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Welcome to Part 1 of California Broker’s 2008 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: PPO, indemnity, voluntary, non-voluntary, groups from two lives and up, individual, dental CDHP, and cost-containment plans.
Anthem Blue Cross: Anthem Blue Cross offers 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: Employer-sponsored PPO and indemnity dental plans are offered to groups enrolling 2+ employees. All plans are available on a voluntary basis to groups enrolling 5+. Term-life and vision coverage are 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: DPPO, DEPO, dental indemnity, DHMO, CIGNAFlex Advantage (monthly switch feature between a DHMO and DPPO or Dental indemnity plans), CIGNAPlus Savings, a dental discount card program, CIGNA Dental Care Value Plans (includes four, flexible plan options with alternative treatment provisions). Some DHMO plans include split copays for general dentists and specialty providers. All plans are available on a stand-alone basis. CIGNA has three WellnessPlus modules, which can be paired with DPPO, DEPO, or dental indemnity products. Members who get any preventive care in one plan year qualify for increased benefits in the following plan year.
Delta Dental: Managed fee-for-service, PPO, and DHMO group dental programs; individual DHMO dental programs and group HMO vision programs
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: Group PPO, indemnity, DHMO, and individual DHMO.
GroupLink: Stand-alone group dental and vision plans. Indemnity PPO, voluntary, and employer paid. Self-funded administration services are also available. We also offer voluntary worksite products and HR administration services; small group and individual major medical; and short term medical. We also offer one-life dental plans for individuals and families.
Guardian: Guardian offers Traditional PPO, Network Access, Indemnity, and Administrative Services Only. We also offer DHMO, underwritten by our wholly-owned subsidiary, Managed Dental Care of California, on a standalone 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. All plans are available on both a contributory and VOLUNTARY basis.
Health Net Dental: DHMO, PPO & indemnity
HumanaDental: PPO, Prepaid/DHMO, Traditional Preferred (passive PPO), and Preventive Plus plans; available as on a voluntary or an employer-sponsored basis. Administrative Services Only plans also available.
MetLife: PPO, Copay, DHMO and indemnity plans, with flexible designs and funding arrangements available to accommodate employer plan requirements — single or multi options, fully insured or self-funded and a full range of contribution options (Group dental insurance policies featuring the Preferred Dentist Program (PPO) are underwritten by Metropolitan Life Insurance Company, New York, NY 10166. DHMO plans are available through subsidiaries of SafeGuard, a MetLife company, as follows: in California, SafeGuard Health Plans Inc., a California corporation.)
Principal Financial Group: We offer employer paid and voluntary plans, including indemnity, PPO, EPO and POS. We also offer a choice between our plans and dental HMO plans through marketing alliances.
United Concordia: United Concordia offers flexible FFS, PPO, and DHMO dental 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: We market a comprehensive portfolio of DMO plan designs.
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 make it easy for our customers to choose from plans that are competitive in the market:
• Aetna Dental offers standard DMO, PPO and FOC (Freedom of Choice) plans for groups with two or more employees. We eliminated dental waiting periods for our standard small group takeover plans, so new hires no longer have to verify prior creditable coverage.
• Aetna Dental offers voluntary plans in CA for small group customers (3-50). The voluntary dental options help meet the needs of members in the face of rising healthcare costs. Administration is easy, and members benefit from low group rates and the convenience of payroll deductions. Employers choose how the plan is funded. It can be entirely member paid or employers can contribute up to 50%.
• Aetna individual plans in California include rider plans that can be offered when the member purchases Aetna Medical coverage. Vital Savings by Aetna is a dental discount program that can be offered to individuals and large groups (it is not available to small groups). Members get services at the negotiated discount from providers in the Access network, which has more than 76,000 dentists nationally.
Ameritas: Small group and one life group plans are rated by industry and are pooled in full or part. Large groups’ experience is rated and includes lower rates in most cases. Plans vary in design and are more restrictive to offset risk.
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. Employers may be able to help control costs by purchasing the Dental Blue network that best suits their needs, instead of reducing their dental benefits.
BEST Life: All of our plan options, including orthodontia, are available to groups 2+ enrolling. If larger groups want different plan designs, we do offer custom plans.
Blue Shield: Rates for our large group dental HMO and PPO plans are usually lower than for 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.
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 - flexible with PPO/indemnity plan designs. CIGNA Dental does not offer plans to individuals.
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, but are competitive within the marketplace and commensurate with the amount of 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.
Dental Health Services: All plans and premiums are developed based on individual and group needs. Copayments 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.
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 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 mid range level of benefits at a monthly fee that is slightly higher than rates quoted for groups. Small groups have several DHMO benefit plans from which to choose. 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.
HumanaDental: We offer flexible plan designs with a range of deductibles, copayments, and out-of-pocket expense limits to meet the needs of small to large groups. 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. DHMO plans offered to individuals provide a mid-range level of benefits at a monthly fee that is slightly higher than rates quoted for groups. Small groups have several DHMO benefit plans from which to choose. Rates are based on location, plan chosen, and participation. Risk evaluation is taken into consideration when underwriting larger groups; individual plans are quoted using shelf rates.
Principal Financial Group: The only significant rating difference pertains to the experience rating, which is used on groups with 100+ employees. There are also 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 strives to offer an array of standard group products and options that provide small businesses with cost effective, quality choices.
Western Dental: The group plans we offer to small and large employers are more comprehensive in coverage than our individual plans. Rates are generally lower for large groups than for small groups.3. Is your plan(s) better than previous incarnations? If so, how?
Aetna: Aetna Dental Preventive Care -- By offering lower-price plans that cover cleanings and fluoride treatments, Aetna makes it more affordable for members to seek preventive dental care for themselves and their children. Aetna Dental now offers the Aetna Dental Preventive Care plan, 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 members 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 in the following plan year for services like fillings and crowns, thereby lowering members’ out of pocket costs. Aetna will reward members with up to three annual increases, not to exceed 100% of coverage for preventive, diagnostic, and basic care and not to exceed 70% for major care. This plan design is available in a PPO or indemnity plan, and at a variety of benefit levels. Our 2008 dental PPO discount is about 36% off area average charges when receiving services from a participating dentist. Designs vary.
Ameritas: Plans are updated constantly to meet market needs. We have released several industry firsts including a rollover maximum product, fully insured Lasik eye benefits, implants, and hearing care benefits in our dental plans.
BEST Life: Increased affordability and offering a full-range of benefit options to groups as small as two lives make our plans very competitive in the CA market. Plan choices include reimbursement levels at 80th/90th percentile, the option to move endo/perio into basic, and voluntary options for groups enrolling 5+. Significant rate discounts are also offered when adding vision and life coverage.
Anthem Blue Cross: Yes. With the Dental Blue PPO plans, there is more access to more dentists in more locations. This increases the likelihood that members will have access to their own 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 teeth whitening, 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 new 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 as a dental plan that’s embedded within a medical product.
CIGNA Dental: CIGNA Dental plans include several procedures and enhancements not generally covered by competitor plans, such as oral cancer screening procedures including 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. Members do not need a referral for their dependent children under age seven to seek dental care from a pediatric dentist. Members can also visit network orthodontists without referral. We can offer added coverage for a third cleaning per 12-month period and benefit designs with general anesthesia/IV sedation coverage. We also have the ability to adjust the percentile of UCR that claims are paid out-of-network and the ability to class-shift certain procedures (as is often found in the industry). CIGNA Dental’s plans are among the most versatile. Our WellnessPlus plans reward members for receiving preventive care by increasing their benefits in the following plan year.
Delta Dental: Last year, Delta Dental added (for fee-for-service groups) enhanced cleaning and periodontal benefits for pregnant women and implant coverage at no additional cost to the purchaser. We also added a D&P maximum waiver option, which allows enrollees of groups choosing that option to get diagnostic and preventive services without counting against their annual maximum. Most Delta Dental programs are essentially customized within basic parameters and we strive to incorporate changes in treatment and technology as they evolve.
Dental Health Services: Our plan benefits evolve to keep pace with changes in dental technology and to respond to market needs. 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 copayments for services are frequently evaluated to ensure that they are appropriate and competitive.
Golden West: We continually update plans and launch new products in order to remain competitive in the market.
GroupLink: Our newest offering, FLEXIDENT, 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, so we can customize benefit plans to meet client needs. 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. We can tailor a plan 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 SGX DHMO plans now offer more covered benefits with added services covering oral cancer screenings and additional teeth cleanings.
HumanaDental: Yes. We continually explore ways to offer more choices and flexibility for our customers. Please see next response.
MetLife: We are continually improving our program contracts; plan design flexibility, claims-processing guidelines, customer service, and quality programs based on clinical research, consumer-value approaches, and dental industry trends. MetLife continues to expand our product offerings and plan design flexibility in the small (<500 employee) market, providing customers with more choices to help them meet cost objectives without sacrificing quality.
Principal Financial Group: Our 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.
United Concordia: Our PPO recently introduced the Smile for Health program, which focuses on the relationship between oral and overall health. The program includes a maternity dental benefit and a Smile for Health enhanced dental benefit. The maternity dental benefit provides an additional dental cleaning during pregnancy to reduce the likelihood of periodontal disease, which has been linked to premature and low birth-weight babies. The additional cleaning also helps reduce the chances of pregnancy gingivitis, which can cause tender, swollen gums. The Smile for Health enhanced dental benefit provides coverage for certain diagnostic, preventive, and periodontal services that help dentists in identify and treat chronic oral infections, which research has linked to medical conditions, such as heart disease, stroke, diabetes, premature births, and respiratory disease.
Western Dental: Our new Series 7 benefit plans cover more procedures and have a cosmetic rider.4. What have been the most recent changes in your plan(s)?
Aetna: DMO Fixed Copay plans - anesthesia – standard coverage. Coverage for anesthesia (IV and general) will be included in all DMO fixed copay plans for all market segments. These services are only covered when performed with another covered service. They may be subject to review from our in-house dentists. This includes existing and new business. PPO and indemnity standard change - standard coverage -- Periapical X-rays are covered as a basic procedure. Standard coverage is to be changed as a preventive/diagnostic procedure. (National, Key & Select: new business quotes effective 6/10/08 for 10/01/08 effective dates. National, Key & Select: existing business can add this at renewal.)
5. Can an insured use their own dentist even if they are not on your participation list?
Ameritas: We have continued to create new benefit and contribution options to meet market needs. Our rollover maximum product, Dental Rewards, continues to set Ameritas sales records. A new fully insured Lasik eye benefit in our dental is being viewed very favorably, and implants and a new hearing benefit.
Anthem Blue Cross: Dental Blue PPO adds offers a three-tier PPO network to help control costs, while offering access to one of the largest dental PPO networks in the country. Also, Dental Blue specialists participate in all three networks. Several of the Dental Blue features include receiving discounts on non-covered services (such as teeth whitening, implants, TMJ and orthodontia), negotiated discounts after the annual maximum has been reached, and negotiated discounts during waiting periods (if applicable). The Dental Blue network is more than 50% larger than our traditional Prudent BEST Life: We have recently lowered rates and expanded our two-year initial rate guarantee option to voluntary groups with five to 50 employees enrolling. We also reduced rates for five to nine dental groups. The Buyer network has more than 20,000 provider locations in California.
Blue Shield: We recently reduced pricing on four of our small group dental plans. We rolled out our Suite Deal Dental package, which increases the number of plans small group employers can offer from two to five.
CIGNA Dental: CIGNA Dental’s plans have been designed to address emerging research on the connection between oral health and overall health. 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. Members do not need a referral for their dependent children under age seven to seek dental care from a pediatric dentist. Members 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 also enhanced its dental treatment cost estimator. Through recent enhancements to CIGNA’s Power Purchasing program, dentists in CIGNA Dental’s network now have access to PreViser’s patented oral risk and disease management software technology at a discounted cost. PreViser’s software is aimed at simplifying the diagnosis and treatment planning process for periodontal disease, in addition to providing accurate assessments of oral cancer, cavities and periodontal disease risk. The software produces reports that provide patients with actionable suggestions to better address their oral healthcare needs. CIGNA Dental also introduced its Cavity Risk Assessment Tool, which is designed to help identify factors that increase the risk of getting cavities.
Delta Dental: The enhanced benefits for pregnant women and implant coverage for California fee-for-service group clients, and the D&P maximum waiver option (see above). We have also redesigned and added various self-service features to our web site that make it a more powerful, user-friendly tool for our dentists, enrollees and group customers.
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: PPO -- We have increased our panel size to more than 13,000 in California and more than 55,000 nationally.
GroupLink: We are now giving full waiting period credit to all employees on the prior plan bill at time of takeover. We are covering implants as a standard benefit in major services. We are offering groups multiple plan options down to five lives. We are offering a new broker bonus program for brokers that have never written a case with us and other incentives through IHC, such as a trip to Tahiti and a stock bonus program for GA’s and Producers.
Guardian: We continuously develop new, innovative ideas in order to meet our customers’ needs by keeping their teeth healthy and saving them money. Recent PPO plan design enhancements include coverage of up to four periodontal treatments per year, periodontal 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 to choose from. This was added to our array of innovative offerings including Maximum Rollover, which allows members to rollover a portion of their unused premium for future use and dental implant coverage.
Health Net Dental: New DHMO Offering -- With the rollout of the new SGX series of DHMO plans, plan participants have coverage for more than 330 dental procedures including additional teeth cleanings, oral cancer screenings and teeth whitening.
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. Updates also 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 marketed products, excluding DHMO/prepaid plans.
MetLife:
• New DHMO Offering -- With MetLife’s recent acquisition of SafeGuard Health Enterprises Inc. (SafeGuard), we now offer access to DHMO plan options in California, Florida, and Texas.
• Graduating Dental Benefits -- Participants, including dependents, are rewarded for maintaining their dental coverage with an increasing annual maximum benefit each year on the participant’s anniversary for up to three years. The only requirement is that participants maintain enrollment (no gaps) in the plan.
• Full Service Dental for Retirees — The turnkey product allows customers to enrich their retiree benefits programs with no benefit expense and minimal administration. Additionally, we’ll be rolling out a trust option in 2008 to further meet the need of administrative ease for employers.
• Dental Procedure Fee Tool — To help patients make better decisions about their dental benefits, MetLife Dental plan participants now have access to the Dental Procedure Fee tool, provided by go2dental.com. It lists requested dental services (depending on the search criteria) 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.
• Additional R&C Flexibility — MetLife offers five Reasonable and Customary (R&C)%ile options—the 99th, 90th, 80th, 70th, or 51st percentiles to help employers balance their benefit cost objectives while maintaining employee satisfaction. (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. The employer determines exact timeframes.) The highest annual maximum level is capped at three years or $3,000.
Principal Financial Group: We recently announced an entirely new dental product – Principal Dental Series II and we continue to focus on consumer driven dental offerings. United Concordia: The most recent changes include the Smile for Health program benefit options.
United Concordia: The most recent changes include the Smile for Health Program benefit options.
Western Dental: We now offer seven standard plans to choose from, with multiple network options available.Aetna: DPPO -- We offer a national network of dentists. Each covered family member is free to 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 may 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: Yes, with all of our PPO plans. Members who choose a provider within the Dental Blue network will enjoy the most savings in their dental costs. Members can even 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 also have the option to access the First Dental Health Network (FDH) for excellent in-network savings.
Blue Shield: Yes, for dental PPO plan members.
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 or with DEPO. Members can nominate their dentist to join our plan and if the dentist wants to participate and meets our criteria, they will be credentialed and join the network. Additionally, DPPO and DEPO plans include savings on 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 a member 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 the more than 21,300 Delta Dental dentists in California. Enrollees may 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 al low 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: Yes, members covered under our PPO and indemnity plans may get services from a non-panel provider.
GroupLink: Yes, 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 are usually paid at a lower coinsurance rate for non-participating dentists.
Health Net Dental: For PPO plans, plans participants can visit any dentist and get benefits. Participants may realize additional expense savings by receiving services from a participating PPO dentist. For DHMO, members must use a participating dentist to utilize their benefits.
HumanaDental: PPO members can visit the dentists of their choice. Out-of-pocket savings are greater when members visit participating network dentists.
Managed Dental Care: On a PPO plan, yes. On a DHMO plan, no.
MetLife: For PPO plans; plans participants can visit any dentist and get benefits. Participants may realize additional expense savings by receiving services from a participating PPO dentist. For DHMO, members must use a participating dentist to utilize their benefits.
Principal Financial Group: Yes. The 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 and still get payment toward covered services. DHMO members must use network providers.
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. We have a hold-harmless agreement in our participating provider contracts that prohibits network providers from billing or collecting from members more than the applicable coinsurance or copayment specified in the members’ plan. Dentists who are not in our networks may balance bill members.
Ameritas/FDH Network: 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. Members are financially responsible for non-covered procedures.
Anthem Blue Cross: No, not when visiting an Anthem Blue Cross’ 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. 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.
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.
CIGNA Dental: In-network DPPO and DHMO dentists are not allowed to balance bill members. 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: A Delta Dental dentist cannot balance bill a fee-for-service patient. Nor can DHMO patients be balance billed, since on the capitation plan, the patient only pays the stated co-payment for covered procedures. Patients are responsible for paying for non-covered and optional services in their entirety up to the allowed amount.
Dental Health Services: No. Members of our prepaid and PPO plans are protected from paying unexpected, additional fees from their dentist.
Golden West: 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. PPO panel dentists cannot balance bill members. They must agree to bill the contracted fee.
GroupLink: Yes.
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, 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.
HumanaDental: A dentist participating in our PPO network may not balance-bill patients.
MetLife: When receiving services from a participating PPO dentist, eligible employees and dependents cannot be billed any charge in excess of our maximum allowable fee (minus any plan benefits). If the patient goes to a non-network dentist, the dentist can bill the patient for the difference between the plan benefit and the dentist’s submitted charge. When receiving services from a participating DHMO dentist, eligible employees and dependents cannot be billed any charge in excess of the specified plan co-payments.
Principal Financial Group: Dentists cannot bill over the UCR amount if they are part of our PPO or EPO network. If the dentist is not a part of one of our networks, he/she can bill the amount over UCR.
United Concordia: Contractually, United Concordia participating providers agree to accept our allowances as payment-in-full for covered services (less any deductibles and coinsurances or copayments).
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: If a member calls for help when a participating provider is balance billing, the customer service representative (CSR) first checks the claim history. If the claim was processed correctly, the CSR gets pertinent information from the member, calls the provider to discuss the claim processing and requests that the provider stops balance billing. Dentists who are not in our networks may balance bill members.
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 copayments, or other issues.
Ameritas: The explanation of benefits automatically calculates the insured’s portion of the bill 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.
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 before receiving 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 can not bill members for fees that exceed the negotiated rate. Any complaints from members balance billing by providers are forwarded to our Provider Relations Department for review and resolution.
CIGNA Dental: We review encounter data and utilization patterns compared to normative data by geographical area, we would then counsel any providers who were found to have patterns outside the norms.
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: The compliance department and dental consultant monitor utilization. Additionally, a proprietary claims system identifies over-utilization trends and patterns.
GroupLink: Claims are paid on a percentage of UCR.
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.
Health Net Dental: For 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. For DHMO, 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.
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 system adjudicates the claim based on the contracted fee schedule. Waiving co-payments does not apply under a PPO.
MetLife: For 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 DHMO, 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.
United Concordia: Thousands of claims are reviewed each year regarding the acceptability of treatment and quality of services. Advisors and consultants also review dental providers’ 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 5,600 available DMO dentist locations and 22,000 available dental practice locations in California. There are more than 41,000 available DMO dentist locations and 108,000 available PPO dentist locations nationally (These numbers are as of 6/1/08). These numbers represent available practice locations.
Ameritas/FDH Network: 27,948 provider access points.
Anthem Blue Cross: As of 05/29/08
California Dental Blue PPO locations: Dental Blue 100 about 15,370;
200 about 19,551
300 about 20,331
Prudent Buyer 13,501
DHMO locations: nearly 5,000 in California
BEST Life: We contract with one of the largest networks in CA, First Dental Health, which has more than 15,300 participating dentists.
Blue Shield: We have more than 70,000 nationwide (including 17,500 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.
CIGNA Dental: Nationally we have more than 38,000 DHMO contracted access points and more than 112,000 DPPO contracted access points. In California we have more than 7,100 DHMO contracted access points and more than 22,000 DPPO contracted access points.
Delta Dental: In California, fee-for-service, 29,000; DHMO, 6,300.
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: There are about 55,000 PPO providers nationally and 4,200 DHMO dentists and specialists in California.
GroupLink: This number is always changing as the networks continue to recruit providers and we add new states monthly. We multiple provider network options depending on the strength and service ability within a certain area.
Guardian: We have more than 100,000 PPO dentist-locations across the country and more than 27,300 in California We have 8,876 DHMO locations across the country and 3,714 in California. We are the largest PPO network in the state.
Health Net Dental: Our PPO network includes more than 14,000 participating providers in California. And, the DHMO network includes more than 4,500 providers.
HumanaDental: We have more than 26,700 network dentist locations in California.
MetLife: As of April 2008, our PPO network includes more than 110,000 par-ticipating dentist locations nationwide, including nearly 20,000 in California. And, the DHMO network includes more than 4,500 participating dentist locations in California, nearly 4,000 in Florida and nearly 1,500 in Texas.
Principal Financial Group: We have about 24,000 PPO provider locations and 9,200 EPO provider locations.
United Concordia: Advantage Plus PPO net work: 13,398 dentists, 18,985 practice locations; and 1,450 DHMO primary dental offices (PDO).
Western Dental: Our network consists of more than 1,000 IPA offices with more than 2,500 dentists. The Western Dental staff model offices have more than 200 locations with access to more than 700 dentists. The Western staff model facilities are not available to any DMO except Western Dental Benefits Division.
9. Can Insureds change providers easily if they are unhappy?
Aetna: For members in our DPPO/indemnity plan, yes. For members in our DMO plan a new provider can be chosen 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.
Anthem Blue Cross: Yes. 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 PPO dental plans. The same is true for our traditional Prudent Buyer dental PPO plans.
The DHMO members can change providers once a month.
BEST Life: Members may choose any dentist they desire, while also using FDH for network savings.
Blue Shield: Yes. DHMO members may 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 may see in-network or out-of-network providers.
CIGNA Dental: The DPPO/DEPO/indemnity plans allow members to change dentists whenever they want. No call is necessary. DHMO members can easily change their primary-care dentist online via myCIGNA.com – our member portal. 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. On CIGNAFlex Advantage plans, members have 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 the customer service Department by telephone, in writing, or through Delta Dental’s web site at www.deltadentalins.com. The change is effective the first of the month after the request is got, provided the request is got before the 20th of the month.
Dental Health Services: Members may change their dentist at any time by contacting their member service specialist by calling 800-63-SMILE or online at www.dentalhealthservices.com.
Golden West: Yes. DHMO members can change their providers once a month by calling our member services department and requesting the change.
GroupLink: Yes. 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. PPO members can see any dentist they want, in-network or out-of-network, at any time.
Health Net Dental: With our PPO plan design, there is no need to select a primary dentist or get referrals for specialty care. For the DHMO, a member can change providers by calling Member Services or by touch-tone phone 24 hours a day and online.
HumanaDental: With the PPO option, the member can change dentists without notifying the dental plan.
MetLife: With our PPO plan design, there is no need to select a primary dentist or get referrals for specialty care. For the DHMO, a member can change providers by calling Member Services or by touch-tone phone 24 hours a day and online.
Principal Financial Group: Yes.
United Concordia: Members can change PPO providers at any time without notice.
The DHMO insured may 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 got before the 10th of the month, the transfer to the new provider is effective on the first of the following month.
Western Dental: Yes, our membership may 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 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 PPO and the FDH Networks: Dentists can access individual plan information using the toll-free voice response system, the fax-back system, or our online benefit Website. In-house consultants and dental claim systems can catch many procedures that are substituted for covered procedures.
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 may contact BEST Life for information about member benefits by calling 800-433-0088. We also have a fax back line dentists can use to get benefit information.
CIGNA Dental: A large staff of network managers, based in specific field locations and in operational offices, meets continuously with providers 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 handbook, which explains policies, procedures, and programs. Detailed program information for all enrollees is available through a secure area of the company web site 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 on news and innovations. 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. Additionally, 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 apprised 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.
Guardian: All PPO dentists get information about Guardian's plans. 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 PPO network. We recommend that members get 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.
Health Net Dental: Provider manuals are updated a distributed whenever there is a plan benefit modification. If a participant should have a complaint charges for services, covered or not covered by a Health Net Dental plan, our trained customer service representatives will review the issue with the participant and generate a response and follow-up investigation, if necessary. For the DHMO, 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.
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 PPO, MetLife has developed a multi-channel technology platform for employers, participants and dental offices, providing 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. Once selected to participate in MetLife’s PPO network, dentist’s treatment patterns are monitored to help ensure maintenance of appropriate practice patterns — not plan design, as they may not address the 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 should have a complaint charges for services, covered or not covered by a MetLife plan, our trained customer service representatives will review the issue with the participant and generate a response and follow-up investigation, if necessary.
For the DHMO, 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. Transactions are processed in real-time except when the systems are undergoing scheduled or unscheduled maintenance or interruption.
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. United Concordia: United Concordia conducts periodic visits and phone calls from provider relations representatives. We also offer benefit and eligibility information 24/7 online or on the phone, quarterly provider newsletters, special mailings, office manuals, dental office seminars and continuing education courses to ensure dentists are aware of how to access information member plans. In addition, thousands of claims are reviewed each year the acceptability of treatment and quality of services.
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 12 months? If asked, will you provide the names and phone numbers of at least three of these offices?
Aetna: Annual provider turnover is about 5%. We have experienced an overall net growth in participating dental offices.
Provider turnover in 2007 was 10.3% for DMO and 7.4% for DPPO – includes GPs and SPs and is 2007 year-to-date.
Ameritas PPO: 1,480 provider access points were lost. Yes, we would provide names, if requested.
Ameritas/FDH Network: 2,340 provider access points were lost. Yes, we would provide names, if requested.
BEST Life: Less than 5% of providers have left the FDH network over the past 12 months. Reasons for leaving include retirement, relocation of practice, changes within group practices, and voluntary terminations. For the sake of privacy, our network does not share such information for the purpose of a general interview.
Anthem Blue Cross: In the past 12 months, we have lost 1.5% of our provider offices in the Prudent Buyer network, but increased the network by almost 5%. Within our Dental Blue network, we have lost 3% of our provider offices, but increased the network by 17%.
Anthem does not make it a practice to provide names and phone numbers of dental offices that have left the network.
CIGNA Dental: While NADP has not yet released their 2007 average turnover rates, our national turnover rates are lower than the most recent NADP data. Provider information can be given to customers and brokers.
Delta Dental: All of our networks increased in size in 2007: Delta Dental Premier, by .2.8%; Delta Dental PPO by nearly 6%, and DeltaCare USA, our DHMO network, by more than 20%. 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 loss, and has increased in size by an additional 5% over the previous year. The names and phone numbers of all offices are available on request.
Golden West: The DHMO panel-retention rate average is 92%, including dental offices that have closed their practices. Yes.
GroupLink: N/A. We are not a network administrator. We do offer PPO options with our plans. Information could be got from them on request.
Guardian: Over the past 12 months, turnover has been less than 6%, terminating for voluntary (retirement, moving from area, closing the practice) and involuntary (terminated by network) reasons. We will provide names and phone numbers of terminated offices, subject to permission from the offices.
Health Net Dental: For PPO, our turnover rate was less than 2% for 2007. For DHMO, less than 3% of contracted dentists left the network in 2007. They have been replaced based on area population studies.
HumanaDental: 72 California dentists were termed during the past 12 months, including 7 that were termed by HumanaDental due to not meeting our credentialing standards. Yes, we will provide the requested information on at least three offices.
MetLife: For PPO, our turnover rate was 1.32% for 2007. In California, the 2007 network turnover rate was 1.08%. For DHMO, less than 3% of contracted dentists left the network in 2007. They have been replaced based on area population studies.
Principal Financial Group: For our PPO network, we’ve lost 830 providers. For our EPO network, we’ve lost 700 providers.
United Concordia: There have been 74 DHMO facility terminations from May 1, 2006 to April 30, 2007. The turnover rate is 5.5%. The names and phone numbers of these offices are confidential.
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.