year. Index annuity sales grew 40% in the second quarter, setting a new quarterly record of $13 billion. This is the first time that quarterly index annuity sales have accounted for more than 50% of total fixed annuity sales, with second quarter sales accounting for 52% of total fixed sales. YTD, indexed annuity sales grew 41%, totaling $24.3 billion. Indexed annuity guaranteed living benefits (GLBs) election rates continue to be strong, with 72% electing a GLB when available (4% higher than in the first quarter). Deferred income annuity (DIA) sales reached $710 million in the second quarter, 33% higher than prior year. In the first six months of 2014, DIAs jumped 43%, totaling $1.3 billion. The top three writers continue to drive most of the DIA sales, accounting for 85% of sales. Single premium immediate annuity sales were up 37% in the second quarter to reach a record-matching $2.6 billion. LIMRA Secure Retirement Institute research shows that this is industry-wide growth — not coming from just one carrier. Variable annuity sales fell five percent in the second quarter, totaling $36.2 billion. YTD, VAs reached $70.4 billion, a four percent drop from 2013. Many of the top VA sellers are focusing on diversifying their VA GLB business. In the second quarter, a few of the top companies entered the market with accumulation focused product without a GLB rider. Election rates for GLB riders, when available, were 78% in the second quarter of 2014. For more information, visit NEW PRODUCTS Worldwide Benefits Minnesota Life and Securian Life are offering comparable and local market-appropriate benefits to employees scattered across the globe with a simplified with a multinational pooling strategy. It simplifies providing group life insurance. For more information, visit Tools For Health Agents Limelight is offering agents new tools to help individual and small business owners make sense of their employee health insurance options. QuotePad is the first live, all-in-one quote engine that provides a quick, real-time platform to quote and compare employee health benefit information. Using QuotePad from a desktop or mobile device, agents can compare thousands of health insurance plans, quote exchange and non-exchange plans, calculate costs with subsidies for individual consumers, and help employers find affordable coverage and adjust their contributions for popular tax-advantaged plans (HSA and HRA).  The proprietary technology is private-labeled allowing agents to personalize with their company logo and branding. For more information, visit Cigna Launches Retail Exchange  Cigna’s private retail exchange will be available to Cigna clients and prospective clients across all of Cigna’s U.S. markets starting September 1. The suite of products available through the private exchange includes a variety of medical, pharmacy, dental, vision, life/accident and disability plans. With Cigna’s new offering, employees can access user-friendly online, interactive shopping tools to get a personalized recommendation for benefits for themselves and their families. For employers, the exchange offers a benefits administration platform that enables them to provide employees with more choice of plan designs and enables defined contribution funding, while simplifying their administrative responsibilities and helping them control their benefit costs. Cigna’s private exchange includes 24/7 live customer service for medical and dental customers, Cigna’s broad network of physicians and hospitals and integrated health and wellness programs, and is available with both fully-insured and self-funded health benefit plans. In addition to this proprietary solution, called Cigna Guided Solutions, Cigna is actively participating in a number of private exchanges administered by benefit consultants and brokerage firms that target active employees and retirees. Cigna also offers Benefits Insight through its Choicelinx subsidiary, providing employers and brokers with customized online enrollment, decision support and benefits administration services. For more information, visit Survivorship Life Lincoln Financial Group expanded its suite of Survivorship life insurance solutions with Lincoln WealthPreserve Survivorship Indexed Universal Life (SIUL), Lincoln’s first SIUL offering. It allows advisors to implement wealth preservation and estate planning strategies for clients, while offering cash accumulation and income potential in a tax-efficient manner. For more information, visit Simplified Life John Hancock Insurance launched Simplified Life, providing a quick and easy solution to help clients meet their protection and wealth planning goals. Simplified Life is designed for consumers seeking the protection, cash value accumulation potential, flexibility and tax advantages offered by a variable universal life insurance policy – with the convenience of a quick-to-issue application process. In fact, with the product’s streamlined and transactional sales process, clients are not required to undergo a medical exam or tests — and most policies will be issued in eight days or less. For more information, visit Disability Guardian Life is expanding its Student Loan Protection Rider to be available to anyone with student loan debt. Guardian is the only individual disability income insurance provider to offer this student loan protection. Available for as little as $5 per month, Guardian’s Student Loan Protection can be obtained for  a 10- or 15-year term. For more information, visit Educational LTC Video Insurance agents and financial professionals are invited to view a video explaining ways consumers can convert life insurance policies to pay for long term care. The video was recorded at the recent national industry conference organized by the American Association for Long-Term Care Insurance. To view the video go to IN CALIFORNIA CAHU Legislative Alerts CAHU wants members to be aware of bills scheduled for hearing in the Legislature. To find out more information, click on the link below to review CAHU’s background on the bill, which includes an option to ask your legislator to take action. Protect Out of Network Options AB 2533 — OPPOSE Protect Employer Choice AB 2088 — OPPOSE Protect Consumer Prescription Options AB 1917 — OPPOSE Protect Consumer Dental Care Options AB 1962 — OPPOSE   WellPoint Changing to Anthem WellPoint, Inc. will change to Anthem, Inc. Pending approval from shareholders, the change is expected to take place by the end of 2014. The company says that it is making the change n order to reduce complexity and express its commitment as a trusted partner in health.   Anthem Signs General Agent Agreement with Warner Pacific  Anthem Blue Cross (Anthem) and Warner Pacific have re-established their general agent agreement. Anthem, said “There have been many changes to the California small group market, such as advanced renewals, the implementation of the Affordable Care Act (ACA), grandmothering, etc. Subsequently, we performed an extensive general agent evaluation. As a result, Warner Pacific and Anthem have come to a favorable agreement… This is an exciting development for the Anthem Small Group team, which provides many partnership and growth opportunities. Some of which are as follows: •Having one of the state’s largest and most respected General Agents representing our Small Group plans. •Expanding our California partnerships and distribution channel. •Enhancing broker influence and reach to promote the growth of our Small Group plans. The agreement is effective for September 1st effective dates.” ... Continue Reading →

CA Voters’ Support for Healthcare Law Increases

The federal health care overhaul is garnering more support from California voters than at any time since its passage in 2010, but they believe the state could still do more to limit the amount insurance companies can charge customers for coverage, according to a new Field Poll. Some 56 percent of registered voters support the law and 35 percent are opposed, contrasting sharply with the national average showing 54 percent oppose and 41 percent approve. Growing approval for the law in California could undercut what many considered a potent issue for Republicans heading into the Nov. 4 election. Many GOP challengers are running on a platform of repealing and replacing the law according to a recent report in the San Luis Obispo Tribune. ... Continue Reading →

Blue Shield, Anthem Bring Healthcare Into 21st century

The California Integrated Data Exchange announced plans to develop a statewide, next-generation health information exchange (HIE). This comprehensive collection of electronic patient records will include clinical data from healthcare providers and health insurers. Cal INDEX will allow physicians, nurses and hospitals throughout the state to share patients’ health information, and will provide them with the tools to help them give their patients the safest, highest-quality care possible.  The result will be one of the largest exchanges of its kind, initially providing physicians and nurses with secure, on-line access to approximately 9 million health information records – or nearly one-fourth of the state’s population according to a recent report at ... Continue Reading →