Dental
Guidelines for Evaluating Dental Plan Options
by Karen Gustin, LLIF

Is medical costs continue to skyrocket, employees are assuming more responsibility for their healthcare plan choices and costs. The Employee Benefit Research Institute reports that, although employees are interested in participating in their healthcare choices, they often feel unqualified in evaluating their options and understanding the differences in plans.
Employers need to provide quality information to help employees evaluate benefits choices and to remind them regularly of the importance of routine preventive care, especially dental, for their own health and well-being. Producers can have an important role in helping employers and employees evaluate the differences in dental insurance carriers, benefits contracts, and plans.
Every insurance carrier has its own strengths and business philosophies. Since each writes dental proposals and contracts differently, it’s hard to compare them without reviewing each component carefully. Evaluating carriers can be a tedious and time-consuming process, but is well worth the effort to find one that best meets the needs of employers and employees alike.
The following guidelines will assist producers in helping employers and employees evaluate dental carriers and plans:

Identify Differences in Coverage
Insurance carriers used to follow the same guidelines for dental coverage and reimbursement. But, there is little consistency in plan design and pricing in today’s dental insurance market. Some carriers have moved traditional procedures from basic into major coverage levels or they may update their lists of usual and customary procedures infrequently so claims are not being reimbursed at current costs. Other carriers are disallowing standard treatment services. Many carriers have changed their business practices to reduce costs and become more competitive in pricing their plans. Review the covered procedures carefully to avoid surprises when claims are filed.

Evaluate Contract and Rate Guarantees
It’s important to make sure the plan information and quotes match up. If you find a discrepancy, follow up with the insurance sales representative to find out which figure is accurate. Consider having the plan or contract rewritten to ensure that the contract and rate guarantees line up.

Clarify Reimbursement Policies for In-Network and Out-of-Network Dentists
Carriers often have different reimbursement policies, such as coinsurance levels for out-of-network dentists. When an employer switches dental carriers, the new carrier may not have a large network of dentists who have agreed to participate with the plans, which means that employees would have to choose from a limited number of dentists or go out-of-network.
Carriers may use different claim percentiles for procedures done by out-of-network dentists. Carriers should typically pay at the 90th percentile, but some take it down to the 50th percentile to reduce premiums. Make sure the carrier is basing the percentile on a Zip code in proximity to the group and not the average for the state. Also, make sure that the reimbursement level is in line with the dentists that employees are more apt to be using.

Define Variations in Actual Network Size
Insurance carriers frequently tout the size of their networks. The numbers may sound great, but verify this information. Does the panel size reflect the actual number of dentists participating in the network that patients may contact for services? If the panel size simply reflects the total number of dentists at every location, it may not offer enough dentists for some employee groups. A dentist who sees patients at more than one office location would be counted more than once even though that dentist would not be available for service in each office 100% of the time.

Verify Information on Dental Offices
Some insurance carriers are disciplined about annually verifying the information about providers in order to maintain a high level of quality. Others rely on information gathered through questionnaires sent to the dental offices for updates on dentist credentials and status changes. Inaccurate records may slow claims processing and employees may incur higher out-of-pocket costs. If an employee visits a dental office that is listed as a member of the dental network, but the dentist is not a registered member, the employee would pay more because services would not be covered at in-network levels. To avoid this problem, ask the dental carrier to provide dental office locations and names of dentists participating in the network.

Review Carriers’ Records
Check the ratings history for excessive losses incurred to gain new business, frequency of renewals, and persistency in maintaining groups as clients. Some carriers price plans unusually low the first year to gain new business, but increase rates at renewal time to cover losses from the first year. While the process takes time, this due diligence will help you find the best benefits partner for employers. If the dental carrier doesn’t have the experience and actuarial team support to design plans with predictable renewal premiums, employees may drop the benefit when the carrier raises rates to recover losses incurred during the previous year.

Consider Carriers with Flexibility and Plan Choices
Employers experience changes in economic and business conditions several times a year, requiring them to gear up to accommodate new staffing needs or trim staffing to adjust to a down-turn in the product cycle. Benefit plans may need to be adjusted accordingly. But, many insurance carriers offer dental plans with limited options in order to reduce premiums. They don’t have the flexibility to rewrite plans to fit employers’ needs.
Consider recommending a carrier that offers plan designs that can be modified easily to fit changing benefits needs. In the process, you may significantly enhance your relationship with the employer.

Making Choices: Details Make a Difference
The details of an insurance plan will make a significant difference in the quality of service and satisfaction among employers and employees. Before making a recommendation, review the contract for prerequisites and restrictions; verify the flexibility of the plan design; and check the network panel to ensure that the employer’s expectations will be met. Once a carrier and plan are selected, work with the employers to communicate benefits options to employees and help them select the plan that will best fit their needs.
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Karen M. Gustin, LLIF, is vice president-group marketing and managed care for Ameritas Group Dental and Eye Care in Lincoln, Neb. Gustin began her career at Ameritas in 1983. Twelve years later, she was appointed to assistant vice president of Marketing and Managed Care. In 2001, Ms. Gustin was promoted to her current position, with responsibilities for group communication, advertising, product development, market research, training, and PPO functions. Ms. Gustin is on the board of the National Association of Dental Plans, the foundation board, and chairs its Statistical Task Force. For assistance in understanding dental and eye care plans or comparing coverage options, contact the Ameritas Group Marketing Department at 800-776-9446.