Up, Up & Away With Dental Sales
Get Carried Away with Our Annual Dental Survey

Welcome to Part 1 of California Broker’s 2009 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. Look for Part II in the August issue. Read the responses and sell accordingly.

1.) What types of plans do you offer?
Aetna: We offer the following dental plans:
• DMO/managed dental
• PPO and indemnity (available in multiple plan designs)
• PPO Max
• Freedom of Choice (offering members their choice of two dental plans)
• Aetna DMO Access
• Aetna Dental Care Reward
• Aetna DentalFund (our consumer-directed dental plan)
• Vital Savings by Aetna, a dental discount program.
Ameritas: Ameritas has 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. For large groups, we also offer EPO plans.
BEST Life: In California we offer PPO, MAC and Indemnity dental plans. We also offer employer-contributory PPO and indemnity dental plans to 2-4 groups. All our dental plans are available on a voluntary basis to groups enrolling 5+. Group term life and vision coverage is also available.
Blue Shield: Group dental HMO and PPO plans are offered on a contributory or voluntary basis. These plans can be sold as riders to health plans or on a stand-alone basis. Individual and family plans (IFP) DHMO and DPPO plans are available to our IFP medical members as riders to health plans.

CIGNA Dental: We offer the following plans:
• DPPO
• DEPO
• CIGNA traditional -- dental indemnity
• DHMO standard plans and split co-pays for general dentists and specialists
• DHMO value plans – including flexible plan options with alternative treatment provisions.
• CIGNAFlex Advantage (monthly switch feature between a DHMO and DPPO or dental indemnity plans)
• CIGNAPlus Savings, a dental discount card program (not an insurance product) that helps meet the needs of employers looking to offer an extra benefit to part-time employees, seasonal employees, or retirees. This is an affordable alternative to offering traditional dental insurance that provides access to dental care services at discounted rates
• Dental Shared Administration -- provides qualified funds and clients the administrative flexibility to pay their own dental claims and still take advantage of CIGNA Dental DPPO negotiated discounts and utilization management tools. 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 modules, 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.
Delta Dental: Managed fee-for-service, PPO, and DHMO group dental plans; individual DHMO dental plans and group HMO vision plans.

Dental Health Services: Prepaid dental benefit solutions for individuals and groups. We also offer PPO, EPO, and indemnity (reimbursement) products for groups and ASO for self-funded groups.

Golden West: Golden West Dental & Vision offers a comprehensive line-up of dental plans and products that include: PP0 (nationally), dual option, triple option, stand-alone and DHMO for individuals, small groups, and large groups. We offer voluntary dental plans for small and large groups.

GroupLink: Stand-alone group dental and vision plans. Indemnity PPO, voluntary, and employer paid. Self-funded administration services are also available. We also fully insured vision programs and one-life dental plans for individuals and families.

Guardian: Guardian offers active and passive PPO, network access, indemnity, and DHMO plans on a stand-alone basis or in dual choice arrangements with an option to elect Monthly Switch. In addition to the dental plans, we also offer vision products. Our plans are available to large and small groups to self-funded, employer-paid, contributory and voluntary groups, and on a stand-alone basis, subject to certain restrictions. Guardian’s flexibility allows us to customize plans based on the needs and prices points of the employer group.

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.

HumanaDental: PPO, Prepaid/DHMO, Traditional Preferred (passive PPO), and Preventive Plus plans available on a voluntary or employer-sponsored basis. Administrative Services Only plans also available.

MetLife: Dental PPO, co-pay, dental HMO and Indemnity plans, with flexible designs and funding arrangements available to accommodate employer plan requirements — single or multi options, fully insured or self-funded as well as a full range of contribution options. (Group dental insurance policies featuring the Preferred Dentist Program are underwritten by Metropolitan Life Insurance Company, New York, NY 10166. Dental HMO plans are available in Calif., Fla. and Texas only, through a domestic company in the applicable state named SafeGuard Health Plans, Inc. The SafeGuard companies are part of the MetLife family of companies. “Dental HMO” is used to refer to products that may differ by state of residence of enrollee, including but not limited to: “Specialized Health Care Service Plans” 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 dental FFS, PPO, indemnity and DHMO plans, and a hybrid PPO/discount plan, Concordia Access. Fully insured and ASO funding arrangements are available based on group size. Most plans can be offered on an employer-sponsored or voluntary basis.
Western Dental offers a DHMO mixed-model provider panel comprised of contracted independent general dentists and specialists along with Western Dental’s employee dentists and specialist who work in the company-owned Western Dental Centers. Western currently operates over 220 general dentistry and orthodontic offices throughout California and Arizona.

2.) How do plans you offer for the individual and 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 make it easy for our customers to choose from plans that are competitive in the market.

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.

BEST Life: One of our PPO/indemnity dental product lines offers customized plans and provides coverage for posterior composites to groups with 5+. Depending on the plan selected, implants are standard for groups with 10+. A dental supplemental accident benefit is standard on all our dental plans, regardless of size.

Blue Shield: Rates for our large group dental HMO and PPO plans are
typically lower than our small group and IFP plans. However, rates may vary depending on the actual plan design. We allow dental plans to be customized based on the clients’ needs for large groups of 300 or more employees.

Anthem Blue Cross: Anthem Blue Cross normally uses the same provider network for individual, small group, and large group. There are different underwriting considerations (waiting periods, for example) for the individual and voluntary group products. Our larger groups can customize benefits to meet their employees’ needs.

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 Dental does not offer plans to individuals. Larger groups generally want more robust and flexible plans while smaller groups gravitate toward standard offerings. We can custom-fit plans with DPPO to offer a variety of cost-saving options for employers that want to keep claims costs low. These options include missing tooth limitations, class shifting, low maximums, varying coinsurance, deductibles, waiting periods, etc. Our DHMO plans start with basic coverage, specialty discount, split co-pays, and other cost savings mechanisms and go up to very rich, low-co-pay plans at the higher end of the cost spectrum. Through recent acquisitions, CIGNA can also deliver solutions for the smaller employer segment through the Starbridge limited benefit dental plan as well as leveraging the small segment capabilities of the former Great West distribution channel. We provide the full spectrum of products, each with varying price points based on product, funding type, and voluntary vs. contributory.

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 two different programs — one for individuals and families and one customized for seniors. The individual and family plan offers a wide range of covered services. The senior plan is designed to offer services most utilized by this particular population, which enables us to keep the rates low. (Waiver of plan co-payments and deductibles is considered fraudulent and is handled by notifying the dentist of the violation and possible network termination.)

Dental Health Services: All plans and premiums are developed based on individual and group needs. Co-payments and treatment options vary by plan, from very low levels of coverage all the way up to plans that provide member care at zero out-of-pocket cost. Customized plan designs are always available.

Golden West: Our small and large group products are specific to location, size, industry and contributions. While larger groups have more flexibility in customizing benefit options than do smaller groups, Golden West still focuses on plan flexibility for all size groups. This enables employers to custom design their products for their personal needs.

GroupLink: We use a state of the art, online system for group proposals called “myGroupLink.” This is available for takeover groups from two to 99 lives. Groups of 100+ with takeover are done in house. Our rates generally are competitive with similarly designed plans from other carriers.
Guardian: We offer the same PPO provider panel to small groups as to large groups. We offer an array of cost-reducing options, such as waiting periods, deferral of services, tie-ins to Guardian vision or Guardian medical products. Rates are based on group size and participation requirements. For DHMO customers, we also offer the same DHMO provider panel to small groups as to large groups. Rates are based on group size and participation requirements. We do not offer dental coverage to individuals.

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 have two comprehensive Health Net Plus DHMO plans from which to choose. 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. Customers who see dentists participating in the HumanaDental PPO Network get deep discounts. All our dental plans provide employees with incentives for preventive dental care, which promotes their overall health. A free vision discount program is included.

MetLife: MetLife offers individual plans in Calif., Fla. and Texas though SafeGuard, a MetLife company. Dental HMO plans offered to individuals provide a mid-range level of benefits at a monthly fee that is slightly higher than rates quoted for groups. Small groups (2-50 eligible lives) have a broad range of options within the Dental PPO and Dental HMO benefit plans. Rates are based on location, plan chosen and participation. Risk evaluation is taken into consideration when underwriting larger groups; individual plans are quoted using shelf rates.
Securian Dental: Small group rates are developed on a pooled basis. Large group rates are developed on a custom basis.

Principal Financial Group:  The only significant rating difference pertains to experience rating which is used on groups with 100+ employees.  There are also, however, a few benefit limitations on very small cases which applies to groups under 10 lives.

United Concordia: The primary factors that affect our group rates are location, experience, and credibility. While larger groups have more flexibility in customizing benefit options than smaller groups, United Concordia offers an array of standard group products and options that provide small businesses with cost effective, quality choices.

Western Dental: Western Dental Benefits Division recently launched the DHMO Series 7 dental plans. Our new plans increased the number of covered procedures and now include coverage for cosmetic procedures and implants

3.) Is your plan better than previous incarnations? If so, how?
Aetna: Preventive Care -- a low-cost dental option that covers preventive and diagnostic procedures from 70% to 100%. Members 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 -- DMO Access offers the advantages of a DMO plan, such as lower out-of-pocket expenses, compared to most traditional indemnity plans. 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 provides access to more dentists and discounts 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 coinsurance and/or annual maximum the next plan year.

Ameritas: Ameritas is known for our flexibility and expertise in dental. We talk to employers all over the country for input on their needs. Our plans are updated constantly to meet those needs. We have released several industry firsts including a rollover maximum product; fully insured Lasik eye benefits; dollar reimbursement plans; combined dental/vision deductible, frequency and maximum plans; and stand-alone hearing care benefits.

Anthem Blue Cross: With the Dental Blue PPO plans from Anthem Blue Cross Life and Health Insurance Company; there is greater access to more dentists in more locations. This increases the likelihood that members will have access to their own current dentist, increasing their satisfaction with their dental plan. The three networks offer flexibility in plan options and Dental Blue specialists participate in all three networks. Additionally, members have access to our negotiated discounts on non-covered services (such as veneers, implants, TMJ, and orthodontia), negotiated discounts after the annual maximum has been reached and negotiated discounts during waiting periods (if applicable). We have eliminated waiting periods for small group dental plans. The Anthem Blue Cross large group DHMO plans – the Dental Net 2000 Series Plans – are more cost-effective and consumer-friendly, with increased flexibility and choice. The plans include enhanced benefits for services not previously offered and often not offered by other plans. Our Tonik and Enhanced Tonik individual plans, designed for younger members, offer choice and affordability with a dental plan that’s embedded within a medical product.

Blue Shield: We now offer the enhanced dental services for pregnant women to all PPO plans including our IFP PPO plan. Pregnant women get one additional routine adult prophylaxis, and/or one course (up to four quadrants) of periodontal scaling and root planning, and periodontal maintenance if warranted by a history of periodontal treatment. Treatment is payable at 100% of the allowable amount for in and up to the allowable amount out-of-network.

BEST Life: We have expanded our plan design options. A maximum allowable charge (MAC) product is available in the Calif. market. perio, endo, and oral surgery may be moved individually into basic. There are more calendar year maximums and coinsurance options – including preventive/basic only plans. Clients can now choose a lifetime deductible in place of a yearly deductible. Most of our dental plans can be built with a focus on cost-effectiveness or provide rich benefits for a company’s employees.

CIGNA Dental: Our new DHMO 07 Series feature easy access to four cleanings per year (two at $0 co-pay and another two available at a minimal co-pay when recommended by the network dentist), expanded fluoride treatment options, and a robust variety of schedules and co-pay structures. The cost effective 07 Plans are focused on affordability, preventive care, and wellness. Teeth whitening, via take-home trays with bleaching gel, is also now available on most of the 07 schedules. We’ve also added Identity theft resolution services free of charge exclusively with this Series. CIGNA Dental added the D Series with preventive and diagnostic coverage only, which provides preventive dental services and access to network discounts for services that aren’t covered under the plan. CIGNA Dental plans include several enhancements we’ve made in recent years, such as coverage for oral cancer screening procedures including brush biopsy and VizilitePlus to aid in early detection of oral cancer. In addition, we removed the age limit on sealants for DHMO plans. Individuals do not need a referral for their dependent children under age seven to seek dental care from a pediatric dentist. Individuals can also visit network orthodontists without referral. Our WellnessPlus plan feature rewards individuals for getting preventive care by increasing their benefits in the following plan year. CIGNA Dental enrollees also get access to discounts in our CIGNA Healthy Rewards program including xylitol products and health management programs.

The DPPO network gives employers more choice. With the Core and Radius Networks, members can select the network that best meets their benefit plan goals. The new, larger Dental Radius Network offers the greatest nationwide access to dental providers at all discount levels and is appropriate for employers where network size is the primary driver.

Our large network of private practice dentists encourages employees to choose CIGNA Dental PPO over more costly options. DPPO/DEPO Discounts. Those enrolled in the CIGNA Dental PPO (DPPO) or Dental EPO (DEPO) plan can enjoy discounts on non-covered services. The discounts also apply to covered services when they exceed their annual maximum or other plan limitations, such as frequency, age or missing tooth. Finally, we have added identity theft and will preparation enhancements to the CIGNAPlus Savings discount card (not an insurance product).

Dental Health Services: Our plan benefits evolve to keep pace with changes in dental technology and work to find ways to provide better dental health to our plan members. Plans include coverage for a wide range of treatment options that were not offered in the past, including many cosmetic procedures. In addition, monthly premium rates and co-payments for services are frequently evaluated to ensure that they are appropriate and competitive.

Delta Dental: Most mid-large group plans are customizable within basic parameters and we incorporate changes in treatment standards and technology as they evolve. Delta Dental’s small business plans added the D&P Maximum Waiver option to its plan selection as well as a Delta Dental PPO plus Premier plan offering lower out-of-pocket costs to enrollees visiting Delta Dental Premier dentists.

Golden West: Yes, most recently we launched our High/Low PPO and Triple Option dental plans, which allow employees to choose their own level of coverage. In addition, our low cost DHMO plans offer cosmetic and elective procedures as an option in addition to our free vision and ortho benefits for all DHMO and PPO (CA) members.

GroupLink: Our FLEXIDENT offering is the most up to date dental benefit plan on the market. We offer many benefit options and offer fully customized options for groups of 5+. We can tailor a plan to satisfy nearly any dental benefit need a broker and his customer could request.

Guardian: We constantly strive to provide more flexibility in benefit design. We can vary deductibles, annual, and lifetime maximums and service frequencies; include deferrals of services; move services or groups of service to different service categories; and many coverage options. We also offer Incentive Coinsurance, Incentive Maximum, Preventive-Only and Preventive-Plus plans, and coverage for dental implants. Plans can be tailored to meet almost any client’s requirements exactly, while providing the prompt case implementation and rapid claim processing that our systems have always provided.

Health Net Dental: The Health Net Dental Plus DHMO plans offer more than 340 covered benefits including oral cancer screening, additional teeth cleanings, teeth whitening and veneers. In addition, members have access to one of the largest DHMO networks in the state. For new groups purchasing a dental PPO plan with coverage for orthodontia, the orthodontic lifetime maximum starts over, even for members who have previously started treatment. We do not require the prior carrier’s PPO orthodontic paid claims and there is no reduction of the member’s lifetime orthodontia maximum for treatment already in progress.

HumanaDental: We continually explore ways to offer more choices and flexibility for our customers. (Please see next response.)

MetLife: We are continually improving our program contracts, plan design flexibility, claims-processing guidelines, customer service, and quality programs based upon clinical research, consumer-value approaches, and dental industry trends. MetLife continues to expand product offerings and plan design flexibility in the small (<500 employee) market providing more choices to help customers meet cost objectives without sacrificing quality.

Principal Financial Group:  Our current plan offers significant flexibility in plan design, options 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.

Securian Dental: We have added greater flexibility.

United Concordia: We introduced more voluntary plan options and added optional coverage for posterior composite restorations and implants to groups with 10 or more enrollees. In 2009, our DHMO plan in Calif. added more than 70 procedures, now covering over 300 in total. We have also launched Preventive Incentive, which encourages members to seek preventive care by covering diagnostic and preventive services without counting them toward the member’s annual maximum. United Concordia has introduced benefit features that focus on the oral and overall health of our members in response to research that has linked dental disease to certain medical conditions such as heart disease, stroke, diabetes, pre-term births and respiratory disease. In 2008, United Concordia introduced the Smile for Health program, which includes a maternity dental benefit, providing an additional cleaning for women during pregnancy, and an enhanced dental benefit, providing coverage for certain diagnostic, preventive and periodontal services that help dentists to identify and treat chronic oral infections.

Western Dental: Our Series 7 benefit plans cover more procedures
and have a cosmetic rider.

4.) What have been the most recent changes in your plan?
Aetna: Last year, we implemented coverage for general anesthesia as standard coverage for our DMO Fixed Co-pay plans, dental PPO, and indemnity plans now cover Periapical X-rays as a Type A service. Many buy-ups are now available for these plans as well.

Ameritas: Ameritas’ rollover maximum product, Dental Rewards, continues to set sales records. SoundCare, a hearing product that can be sold stand-alone or tied to dental, is gaining popularity.

Anthem Blue Cross: We recently simplified and streamlined our small group dental plan portfolio as a result of focus group sessions and one-on-one telephone calls with brokers we conducted last year. The redesigned portfolio includes uncomplicated and straightforward plans that are easier for brokers to sell and clear-cut so clients understand. For instance, we reorganized and restructured our portfolio, which resulted in the elimination of several old plans. So now, we offer 12 plans to small groups in California. Our goal is to continue to create and offer plans that meet the needs brokers hear from their clients. We believe our new dental portfolio meets this goal.
Blue Shield: We recently reduced pricing on four of our small group dental plans. We rolled out our Suite Deal Dental package that increases the number of plans small group employers can offer from two to five.

BEST Life: We have created three new product lines, each offering dental PPO and a dental passive PPO plan that works like an indemnity plan. See #3 for more details. Additionally, we offer a secondary dental PPO network through DenteMax. This allows members who cannot access a First Dental Health provider the option to utilize in-network benefits through DenteMax.

CIGNA Dental: CIGNA Dental’s plans address emerging research on the connection between oral health and overall health. CIGNA pioneered the introduction of integrated benefits between medical and dental in 2006 with our Oral Health Integration Program, which offers enhanced dental benefits to address populations at risk, such as those with diabetes, heart disease, or those who are pregnant. In addition, CIGNA Dental plans cover oral cancer screening procedures such as brush biopsy and VizilitePlus to aid in early detection of oral cancer. In addition, we do not have an age limit on sealants for DHMO plans. Individuals do not need a referral for their dependent children under age seven to seek dental care from a pediatric dentist. They can also visit network orthodontists without referral. CIGNA offers a complete package of very competitive plan designs with one of the largest national provider networks. CIGNA Dental enhanced its dental treatment cost estimator and also introduced its Periodontal Risk Assessment Tool and Cavity Risk Assessment Tool, designed to help individuals identify factors that increase the risk of gum disease and cavities. Both assessment tools are available in English and Spanish. CIGNA also developed an online toolkit to help parents care for their children’s teeth.

Delta Dental: We have redesigned and added various self-service features to our Web site to make it a more powerful, user-friendly tool for our dentists, enrollees and group customers. A new suite of open enrollment materials were created for benefits managers to provide to their employees to make using and understanding our dental plans and enhanced Web services easier.

Dental Health Services: Our plans now feature coverage for composites on posterior teeth, re-treatment on root canals, fixed fees for precious metals and porcelain on molars, titanium crowns, teeth whitening, and other cosmetic procedures.

Golden West: Our DHMO network has increased to over 4,800 participating providers; our national PPO plan reaching over 79,000 participating providers. Our PPO plans offer industry discounts which qualifies employers up to as much as 15% discount off PPO pricing. For DHMO plans, self-referrals have been routine for our plan participants. Our Individual SmileChoice plan includes Cosmetic/Elective Benefits, Vision and Ortho coverage.

GroupLink: We are about to introduce our new dental wellness option that will allow for preventive and diagnostic services to not be counted toward the annual maximum. We also will be coming out with more competitive voluntary rating options in the next 30-60 days.

Guardian: Guardian constantly develops new, innovative ideas in order to meet our customers’ needs by keeping their teeth healthy and saving them money. We have introduced new features that encourage preventive care, allowing members get even more value from their annual maximums including Maximum Rollover and Preventive Advantage. Other PPO plan design enhancements include coverage of up to four periodontal treatments per year and covered as a preventative benefit, oral cancer screening exams, adult fluoride treatment coverage, cosmetic teeth whitening coverage and the ability for planholders to offer their employees three plan designs. Our new enhanced DHMO plans will waive copays after three years and include orthodontia in progress benefit and coverage for services such as oral cancer screenings and adult fluoride. We also introduced the Direct Referral program that gives DHMO members access to any in-network specialist without pre-authorization, providing faster, easier access to important treatment.

Health Net Dental: On January 1, 2009, Health Net selected OptumHealth Specialty Benefits to administer Health Net’s commercial DHMO and dental PPO plans. Health Net Dental DHMO plans are provided by Dental Benefit Providers of California, Inc. and Health Net Dental PPO and indemnity plans are underwritten by Unimerica Insurance Company.

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, where members get 30% coinsurance on services rendered after they reached their annual maximum. 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.

MetLife:
• Dental HMO Offering: Customers have more choices to help balance the needs of employees with their own benefit objectives.
• Graduating Dental Benefits: Participants, including dependents, are rewarded for maintaining their dental coverage with an increasing annual maximum benefit each year upon the participant’s anniversary for up to three years. Participants must maintain enrollment (no gaps) in the plan.
• Full Service Dental for Retirees: Customers can enrich their retiree benefits programs with no benefit expense and minimal administration.
• Dental Procedure Fee Tool: The dental procedure fee tool, provided by go2dental.com, lists requested dental service or services along with their appropriate in-network (PDP fee) and out-of-network fee information. Search results are based on the requested zip code. The out-of-network fees are provided by go2dental.com Inc., an industry source independent of MetLife. (Group dental insurance policies featuring the Preferred Dentist Program are underwritten by Metropolitan Life Insurance Company, New York, NY 10166. Dental HMO plans are available in CA, FL and TX only, through a domestic company in the applicable state named SafeGuard Health Plans, Inc. The SafeGuard companies are part of the MetLife family of companies. “Dental HMO” is used to refer to “Specialized Health Care Service Plans” in California. At this time, each increment to the annual maximum can be $250 for in-network and out-of-network or $500 for in-network only. Exact timeframes are determined by the employer. The highest annual maximum level is capped at three years or $3,000.)

Principal Financial Group:  Our most recent dental plan change was to add additional benefits of fluoride for members going through cancer treatments.

Securian Dental: More flexible participation guidelines and escalating annual maximum and lifetime deductible options.

United Concordia: United Concordia is offering additional voluntary plan options and optional coverage for posterior composite restorations and implants to groups with 10 or more enrollees. Recent changes also include additional covered procedures in our CA DHMO plan, the Smile for Health program and our Preventive Incentive benefit feature.
Western Dental: We now offer seven standard plans to choose from,
with multiple network options available.

5.) Can an insured use their own dentist even if they are not on your participation list?
Aetna: DPPO -- We offer a national network of dentists. Each covered family member can visit any licensed dentist for covered services. When members visit dentists who participate in our network, their out-of-pocket costs are generally lower. Indemnity – Members can visit any licensed dentist. DMO – Members must seek care from a participating DMO provider.

Ameritas: Insureds can use any provider, but they may incur additional out-of-pocket expenses.

Anthem Blue Cross: 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.

BEST Life: PPO and IndemnityPlus plans allow members to visit any dentist of their choice and get coverage for services. Our members can also access the First Dental Health Network (FDH) for excellent in-network savings. If a FDH provider is not available, they can use a provider from the DenteMax network.

Blue Shield: Dental PPO plan members can.

CIGNA Dental: 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; a dentist wants to participate and meets our criteria will be credentialed and join the network. Additionally, DPPO and DEPO plans include savings on most non-covered services. Our DPPO network dentists offer their negotiated contracted fees to customers and their covered dependents for most non-covered services. 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.

Delta Dental: Fee-for-service enrollees can visit any licensed dentist for care, although there are advantages to visiting one of nearly 22,000 Delta Dental 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. PPO patients also have freedom of choice in selecting a dentist and access to two Delta Dental dentist networks with different levels of savings. DHMO enrollees must use a participating general dentist or approved specialist, except for emergency care.
Dental Health Services: Our PPO and reimbursement plans allow members to get treatment from any dentist. Members of Dental Health Services’ prepaid and EPO plans choose their dentist from our extensive network of participating dentists.

Golden West: Members covered under our True Advantage PPO and indemnity plans can get services from a non-panel provider. Their greatest discounts will be received through accessing our panel providers under our True Advantage PPO plan.

GroupLink: All of our indemnity plans offer freedom of choice. However, our true PPO plans do have in-network versus out-of-network benefits for seeking care from a network dentist. Covered Insureds will get a higher benefit for doing so.

Guardian: Yes, members covered under our PPO plans can go to any dentist they want to use. Benefits may be paid at a lower coinsurance rate for non-participating dentists.

HumanaDental: PPO members can visit the dentists of their choice. Out-of-pocket savings are great when members visit participating network dentists.

MetLife: For Dental PPO plans, plan participants can visit any dentist and get benefits. Participants may have additional savings by getting services from a participating dentist. For Dental HMO, members must use a participating dentist to utilize their benefits.
Securian Dental: Yes.

Principal Financial Group:  Yes, insured can see any dentist even if the dentist is not on the “participation” list.

United Concordia: Our FFS and PPO plans allow insureds to visit any dentist. However, insureds’ out-of-pocket costs may be higher when visiting a non-participating dentist. DHMO members must use network dentists.

Western Dental: Through the DMO plans, the member must use a dentist who participates in our network in order to have coverage.

6.) If the dentist bill exceeds UCR, can the dentist bill the patient for the difference?
Aetna: Network dentists are contractually prevented from balance billing above the negotiated rate. Dentists who are not in our networks may balance bill members.

Ameritas PPO and the 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. Most Ameritas PPO providers offer a discount on noncovered procedures and members are financially responsible for those charges.

Anthem Blue Cross: No, not when visiting an Anthem Blue Cross dental PPO provider. 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.

BEST Life: When visiting an FDH provider, members will not be balanced billed for amounts that exceed their plan’s UCR. Those who choose to visit a non-participating dentist may be balanced billed. Our 90% UCR choice is a great cost-effective option for groups that have limited network access.

Blue Shield: Innetwork providers cannot bill members for fees that exceed the negotiated rate. However, out-of-network providers can bill for charges that exceed the plans’ allowed amount.

CIGNA Dental: In-network DPPO and DHMO dentists are not allowed to balance bill for covered services. The only time dentists are allowed to balance bill the patient is with the out-of-network DPPO and, of course, with the dental indemnity plans. We cannot prevent non-network dentists from balance billing.

Delta Dental: Participating dentists agree not to balance bill patients above the Delta Dental approved fee. DHMO covered procedures are co-payment based. Patients are responsible for paying for non-covered and optional services in their entirety up to the allowed amount.

Dental Health Services: Members of our prepaid and PPO plans are protected from paying unexpected, additional fees from their dentist.

Golden West: Network dentists are contractually prevented from balance billing above the negotiated rate. Non-panel dentists can balance bill a PPO or indemnity member the difference of the billed fee and the average fee charged for that particular geographic area.
GroupLink: Claims are paid on a percentage of UCR.

Health Net Dental: When getting 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.

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.
HumanaDental: A dentist participating in our PPO network cannot balance-bill patients.

MetLife: When getting services from a participating Dental PPO dentist, eligible employees and dependents cannot be billed any charge in excess of our maximum allowable fee (minus any plan benefits). If the patient goes to a non-network dentist, the dentist can bill the patient for the difference between the plan benefit and the dentist’s submitted charge. When getting services from a participating Dental HMO dentist, members cannot be billed any charge in excess of the specified plan co-payments, listed in the Schedule of Benefits for their plan. For some SafeGuard Dental HMO plans, there is a 25% fee reduction off of a participating dentist’s customary fee for non-listed procedures. (Members are responsible for the participating dentist’s full fee for procedures specifically excluded from coverage.)

Principal Financial Group:  Dentists cannot bill over the UCR 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: Not if the dentist is part of our network. However, a dentist who is not part of our network can do so.

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 focus is to respond to the member’s concerns and follow up with the provider as necessary for resolution. If necessary, the provider-relations area helps to resolve any issues whether related to over billing, waiver of co-payments, or other issues.

Ameritas: The explanation of benefits calculates the insured’s portion of the bill automatically to prevent these kinds of problems.

Anthem Blue Cross: Anthem Blue Cross’ extensive contracts with participating Dental Blue providers address these issues to avoid over billing and co-payment waivers. The same is true for our traditional. Prudent Buyer PPO dental plans. Additionally, our quality assurance teams assess claims and providers regularly to ensure our members are getting the highest level of service and satisfaction.

BEST Life: We do this in several ways: 1) Provider network discounts are applied at the time a claim is processed; 2) Pre-determination services are available to inform members what their charges will be prior to getting service; 3) We provide easy to understand EOBs that clearly illustrate network savings when utilizing an FDH provider; 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: Our contract with our in-network providers stipulates that they cannot bill members for fees that exceed the negotiated rate. Any complaints from members about balance billing by providers are forwarded to our Provider Relations Department for review and resolution.

CIGNA Dental: 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 Dental monitors allegations of overcharging through enrollee feedback, surveys, and the network management staff. For DHMO plans, the collection of co-payments is between the patient and the dentist. We encourage dentists to collect co-payments at the time treatment is rendered. For DPPO/Indemnity plans, it is illegal in many states for dentists to waive deductibles. Since our group contracts indicate that CIGNA Dental is not responsible for any charge the patient is not required to pay, we will reduce our claim payment by the co-payment amount waived by the dentist. Our Investigations Unit may also contact the dentist and the patient for further information. Our system also has the ability to “flag” a specific dentist’s file when there is a history of balance billing so we can investigate future claims before processing.
Delta Dental: Delta Dental dentists contract with us to establish acceptable fees and formally agree to certain protections for Delta Dental enrollees. Protections include: no balance billing; contracted dentists cannot charge enrollees for the difference between their filed (accepted) Delta Dental fee and their submitted charge for a service; they can only collect the patient portion (co-payment plus any deductible and/or amount over the annual maximum) at the time of service. They agree not to unbundle a procedure that is on file with Delta Dental as one procedure.

Dental Health Services: Participating dentists are audited on-site on an ongoing basis to ensure treatment is rendered in accordance with Dental Health Services’ policies.

Golden West: Explanation-of-benefits statements are sent to members identifying the discounts taken and the member’s responsibility. The compliance department and dental consultant monitor utilization. Additionally, a proprietary claims system identifies over-utilization trends and patterns.
Health Net Dental: Under our PPO and DHMO plans, participating dentists are contractually prohibited from balance billing a member more than the maximum allowable charge or the contracted co-payment 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 who follows the 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.

Guardian: Guardian’s PPO dentists are prohibited from billing members for any amount for covered charges other than the deductible or coinsurance that may apply to the discounted fee schedule amount. Explanation of benefits statements sent to members specifically identify the discounts taken and the member’s responsibility.

HumanaDental: The dentist and the patient get an explanation of benefits to ensure that the dentist does not overcharge or omit fees. The claims processing systems adjudicates the claim based on the contracted fee schedule. Waiving co-payments does not apply under a PPO.

MetLife: For Dental PPO, our first protection for the patient against over-billing is our explanation-of-benefits, which clearly identifies the charges for services that the patient has a responsibility to pay. In addition, our customer service area is responsive to patient inquiries about questionable billing items. This area gathers information from the patient and investigates the issue fully. A response with our findings is provided to the patient. Waiver of co-payments can also be identified from calls to our customer service center and our auditing unit, which looks for atypical billing patterns. For Dental HMO, the dentist’s agreement prohibits billing a member above the specified co-payment. The plan conducts a thorough orientation with each dental office. The Quality Management department reviews member complaints that relate to charges. The Office Quality Assessment reviewer notes any apparent overcharges during the patient-record audit and works with the dentist’s office to correct the issues.

Principal Financial Group:  Provider utilization patterns are studied and issues are addressed as uncovered.

Securian Dental: We systematically check every submitted claim.

United Concordia: Members are provided with explanations of benefits that clearly describe the services received and which charges are the member’s responsibility. United Concordia’s responsive customer service representatives also assist members with questions regarding their benefits. Thousands of claims are reviewed each year to ensure the acceptability of treatment and quality of services. Advisors and consultants also review dentists’ fees and practice patterns.

Western Dental: Providers are bound by contract to accept the member’s schedule of benefits.

8.) How many provider locations do you have?
Aetna: Aetna has more than 6,382 available DMO dentist locations in California. There are more than 42,000 available DMO dentist locations and 114,000 available PPO dentist locations nationally (These numbers are as of 6/1/09). These numbers represent available practice locations.
Ameritas/FDH Network: 30,527 California provider access points. (18,344 Ameritas, 12,183 FDH); 14,237 California locations (9,070 Ameritas, 5,167 FDH)

Blue Shield: We have more than 75,000 nationwide (including 19,000 in California) dental PPO directory entries and more than 8,600 dental HMO provider directory entries in California. These are two of the largest statewide provider networks in the industry.

BEST Life: We contract with one of the largest networks in Calif. First Dental Health, which has over 12,000 participating dentists.

Anthem Blue Cross: As of 05/4/09
California Dental Blue PPO locations:
Dental Blue 100 about 17,990
Dental Blue 200 about 19,813
Dental Blue300 about 20,647
Prudent Buyer 18,497
DHMO locations: over 5,000 in California

CIGNA Dental: Nationally, we have more than 42,000 DHMO contracted access points and more than 131,000 DPPO contracted access points. In Calif., we have more than 9,200 DHMO contracted access points and more than 27,000 DPPO contracted access points. CIGNAPlus Savings (dental discount card, not insurance) has more than 78,000 contracted access points.
Delta Dental: In Calif., Delta Dental Premier dentist locations, 30,500; Delta Dental PPO dentist locations, 18,200; and DHMO facilities, 4,200.

Dental Health Services: Our network of participating dentists includes more than 2,900 prepaid dentists and more than 13,000 PPO dentists throughout California.

Golden West: Our National Wellpoint PPO Network contracts with over 79,000 providers. Our DHMO network has over 14,700 statewide participating providers.

Health Net Dental: As of April 2009, our California PPO network includes 24,045 access points in 8,574 locations. Our California DHMO network includes 2,976 locations.

GroupLink: This number is always changing as the networks continue to recruit providers and we add new states monthly. We have multiple provider network options depending on the strength and service ability within a certain area

Guardian: There are over 120,000 PPO dentist-locations across the country and more than 20,000 in California. For the DHMO, there are 8,876 locations across the country and 3,714 in California. We are the largest PPO network in the state based on unique dentists.

HumanaDental: We have more than 26,600 network dentist locations in California, and over 120,000 locations nationwide.

MetLife: As of May 2009, our Dental PPO network includes over 121,000 participating dentist locations nationwide, including over 21,000 in California. And, the Dental HMO network includes more than 11,000 participating dentist locations in California, Florida and Texas, including over 6,000 in California, over 3,700 in Florida and over 1,800 in Texas.

Principal Financial Group:  We have approximately 24,000 PPO provider locations and 12,400 EPO provider locations.

Securian Dental: 87,000 dentist access points.

United Concordia: We have more than 67,600 dentists at nearly 130,000 total locations nationwide in our Advantage Plus PPO network. In Calif. alone, we have more than 13,700 dentists at over 30,200 total locations. Our DHMO network includes more than 2,500 general dentists and 1,700 specialists nationwide, with over 1,500 general dentists and 760 specialists in California

Western Dental: We currently have over 1,000 IPA contracted offices with more than 2500 dentists. We also have over 200 Western Dental office locations that are unique to our panel, as they do not contract with any other DHMO.

9.) Can insureds change providers easily if they are unhappy?
Aetna: Members in our DPPO/indemnity plan can do so. 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.

Ameritas PPO and the FDH Networks: Insureds can choose any provider at any time for procedures.
BEST Life: Members can choose any dentist without calling BEST Life to switch providers even if they are using the First Dental Health or DenteMax networks.

Blue Shield: DHMO members can change in-network dentists on a monthly basis. Requests must be made by the 10th of the month in order to be effective the first of the following month. DPPO members can see in-network or out-of-network providers.

Anthem Blue Cross: Dental Blue PPO members can visit any licensed dentist and will normally have more cost-savings when services are completed by a Dental Blue provider. There is no gatekeeper for the dental Blue PPO dental plans. The same is true for our traditional Prudent Buyer dental PPO plans. The DHMO members can change providers once a month.

CIGNA Dental: The DPPO/DEPO/indemnity plans allow individuals to change dentists whenever they want. No call is necessary. DHMO enrollees can easily change their primary-care dentist online via myCIGNA.com – our secure Website. They can also use our automated Quick Transfer option or simply call customer service. The change is effective on the first day of the month following the date they make the change. The CIGNAFlex Advantage feature provides individuals the flexibility to switch monthly between DHMO and DPPO or indemnity plans, depending on the plan design chosen by the employer.

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 www.deltadentalins.com. Requests submitted before the 20th of each month are effective the first of the following month.

Dental Health Services: Members can change their dentist any time by contacting their member service specialist by calling 800-63-SMILE or online at www.dentalhealthservices.com.

Golden West: DHMO members can change their providers once a month by calling our member services department and requesting the change. In addition, members are allowed up to three dental offices per family unit. For the PPO plan, members choose their dental office from a list of participating providers through our Website or their own (non-contract) provider.
GroupLink: They can change providers any time.

Guardian: Members covered under Guardian’s PPO plans can change dentists at will, regardless of whether the dentists are participating or non-participating. The PPO plans do not require members to select primary care dentists; they can see any dentist they wish at any time. Members covered under our DHMO plan can change dentists by simply calling our toll-fee number. Requests made by the 20th of the month are effective the first of the following month. 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 can 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.

MetLife: With our Dental PPO benefit plans, there is no need to select a primary dentist or get referrals for specialty care. For the Dental HMO, a member can easily change their selected dentist online or by calling customer service.
Securian Dental: Yes.

Principal Financial Group:  Yes.

United Concordia: Members can change PPO providers at any time without notice. The DHMO insured can change dentists by writing or calling customer service and requesting a new DHMO provider, as long as there is no existing balance due to the dentist or treatment in progress. If the request is received before the 10th of the month, the transfer to the new provider is effective on the first of the following month.

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 your plan? Do you have a way of knowing if the dentists are soliciting or recommending services that are not compensated by your plan?
Aetna: Participating dental offices get a dental office guide that includes information on plan designs, policies, and procedures. We offer a Website for dentists, which includes real-time eligibility and benefits information, a 24/7 speech recognition system called Aetna Voice Advantage, and a dentist solutions team in our dental service centers. 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. The results are discussed with the dentist and recommendations are made for improvement.

Ameritas: Providers can access individual plan information using the toll-free voice response system, the fax-back system, or our online benefit Website. Also, 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 Web site, through our interactive voice response system, directly from our provider relations and customer service representatives and through occasional mailings. Practice patterns of participating providers are routinely monitored and reported through monthly utilization reports and claims experience. A network representative and the dental director are contacted when suspected over- or under-utilization patterns are identified. In such cases the dentist is contacted and we discuss findings along with a plan of action to help bring the practice within the standard.

BEST Life: Dentists can contact BEST Life for information about member benefits by calling 800-433-0088. We also have a fax-back line dentists can use to obtain benefit information.
Blue Shield: Each provider gets a Provider Manual upon acceptance into the plan, which outlines requirements of participation and details on plan administration. Providers can get in-person training with their staff, if requested.

CIGNA Dental: A large staff of network managers, based in specific field locations and in operational offices, meets continuously with dental care professionals on our administrative and quality policies. Our network teams counsel any offices found to not be in compliance and remediation plans are put into place to ensure compliance.

Delta Dental: Each dentist gets a regularly updated dentist’s hand book, which explains policies, procedures and programs. Detailed program information for all enrollees is available through a secure area of the company Website and through a toll-free telephone number including deductibles, maximums and benefit levels. Delta Dental publishes a quarterly dentist newsletter and holds 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: We regularly provide on-site training, auditing, and service visits for our participating prepaid dentists. Each office gets a comprehensive manual, and we monitor all services and treatments got by our members through monthly utilization reports.

Golden West: Network-area managers keep panel offices appraised of plan-design enhancements. Provider guides, which are kept in the dental offices, reflect the various plan designs and co-payment schedules. The guides are updated and reviewed regularly with the dental office staff.

GroupLink: The 24-hour, seven-day a week automated-eligibility system is accessed via an 800 number. Benefit information is faxed back automatically. Quality Management reviews member concerns and conducts regular chart audits.

Guardian: All PPO dentists get information about Guardian’s plans through local network recruiters as well as mailings of pertinent information. Our claim system tracks and monitors each dentist’s practice patterns for bundling, over-utilization, etc. PPO dentists whose patterns are flagged are counseled, and if they show no improvement, they may be terminated from the network. We recommend that members obtain a voluntary pre-determination of benefits before proceeding with any treatment that will cost $300 or more, but we do not reduce or deny benefits if the member does not submit the treatment plan for predetermination. The member will be advised if the treatment plan includes services that are not covered under his or her plan. All offices that join the DHMO network get an orientation that fully explains the plan. Additionally, Regional Network Managers from our DHMO network periodically visit the offices to review the plan. Dental Offices submit encounter data of services provided to DHMO members. Our Quality Assurance Committee reviews this information quarterly.

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 get 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: We recommend to members and dentists that a pretreatment plan be submitted for approval, if services are expected to exceed $300. If a procedure were not covered under the member’s benefit plan, we would notify the dentist and member at that time. Also, the claims system would reimburse only for the covered services.

MetLife: For our Dental PPO, MetLife provides access to information via Internet, fax, or phone. At the time of service, dental offices can access eligibility, plan, and other information through dedicated real-time channels. Treatment patterns are monitored to help ensure maintenance of appropriate practice patterns, but not plan design as they may not address the unique needs of individuals. If a dentist’s treatment patterns become unacceptable, the dentist is educated and monitored via MetLife claim review processes, and, if warranted, removed from the network. If a participant has a complaint regarding charges for services, covered or not covered by a MetLife plan, customer service representatives review the issue with the participant and generate a response and follow-up investigation, if necessary. For the Dental HMO, each dental office gets a facility reference guide with a section on the plans. A provider relations representative conducts a thorough orientation with the dental office staff to help them fully understand the plans. Quality Management reviews member concerns and conducts regular chart audits.

Principal Financial Group:  We provide on-line and telephone service options for providers to verify benefits and eligibility.  We encourage pre-determination 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 via “My Patients’ Benefits” on our Website, our Interactive Voice Response phone system, or by speaking live to a customer service representative. In some instances, we also inform dentists of important benefit changes through our quarterly newsletter, a stuffer included with dentist checks, and/or with an automated telephone call. Dentists can check benefit information on our “Dentist Reference Guide,” available on our Website. Professional relations representatives are available to provide assistance when necessary. We identify abnormal practice patterns through a comprehensive quality assurance process. United Concordia reviews of thousands of claims are reviewed each year to ensure the acceptability of treatment and quality of services. Advisors and consultants also review dentists’ fees and practice patterns.

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.

Look For Part II of the Dental Survey in our August Issue