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Insurance Insider News
Public Support for Rate Regulation Decreases
by Leila Morris – 9/17/14

Support has dropped by nearly 30 points for heath insurance rate regulation (Proposition 45), according to Field Poll results. The Health Insurance Rate Changes initiative would require the state insurance commissioner to approve any health insurance rate changes. Forty-one percent of likely voters are inclined to vote yes on Prop. 45; 26% are inclined to vote no; and a growing number (33%) are undecided. At the August Covered California board meeting, board members expressed their opposition to the measure, saying that it could interfere with the exchange’s operations. For more information, visit www.stophighercosts.org. HEALTHCARE Health Benefit Costs to Edge up in 2015 Employers are predicting that health benefit costs will rise 3.9% per employee in 2015, according to a Mercer survey. At 2.1%, cost growth reached a 15-year low in 2013, but appears to be edging back up. Employers say that costs would rise 5.9% if they made no changes to their plans for 2015. But only 32% of employers are simply renewing their plans without making changes. “Employers have to work hard each year to keep cost increases manageable. And health reform is certainly creating new challenges,” said Tracy Watts, senior partner and Mercer’s National Health Reform leader. Twenty-two percent of employer health plans are likely to see enrollment grow next year when they open their plans to all employees working 30 or more hours per week. Thirty-nine percent of the large retail and hospitality businesses, which typically employ many part-time workers, will need to extend coverage in 2015. Beth Umland, Mercer’s director of Research for Health and Benefits said, “While there has been much speculation that employers would reduce staff or cut hours to limit the number of employees becoming eligible in 2015, few…will take of those routes.” However, many say they will manage schedules more carefully to avoid workers’ occasionally working 30 or more hours in a week or to make it clear to new hires that they will work fewer than 30 hours, she added.” It’s hard to predict how many newly eligible employees (generally lower-paid, variable-hour workers) will enroll in health plans. The tax penalty for individuals who do not get coverage will rise in 2015 to a minimum of $325. The minimum was only $95 in 2014. Few employers have seen significant growth in enrollment. But 2015 could be a different story, not just because the penalty is higher, but also because many employees now have the option to enroll, said Watts. Consumer-directed health plans (CDHPs) that are eligible for a health savings account cost 20% less than traditional health plans. While about half of large employers offer a CDHP, 73% expect to have a CDHP within three years. And 20% say it will be the only option for employees. Today, only 6% of large employers have moved to full-replacement CDHPs. The move toward high-deductible consumer-directed plans is spurring more voluntary options. In addition, private benefit exchanges make it easier for employers to offer a range of medical plan options and voluntary benefits. For more information, visit www.mercer.com. Private Exchanges Expected to Take Off Thirty-two percent of employers are considering moving employees to a private exchange in the next three years, according to a report by PwC. Public exchanges have already enrolled eight million in the first year and are poised to grow rapidly over the next few years. But the shift to retail-style private exchanges may be a longer process. Barbara Gniewek principal of PwC’s Human Resource Services practice said, “Employers are expressing significant interest in private exchanges, but [they’re] taking the time to evaluate the various exchange offerings. Exchanges that can deliver sustainable cost savings and enhance the customer experience while reducing the administrative burden will be best positioned for success.” Kelly Barnes, PwC’s U.S. Health Industries leader, said “The push to retail means more transparency on pricing, products, and services, In today’s new health economy, healthcare companies will need to find innovative ways to demonstrate value and quality to their customers with quality in assurance, tax and advisory services.” For more information, visit www.pwc.com/US. How Price Transparency Lowers Healthcare Costs Parents are almost twice as likely to choose a less costly procedure to treat their children’s appendicitis when they are aware of the cost difference, according to a study published in the September issue of Annals of Surgery. The study compared the choice of an open procedure to a more costly laproscopy to treat appendicitis. Sixty-three percent of parents who got pricing information chose the less costly operation compared to 35% of those who were not aware of the cost difference. Costs averaged $1,554 less for open operations than for laparoscopy. New IRS Guide Tells You if You Qualify for a Health Coverage Exemption The Affordable Care Act calls for each individual to have qualifying health insurance coverage, but there are exemptions under the following circumstances: Your annual premiums would be more than 8% of your household income. You have had a gap in coverage for fewer than three consecutive months. You qualify for an exemption for one of several other reasons, including having a hardship that prevents you from getting coverage or belonging to a group that is exempt. On IRS.gov/ACA, you can find a comprehensive list of the coverage exemptions. Grant Program for State Health Reform Research The Health Care Cost Institute (HCCI) and the National Academy for State Health Policy (NASHP) will issue grants for studies that analyze how the states are implementing the Affordable Care Act (ACA) and other health reforms. The program is funded by a $1.5 million grant from the Laura and John Arnold Foundation. Funding will support five research projects that shed light on the most effective ways to improve health care quality and lower costs. Researchers who are funded by the program will have access to HCCI’s commercial claims data for over 50 million insured Americans. For more information, visit grantprogram.nashp.org. Millions of Children Don’t Get Recommended Preventive Care  Millions of infants, children, and adolescents in the United States didn’t get key clinical preventive services, according to a report published by the Centers for Disease Control and Prevention (CDC). Clinical preventive services include medical or dental care that supports healthy development. The CDC report focuses on the following: prenatal breastfeeding counseling, newborn hearing screening and follow-up, developmental screening, lead screening, vision screening, hypertension screening, use of dental care and preventive dental services, human papillomavirus vaccination, tobacco use screening and cessation assistance, chlamydia screening, and reproductive health services. In 2007, 79% of parents with children aged 10 to 47 months said that their healthcare providers hadn’t asked them to complete a formal screen for developmental delays in the past year. In 2009, 56% of children and adolescents didn’t visit the dentist in the past year, and 86% didn’t get a dental sealant or a topical fluoride application. Forty-seven percent of girls 13 to 17 years had not received their recommended first dose of HPV vaccine in 2011. Thirty-one percent outpatient clinic visits from 11- to 21 year-olds during 2004 to 2010 had no documentation of tobacco use status; 80% of those who screened positive for tobacco use didn’t get any cessation assistance. Twenty-four percent of outpatient clinic visits for preventive care for three- to 17-year olds had no documentation of blood pressure  measurement.“The Affordable Care Act requires new health insurance plans to provide certain clinical preventive services at no additional cost with no copays or deductibles. Parents need to know that many clinical preventive services for their children, such as screening and vaccination, are available for free with many health plans,” said Lorraine Yeung, M.D., M.P.H., a medical epidemiologist with the CDC. For more information, visit www.cdc.gov/childpreventiveservices. Premiums Rise 3% for Employer-Sponsored Family Coverage  Average annual premiums for employer-sponsored family health coverage reached $16,834 this year, up 3% from last year. This continues a recent trend of modest increases, according to a survey by the Kaiser Family Foundation/Health Research & Educational Trust (HRET). Workers are paying an average of $4,823 annually toward family coverage this year. The increase continues a recent trend of moderate premium growth. Premiums have increased 26% over the past five years compared to 34% in the previous five years and well below the annual double-digit increases recorded in the late 1990s and early 2000s. This year’s increase also is similar to the year-to-year rise in worker’s wages (2.3%) and general inflation (2%). Annual premiums for worker-only coverage are $6,025 this year. Workers have contributed an average $1,081 toward the cost of worker-only coverage this year. The survey also reveals the following: 80% of covered workers have a general annual deductible, with the average reaching $1,217. For most services, workers typically pay this deductible before their health plan provides coverage. Since 2009, the average deductible has risen 47% from $826. “The deductibles for workers have crept higher over time, topping $1,200 on average this year. Today, four in 10 covered workers have at least a $1,000 deductible, nearly double the share from just five years ago,” said study lead author Gary Claxton, director of the Health Care Marketplace Project. 41% of covered workers have an annual deductible of at least $1,000, including 18% with a deductible of at least $2,000. Sixty-one percent of covered workers at small firms (three to 199 employees) have deductibles of least $1,000; and 34% have deductibles of at least $2,000. There has been little change in other forms of cost sharing, including co-payments for in-network physician visits (an average of $24 for primary care and $36 for specialists) and for prescription drugs ($11 for generics, $31 for preferred brands, $53 for non-preferred brands and $83 for specialty drugs). 98% of large employers that offer health benefits also a wellness program. 73% of smaller employers that offer health benefits also a wellness program. 36% of large employers that offer wellness programs provide a financial incentive participation, such as a lower premium or deductible, a larger contribution to a tax-preferred savings account, a gift card, cash, or merchandise. 18% of small employers that offer wellness programs provide a financial incentive for workers to participate, such as a lower premium or deductible, a larger contribution to a tax-preferred savings account, or a gift card, cash or merchandise. 51% of large firms (at least 200 workers) that offer health benefits also offer biometric screenings. Just 1% require workers to complete the screening to enroll in the company’s health benefits, and 8% reward or penalize workers financially based on biometric outcomes. 94% of employers with at least 100 workers offer health benefits to at least some workers. 52% of employers with fewer than 50 workers offer health benefits. Since most employers are small, this group drives the offer rate for employers, which stands at 55% this year, similar to the 57% recorded last year. Firms that do not offer health benefits most often cite cost-related reasons, though one in 10 say that the coverage available to workers through the ACA insurance exchanges as a factor. 26% of covered workers are in grandfathered plans, down from 36% last year and 48% two years ago. This means that more workers will benefit from reforms, such as coverage of preventive benefits without cost sharing and an external appeals process. Starting in January for non-grandfathered plans, the ACA set 90 days as the new limit for the waiting period before new hires become eligible for health benefits. Twenty-three percent of large firms and 10% of small firms reduced their waiting period during the past year. The average length of waiting periods for covered workers decreased from 2.3 months in 2013 to 2.1 months in 2014. 23% of large firms that offer retiree health benefits are considering changes because of the ACA’s new public health insurance marketplaces. The Foundation also released a graphic that charts the survey’s premium trends since 1999 for different types of firms. For more information, visit http://kff.org/EHBS. The Obamacare Debate Loosens its Grip on Congressional Elections Republicans have a modest edge in voter enthusiasm, but Obamacare is not their main motivator, accord to a Kaiser Family Foundation Health Tracking Poll. Twenty-seven percent of Republicans say they are more enthusiastic about voting this year. But the most common reason is to help Republicans gain control of the Senate at 13% while just 3% mention the health care law. Forty-seven percent are in favor of the ACA, and 35% are against it. Sixty-three percent want Congress to improve the law while 33% want Congress to repeal it. Thirty-eight percent of voters say they would be less likely to vote for a candidate who voted for the health care law while 29% would be more likely. Forty-one percent say they would be more likely to vote for a candidate who voted to repeal the law while 30% would be less likely. In the 11 states with the most competitive Senate races, 72% of those surveyed say they have seen ads about the health care law. Thirty-four percent saw more ads against it and 4% saw more ads in favor. Sixty percent of Republicans and other voters who don’t like the ACA want candidates to keep up the Obamacare debate. Similar shares of Democrats and other voter who like the law want candidates to move on to other issues. Twenty-seven percent of Democrats, 11% of independents, and 2% of Republicans say the ACA has helped them. On the other hand, 45% of Republicans, 31% of independents, and 10% Democrats say that the law has hurt them. For more information, visit www.kff.org. Increase Expected in COLI Life Settlements Asset Life Settlements, LLC issued a statement saying that, as business owners seek to cash out and retire, an increasing number of corporate owned life insurance (COLI) policies will be brokered in the secondary market. “The improving economy and financial performance of small businesses is the driving force behind the recent spike in the sale of small businesses by aging owners,” said Scott Thomas, co-founder of the company. Economists estimate that 70% of the 12 million privately owned businesses in the U.S. will change hands as Baby Boomers retire in the next decade. Some of those retiring business owners who carry key person life insurance may qualify for a life settlement to boost their retirement nest egg. Company co-founder Jeff Hallman says that discussions with agents and recent market studies support the company’s optimistic outlook. According to BizBuySell.com, small business sales in 2013 were up by 42% from the previous year. Sixty-five percent of the businesses sold in the first quarter for 2014 were by Baby Boomers. Also, 67% of business owners expect to retire in the next 10 years, according to a Pepperdine study. Hallman expects the recent upturn in mergers and acquisitions and the projected sale of businesses to present new opportunities for insurance advisors when it comes to the disposition of corporate owned life insurance. “It makes sense that aging business owners who survived the recent economic downturn are motivated to cash out now. Insurance advisors should remind retiring business owners and business brokers not to overlook the possible hidden asset value of key person life insurance,” he said. For more information, visit www.assetlifesettlements.com or call 888-335-4769. EVENTS You can now complete your Certified in HealthCare Consumerism (CHCC) education as part of the 4th IHC FORUM West conference in Las Vegas November 10 to 12. For more information, visit http://www.theihcc.com/en/0/become-an-ihc-member_h9a60onj.html. EMPLOYEE BENEFITS Preparing Workers for Open Enrollment  A report by AON Hewitt reveals how employee benefits will change during this year’s open enrollment. The report also gives tips to respond to the changes. Aon Hewitt finds that employees will see the following changes as they enroll in benefits for 2015: • Rising health care costs – Most employers plan to subsidize employees’ health coverage at a similar rate as this year, but as health care costs continue to rise, employees are likely to see higher premiums and out-of-pocket costs. Half of employers increased participants’ deductibles or copays in 2014, and 39% are planning to do so in the next three-to-five years. Employees who cover spouses and other dependents through their employers’ plans may see an even steeper cost increase. Twenty-two percent of employers have reduced subsidies for covered dependents while 18% added a surcharge for adult dependents with access to other health coverage. An additional half of employers surveyed are exploring such approaches over the next few years. Greater likelihood of seeing consumer-driven health plan (CDHPs) options – CDHPs are the second most popular plan choice offered by employers, surpassing HMOs. Fifteen percent of companies offer a CDHP as the only health plan option, and another 42% are considering doing so in the next three to five years. Many employers are also offering a wide range of voluntary benefits, such as critical illness coverage, to help minimize out-of-pocket costs. Programs and incentives that promote healthy behaviors – Most employers are focusing more on health and wellness programs. Seventy-five percent of employers offer health risk questionnaires; 68% offer disease and condition management programs; and 71% offer biometric screenings (e.g., for blood pressure and cholesterol). More companies offer incentives for completing these screenings or participating in certain programs, such as lower medical plan premium. Twenty percent of employers require employees to complete these activities to get expanded health plan choices with additional levels of coverage. In addition, more than a third of employers are tying incentives to outcomes, such as quitting tobacco use, lowering blood pressure, or improving body mass index. • More transparency on costs and health plan choices – Almost all employers are offering health care cost estimators that allow employees to evaluate two or more health care plans at a time, factoring in monthly premiums, co-payments, deductibles, and coinsurance payments. More employers are also providing decision-support tools that enable employees to model out-of-pocket costs based on anticipated health plan use or prior claims information. New ways to select and purchase health care benefits – A small, but growing number of employers are offering group-based health benefits to active employees through private health exchanges. Private health exchanges create a new competitive market for health insurance that provide employees with more health plan options at different coverage levels and price points. Aon Hewitt’s data shows that while just 5% of employers allow employees to purchase benefits through a private health exchange today, 33% said it will be their preferred approach in the next three-to-five years. For more information, visit www.aon.com. Dental Carriers Share Networks United Concordia Dental, Dental Network of America, and DenteMax have entered into a network sharing agreement to provide greater access and deeper discounts for their dental members and clients. As a result of this partnership, the networks of United Concordia Dental and Dental Network networks will now each exceed 100,000 dentists and 280,000 access points. NEW PRODUCTS Defined Benefit Expense Benchmarks Report The new Penbridge defined benefit expense survey captures all plan expenses paid by the plan or the plan sponsor. Expense categories include trust and custody, administration, actuarial, investment management, investment advisory (discretionary and non-discretionary), total PBGC premiums, legal, plan audit, insurance (operational) and other expenses. The report compares plan’s relative ranking to similar plans. For more information, visit www.penbridgeadvisors.com/join. High Net Worth Marketing Tools John Hancock Insurance is offering advisors the “Seller’s Guide to the Global High Net Worth Market” as well as additional support materials. For more information, visit johnhancock.com. ... Continue Reading →
EmployeeInfo

Employees Need More Information About Their Benefits
by Leila Morris – 9/10/14

This enrollment season, employees have a message for employers about their benefits: “Tell us more, please.” Only 33% of employees rated the benefit education they received in 2013 as excellent or very good — a drop from 37% in 2012 and a reversal to the upward trend since 2009. In addition, 27% rated their benefit education as fair or poor, according to a survey conducted by the Harris Poll on behalf of Unum. Employees they say they understand the following types of coverage at least somewhat: 74% life insurance. 71% vision insurance. 47% critical illness insurance. 40% medical understand coverage. Forty-eight percent of those with long-term or short term disability benefits say that no one has explained disability insurance to them. Sixty-six percent say that their employers should do a better job of explaining these benefits. Seventy-nine of those who say that get excellent or very good education about their benefits also rate their employer as excellent or very good compared to only 30% of those received fair or poor education about their benefits. Eighty-three percent of employees who did get education on their disability benefits gave that education a positive rating. “The Affordable Care Act is raising lots of questions and leading to changes that extend beyond health coverage. Employees are making decisions about their benefits that they have never had to make before. It’s vital for employers to provide the right tools and information for employees so they can understand their benefits options and choose the coverage that is right for them,” explains Bill Dalicandro, vice president of Unum’s Consumer Solutions Group. For more information, visit www.unum.com. What Consumers Want in a Critical Illness Product Patients are getting medical diagnoses at earlier stages than ever due to medical advances, better treatment, and the fact that more people understand the importance of preventive care and early detection. However, critical illness contracts don’t typically pay a benefit for earlier diagnoses, so those claims are not triggering a benefit and policyholders are not getting paid when they think they should, according to a study by Trustmark. Carriers have added conditions to the list of what they cover, but it’s not as helpful as it sounds. Less than 12% of people are ever paid a benefit for these conditions while the added coverage increases the cost of their policy. Consumers say they want the following in a critical illness policy: • A benefit for an early-stage diagnosis. • Access to a medical expert or doctor for advice. • A policy that lasts throughout their lifetime with multiple benefits, regardless of whether they get sick. They don’t want something that only centers on them being ill. • Less confusion on what qualifies for a benefit and whether enough time has passed to pay a benefit • A benefit even if they were previously diagnosed for a condition • A commitment that their premiums will not change over the life of the policy. For more information, visit www.trustmarksolutions.com. The Haves and the Have Nots of Dental Care A survey by Oral Health America (OHA) reveals that there are two Americas when it comes to oral healthcare. Those with a household income of under $50,000 are more likely to skip dental visits, with 74% delaying care for financial reasons or lack of insurance coverage. Low-income Americans, young adults, students, and those with less education are less likely to floss (43% compared to 56% overall), less likely to eat healthy foods (56% compared to 62% overall), and more likely to smoke. OHA and the Dental Trade Alliance are bringing together oral health leaders on Capitol Hill today to address issues that affect lower-income communities. OHA board members and supporters will meet with members of Congress to encourage them to support policies that improve oral health. For more information, visit www.oralhealthamerica.org/fallforsmiles. IN CALIFORNIA Heffernan Insurance Brokers Honored for Corporate Wellness Bay Area Heffernan Insurance Brokers is number two on the list of  the 2014 Healthiest Employers in the Bay area, according to the San Francisco Business Times and the Silicon Valley Business Journal. Hefferan is one of the largest full-service, independent insurance brokerage firms in the United States. For more information, visit www.heffins.com. Some Could Lose Exchange Coverage If They Can’t Prove Immigration Status Covered California is contacting about 98,000 families who need to resolve eligibility inconsistencies in their 2014 enrollment documents. Some consumers provided the required documents, but the agency could not reconcile the information to verify citizenship or immigration status. For example, some documents were illegible. In some cases, two pieces of proof were needed, but only one document was sent. The agency is asking consumers to submit documents showing that they are U.S. citizens, U.S. nationals, or individuals with eligible immigration status. Peter V. Lee, Executive Director for California’s health benefit exchange said, “If we do not get your documents, Covered California must cancel your health insurance, along with any federal tax credit you may be receiving that lowers your monthly premiums. If you have received tax credits, and your health insurance is canceled, you may have to repay those tax credits. If your health insurance is canceled, you may also have to pay a tax penalty.” Covered California is mailing emailing notices to consumers beginning this week. Consumers who don’t provide proof by September 30 risk losing their health coverage. Thousands of partners, including Covered California certified insurance agents, certified enrollment counselors, service center representatives and county eligibility workers, will be available to help consumers submit the necessary documentation. Lee stressed that consumers should act quickly to submit the requested documents. For more information, call www.CoveredCA.com. Doctor Shortages in LA Among the Worst in the U.S. Los Angeles has the third most severe doctor shortage of any city in the nation, according to BetterDoctor.com. Los Angeles has 3,062 residents per doctor while San Francisco has only 1,466. Two California cities are in the nation’s top 25 with the highest ratio of doctors to patients: Sacramento has 1,090 residents per doctor and San Diego has 1,289. LIFE SETTLEMENTS AIG and Coventry Sue Each Other AIG’s Lavastone Capital filed suit in New York federal court saying it had paid Coventry First more than $1 billion since 2006 to help it acquire life settlements. Lavastone says that Coventry used a network of shell companies to inflate prices, costing Lavastone more than $150 million. In a countersuit, Coventry accused Lavastone of breaching an exclusive contract by allowing an affiliate to purchase life settlements from other businesses. Conventry says that Lavastone made up the fraud allegations to escape a contract that limits its ability to resell certain policies, which Coventry estimated could cost AIG $700 million. Coventry is asking for an award of more than $100 million and declaration that Lavastone is not entitled to damages. Lavastone spent about $6.5 billion over a decade to acquire nearly 7,000 life settlements with a face value of $20 billion, but has wound down its life settlement business. Coventry issued the following statement: We are disappointed by AIG’s breaches of our agreements, and by our need to resort to litigation to remedy those breaches.We are astounded that AIG would bring a lawsuit that as AIG knows, rests on a fiction. AIG claims to have been unaware of practices that were documented and acknowledged through a process that AIG requested. Further, every year, AIG’s independent internal audit group audited its transactions with Coventry First, fully aware of and focused on the very practices it now claims were fraudulent, and found no violation of the agreements between the parties.  AIG’s lawsuit also is an attempt to negotiate by litigation. In an effort to rewrite long-standing agreements that it now finds onerous, AIG has concocted allegations to escape contractual provisions that limit its ability to resell policies in the tertiary market. AIG’s complaint is a cynical attempt to distract its shareholders from its own breaches and its failure to disclose the contract restrictions it seeks to escape. These limitations have an estimated value to the portfolio, and to Coventry First, of $700 million. Going forward, Coventry will aggressively prosecute its lawsuit against AIG, defend itself against AIG’s retaliatory lawsuit, and require AIG to adhere to all contract provisions in the existing business agreements. HEALTHCARE Comprehensive Cost Transparency Tool to Be Online Soon Early 2015 is the kickoff time for free and comprehensive healthcare transparency tools, according to the Health Care Cost Institute (HCCI). The tools, which offer information on price and quality of health care, will be available to consumers, purchasers, regulators, and payers in an easy format. Employers will be able to customize their employees’ experience. Future updates will include the ability to compare provider prices. The tools will link aggregated data from commercial health plans to data from Medicare Advantage and Medicaid health plans. Price data includes the allowed amount paid by the insurer plus copays and deductibles. Assurant Health will join Aetna, Humana and UnitedHealthcare to work with HCCI on the tools. Other carriers are expected to sign on. Health Net, Kaiser Permanente, and Partners HealthCare are helping develop consumer transparency and public reporting standards for capitated, integrated, and valued-based health plan designs. “These recommendations will offer valuable insights about health costs and resources and make information on the cost and quality of health care more accessible and easier to understand, particularly in light of new payment models,” said David Newman, Executive Director of HCCI. GAO Finds Flaws in CMS Audit Program The Centers for Medicare & Medicaid Services (CMS) does not provide enough oversight to the contractors that audit Medicare reimbursement claims, according to an investigation by the Government Accountability Office (GAO). GAO finds that inappropriate and multiple audits are crippling the operations of many home medical equipment providers. Last December, administrative law judges suspended action on new audit appeals because of a backlog of more than 600,000 cases. Closing down the appeals process has forced many to shut their businesses or stop seeing Medicare patients because they don’t get paid during the appeals process. “The information in this report can now be used by Congress and CMS to…ensure more consistent oversight of  the contractors and audit process,” said Rep. Diana Louise DeGette (D-CO). For more information, visit www.aahomecare.org . Experts Predict A Big Boost in Access to Mental Health Drugs Doctors and managed care organizations anticipate increased demand for drugs that treat major depression, bipolar disorder, and schizophrenia, according to a survey by Decision Resources Group. The demand for these drugs will rise thanks to Medicaid expansion in 24 states and affordable coverage through the exchanges. Doctors expect to see 30% more patients with these conditions. Managed care organizations say that drug formularies in the exchanges are the same or compare favorably to those of traditional group health plans. While there are many generic drugs to treat these behavioral health conditions, managed-care organizations offer favorable tier placement to brands they believe offer superior efficacy, safety, and tolerability. Branded behavioral drugs, such as Brintellix, Saphris, and Fanapt are excluded less often from exchange plans than from commercial group plans. Abilify will launch generically in 2015, which is expected to increase utilization, especially in Medicaid plans and in managed-care plans that offer higher payments for physicians with high generic prescribing rates. Narrow provider networks in the exchanges are expected to drive many patients to visit primary care doctors for  behavioral conditions. Compared to psychiatrists, these generalists are not as familiar with the newer branded drugs, and they welcome information about pharmaceutical companies’ patient assist programs. Doctors overwhelmingly support patient assistant programs. They say that patients will still need drug coupons when they face high deductibles or formulary exclusions through an exchange plan. For more information visit www.DecisionResourcesGroup.com. Workers Spend Less Than 15 Minutes Choosing Health Benefits Forty-one percent of employees spent 15 minutes or less analyzing their health benefit options during the 2013 open enrollment season; and 24% spent five minutes or less, according to a recent Aflac open enrollment survey. Forty-two percent waste up to $750 a year on mistakes with their insurance benefits. The survey also found the following about workers: • 90% auto-enroll or keep the same benefits year after year. • 73% sometimes, rarely, or never understand everything their policy covers. • 64% sometimes, rarely, or never understand changes in their coverage. • 64% disagree or only somewhat agree that they are more prepared for open enrollment this year compared to last year. For more information, visit AflacWorkForcesReport.com or follow @aflac on Twitter. NEW PRODUCTS Enrollment Support Tools Transamerica Employee Benefits is offering interactive enrollment education and decision support tools at no cost to eligible employer groups. This limited time offer will be available September 1 to January 1, 2015. The platform will include educational modules for voluntary products underwritten by Transamerica Life Insurance Company – critical illness and accident insurance – along with medical, term life, hospital indemnity, dental, and vision insurance modules. It makes it easy for producers and employers to provide a personalized enrollment experience. For more information, visit www.transamericaemployeebenefits.com. Social Media Content For Financial Reps Guardian Life is expanding its social media program to financial representatives and wholesalers. They now have access to articles, images, and videos that they can post to their followers and prospective clients. On average, Guardian’s users share eight pieces of content each month. The program was recently recognized at the LIMRA LOMA 2014 Social Media Conference for Financial Services with the Best Use of LinkedIn Award. For more information visit www.GuardianLife.com. New Investment Options There are 21 new investment options with the Guardian Choice and The Guardian Advantage investment lineups. The enhancements increase the flexibility and breadth of asset classes.  The additions include offerings from new fund families, such as American Funds, Morgan Stanley Investment Management, Natixis Funds, OppenheimerFunds, and Putnam Investments. There are also offerings from existing fund families including Vanguard, MFS, Franklin Templeton Investments and Invesco. With these news funds, The Guardian Choice now totals 138 funds while The Guardian Advantage has 111. For more information, visit 401k.GuardianLife.com. Annuity Fidelity & Guaranty Life launched an annuity product, Income and WealthBuilder. It’s for retirement savers who want accumulation and income benefits. The product offers a seven-year and 10-year surrender schedule option for maximum flexibility. It features five interest-crediting options. Income and WealthBuilder offers an optional guaranteed minimum withdrawal benefit rider (GMWB) that allows the owner to receive the larger of premiums paid in the first contract year accumulating based on a 7.2% compounding roll-up rate or the initial premium plus an 18% income base bonus credited to the client’s income benefit value. These features are designed to meet the needs of annuity policyholders who are seeking accumulation and income in the near future. Voya Debuts Brand Campaign Voya Financial, formerly known as ING, launched a consumer marketing campaign that runs through the rest of 2014. The campaign includes television, digital, mobile, search, social media and trade advertising. Voya’s rebranding began in April when its holding company and philanthropic foundation transitioned to the new brand. The company’s five business segments now operate as Voya. The company also introduced its new website, http://voya.com.  A new television commercial will run September through November on a wide range of network and cable media properties during professional sports, news, and late night programming. The spot can be viewed at http://go.voya.com/ButterflyAd. ... Continue Reading →
Capital

60-Day Limit on Waiting Periods for Group Health Contracts Repealed

California passed Senate Bill 1034, which repealed an insurance law (Assembly Bill 1083) that prohibited insurance companies from including waiting periods in excess of 60 days in their group health insurance contracts.  The new law, effective January 1, 2015, prohibits California insurance companies from applying any “waiting or affiliation period” under a group or individual health benefit plan. So where does that leave California employers, who are permitted under federal law (the ACA) to have a one-month orientation period and up to a 90-day waiting period? They’ll be able to continue applying ACA-compliant orientation periods and waiting periods, as the law prohibits carriers—but not employers—from imposing a waiting period according to a recent report in the National Law Review. ... Continue Reading →
ViewFromTop

View from the Top:
Life Insurance Survey

by Leila Morris The life insurance market has picked up, but continues to face challenges that began with the Great Recession in 2008, according to executives who participated in this year’s View From the Top Life Insurance survey. For example, the continued low interest rate environment continues to plague insurance sales. A bright spot is in workplace sales. With health reform, brokers and employers are showing more interest in voluntary products that can boost benefit plans. In fact, whole life sales through the workplace are growing at 6% to 7% annually. As for popular product types, executives list a variety of new index universal life products, updated term portfolios, and even a resurgence of variable life products. While there has been a steady increase in term requests, consumers are becoming more intrigued by permanent guaranteed products. Executives have seen a boost in indexed universal life products for consumers who want better returns, but are not willing to commit to variable universal life. Also, with an increase in income tax rates more clients are asking for nonqualified deferred compensation plans, which are plans funded with corporate owned life insurance. As for distribution, there are fewer brokers to work with because of tremendous broker consolidation. The traditional independent insurance agent is slowly being replaced by a new breed of insurance producer who relies on non-traditional training in order to compete. How Is the Life Insurance Market Faring In Today’s Economy? Dennis Brown, chief marketing office and co-owner of M&O Marketing: The life insurance market has picked up over the past few years. When the economy turned for the worse in 2008 and unemployment was on the rise, many lost their life insurance benefits and realized the need to replace the protection for their families. In a strong economy people become much more comfortable and the importance of life insurance just isn’t a priority. Dave Donchey, CLU, president, Leisure Werden & Terry Agency: The market has been challenged since 2008; and what we are experiencing today is a hangover from that. The continued low interest rate environment that we have been stuck in will continue to plague insurance sales. Todd Mason, Public Sector sales director, West Region Colonial Life & Accident Insurance Company: Worksite sales have continued to grow year over year. Based on 2013 data, the life segment has shown the most growth. Term life products continue to hold first place in the life insurance sales category for worksite, based on the latest data from Eastbridge. The life market isn’t growing as fast as the overall economy, but there are pockets of opportunity for life products sold at the workplace. Whole life sales through the workplace are growing at 6% to 7% annually. There has been a slight increase in the volume of term life insurance sold in the past five years, but the premium associated with those sales is down as rates have declined, mostly because of improvements in mortality. Another factor at play is that the vast majority of all life insurance policies are sold at the workplace. The high-volume, low-touch nature of the workplace sales channel is best suited to the sale of simpler products that are designed to meet less complex consumer needs. Life policies sold at the workplace, therefore, tend to carry significantly lower face amounts than those sold through other channels. Has There Been A Significant Change In Product Mix Over the Past 12 Months In Terms Of Guarantees, Variable, or Term? Dave Donchey, CLU, Leisure Werden & Terry: There have been quite a few product changes over the past year. However, this is not much different than what we have been experiencing over past few years. Most carriers have no choice but to become innovative with product design to create a balance between manufacturing products that are attractive to consumers and those that agents are anxious to sell in order to make money. This would include a variety of new index universal life products, updated term portfolios, and even a resurgence of variable life products by some carriers. Eric Henderson, senior vice president, Individual Products and Solutions, Nationwide Financial: We’ve seen a big boost in sales of indexed UL, and that trend holds true across the industry according to LIMRA’s sales data for the first quarter of 2014. We believe that the acceptance of new products and brokers seeing value in those products for their clients in today’s market are driving the interest in indexed UL. In response, we’re focused on continued innovation in this area. Additionally, industry sales of no-lapse guarantee universal life reduced by 32% in 2013, year-over-year, according to LIMRA. Conversely, Nationwide’s sales in this product line doubled. Thom Freismuth, a broker with Hub International: Indexed life is probably one of the more sought after products in the marketplace today. It is tied to various indices, such as the S&P 500, with a minimum floor guarantee of zero. The product caps your upside advantage at perhaps 13%, but in under no circumstances can your return go below zero. Dennis Brown, M&O Marketing: There is a steady increase in term requests, however the public has become more intrigued in the permanent guaranteed and the industry has seen a rapid increase in demand for this product. The variable products are changing for the better, but overall people are still skeptical because of the poor performance of older versions. Barron Dorf, senior market manager at Unum: On the voluntary side more employers are seeing the value in offering choice to their employees in the combination of group term and individual whole or universal life. Todd Mason, Colonial Life: As health care costs increase and employers increasingly shift to a defined contribution model for their benefit plans, there’s likely to be a general upturn in term life sales as its low cost becomes increasingly attractive to consumers. As LIMRA’s 2013 Industry Predictions report points out, the market has moved back and forth over the years between placing risk on individuals and on carriers. Right now, companies are increasing product pricing while reducing the benefits on these guarantees, discontinuing sales of some products or riders, and in some cases exiting the market entirely. Do You See Growth In Particular Niche Markets? Todd Mason, Colonial Life: Life insurance is needed across all markets as working Americans in general are uninsured or underinsured. A 2013 LIMRA study reported 50% of U.S. adults don’t have enough life insurance, and 30% have no life insurance at all. This tends to be especially true of younger workers who may not yet have families and mortgages, so they don’t see the need as strongly as older workers. But as Gen Y begins to take over the workplace in the coming years, this represents a good opportunity to educate employees about their needs and help them match those needs with the right type and amount of coverage. The Hispanic population is growing also, so to be effective in this market there’s a growing need for benefit counselors who not only speak their language, but also understand their culture. Thom Freismuth, Hub International: We are seeing growth in the corporate owned life insurance since these products are used to fund nonqualified deferred compensation plans. Barron Dorf, senior market manager at Unum: The voluntary market has grown substantially as more employers are looking to offer more benefit choices to employees and round out core benefits that, in many cases, have been cut back for many employees. Dave Donchey, CLU, Leisure Werden & Terry: We have seen an increase in indexed universal life sales catering to the consumer who is looking for better returns on their investments, but is not willing to commit to variable universal life. The challenge is getting more agents to invest the time needed to understand how these products work and how to sell them responsibly to their customers. Dennis Brown, M&O Marketing: We are seeing the biggest growth in retirement and college planning. Assumption/cash assumption products and IULs, in particular, are on the rise. Eric Henderson, Nationwide Financial: Clients, especially Baby Boomers, need help planning for their impending long-term care needs. According to the Dept. of Health and Human Services, 70% of people over 65 will need some type of long-term care. Our own research indicates that Boomers drastically underestimate how much long-term care cost, and only 8% have purchased any type of long-term care insurance. We’re focused on providing advisors and brokers with innovative solutions to help clients fill their long-term care funding gap. What Is Happening With Your Distribution Systems? If You Have An Agency Force, Is It Growing, Are You Hiring, And Is There More Attrition Than Usual? Dennis Brown, M&O Marketing: M&O Marketing is an independent marketing organization, however we are receiving more requests from captive agents. Considering most agents are allowed to broker business outside their own carrier the new attractive products on the market are encouraging them to call us for case design. Todd Mason, Colonial Life: Colonial Life’s career agency distribution system is strong and growing. It was at a record high last year and we plan to continue building it this year. There is a tremendous opportunity in worksite benefits for people who care about helping others, who want to be their own boss and who want to set their own level of earnings and success. Especially since the recession, a lot of people are seeing the value in being able to determine their own future. Our agency sales organization works directly with employers and through brokers to serve their clients. Barron Dorf, senior market manager at Unum: There has been tremendous broker consolidation so there are fewer brokers to work with. However, the size of the agencies today are much larger than in years past with extensive resources and expertise like executive planning and voluntary benefits. These dedicated resources can help the carriers focused on life insurance to grow market-share. Eric Henderson, Nationwide Financial: We are hiring new primary agents for our exclusive agency channel although we have largely maintained the size of this distribution force. We’re also developing a growing number of strong relationships within the independent agent channel. Our relationships with non-affiliated distribution channels, including brokerage general agents, regional and national brokerages, wirehouses and banks, continue to yield positive results. Our application volume has increased 65% since 2011; we exceeded sales targets more than 152% last year; and we are well above plan this year. Non-affiliated channel sales are driving those numbers. Dave Donchey, CLU, Leisure Werden & Terry: There is a common thread in which the traditional independent insurance agent is slowly being replaced by a new breed of insurance producer who has to rely on nontraditional training in order to compete. There are fewer career oriented carriers providing high levels of training, which means that people who sell life insurance today do so by first focusing on some other non-life insurance product. This new environment means that more of the training responsibilities fall on the general agent than in years past. What Kind Of Growth Do You See In Life Insurance Sales As An Employee-Paid or Employer-Paid Benefit? Dave Donchey, CLU, Leisure Werden & Terry: I am not sure that we are seeing or will see tremendous growth in of these areas. With today’s economy, employees are not highly motivated to buy employer sponsored benefit plans that they have to pay for. At the same time, employers are being squeezed financially to continue to fund benefits for their employees. The exception may be employers who are paying for key person life insurance coverage and buy/sell life insurance coverage to protect their businesses. Barron Dorf, senior market manager at Unum: The growth we are seeing is on the voluntary side for the following reasons: • Brokers are looking to diversify their revenue by selling more ancillary products like life insurance • Employers are looking to attract and retain key employees by offering a stronger package of ancillary products with more choices like term life and permanent life. • Brokers are providing more services to employers like benefit administration and employee communication during a very confusing time with health care reform. • Fewer individual agents are marketing to the middle income and hourly workforce outside of the workplace these days. The kitchen table life insurance sale for middle income America is no longer. Mark J. Hanna, CLU, ChFC, REBC, RHU, chairman of Hanna Global Solutions in Concord. Calif: We focus almost entirely on employer sponsored life insurance plans. This includes not just the traditional group-term (and excess group-term) plans, but a range of employer sponsored welfare benefit plans that offer permanent life insurance solutions whether universal, variable, or index. Permanent and individual term plans have tremendous appeal as part of a robust benefit platform that may also include Internal Revenue Code ß162 or bonus plans and payroll deduction. I believe that delivering life insurance solutions, through an employer/employee relationship, is the most efficient way to serve the vast majority of prospective life insurance consumers. Our sales volume continues to grow each year as employers learn that they can diversify their benefit offerings using non-traditional life insurance solutions. Todd Mason, Colonial Life: The shift toward employees taking more responsibility for benefit decision-making and purchasing will continue. In today’s economic environment, employers aren’t looking to increase their costs. Even for employers who continue to offer some employer-paid life insurance, the amount usually is far less than what a typical employee’s family would need. That’s why voluntary life insurance is so important. It gives employees access to the additional coverage they need at more affordable rates and an easy underwriting process — plus in some cases, the opportunity to talk to someone face to face so they understand their needs and what they’re buying. Dennis Brown, M&O Marketing: The most growth we are seeing is in the executive life insurance area, but it’s a slow growth. Business-continuation plan requests are slightly climbing in our business as well. Are You More Or Less Active With Alternative Distribution Systems (Banks, Stockbrokers, Direct)?  Dennis Brown, M&O Marketing: We rarely deal with banks or other alternative distribution systems at this point. Eric Henderson, Nationwide Financial: We remain very active with banks and wirehouses and value their business and partnership. Brokerage general agents are also important partners for Nationwide on the life side. Barron Dorf, senior market manager at Unum: We are less active as there is plenty of change and opportunity in the employer and executive market right now. Dave Donchey, CLU, Leisure Werden & Terry: To this point, we have not been involved in alternative distribution systems. However, we are partnering in creating a consumer facing website tool that insurance producers within alternate distribution systems can use to brand themselves and give clients an opportunity to request life insurance quotes and apply online. We feel that, by offering this tool, we will be better able to interact with and be successful within some of these alternative distribution systems. What Recent Events Have Affected The Way You Do Business? Thom Freismuth, Hub International: Increases in income tax rates have caused the growth in the request for nonqualified deferred compensation plans. These plans are funded with corporate owned life insurance. Dennis Brown, M&O Marketing: AG38 had a big effect on which carriers’ products were requested considering a majority of our business deals are guaranteed UL products. Agents had sticker-shock when new pricing was put into effect. The time it took to recover from the slow-down in guaranteed sales was longer than anticipated by some of the carriers. Barron Dorf, senior market manager at Unum: Health care reform has caused brokers and employers to take a closer look at employee benefits, which has enhanced the desire to offer voluntary products to fill necessary gaps and help fund communication and enrollment needs. Dave Donchey, CLU, Leisure Werden & Terry: The most significant recent event that has affected the way we do business is our adoption at a powerful CRM and marketing program that has allowed us to expand our marketing capabilities and communicate with our customers much more effectively than ever before. We are now looking to take advantage of technology to get better data on our customers in order to target market to them more appropriately. We are already seeing good results. Todd Mason, Colonial Life: Health care reform is on everyone’s mind, but it really hasn’t changed the way we do business. Voluntary benefits are mostly exempt from the health care reform law, and they still offer a great way for brokers to help clients have a more competitive, customizable benefit package with no effect on the bottom line. This is true for all employers, even those sending employees to exchanges for major medical coverage; they can still make their benefits stand out from similar employers by offering voluntary benefits to their employees. And no matter which route the employer takes, there’s still a tremendous need to help people understand their needs, coverage gaps, and which options best meet those needs. So one-to-one benefit education and counseling is going to be more important than ever as health care reform is implemented. What State Or Federal Legislative Issues Are You Concerned About? Thom Freismuth, Hub International: Certainly, if the government were to curtail or eliminate the tax-free buildup of cash values life insurance, it would have a significant effect on the marketplace. If legislature were to eliminate the marital deduction or the $5 million+  estate tax-free amounts, it would cause need for more life insurance. Dave Donchey, CLU, Leisure Werden & Terry: Like most general agencies, we have been concerned about the fewer number of traditional estate planning cases we are seeing, given the lifetime exemption and the tax law roller coaster that estate planning has endured in recent years. If nothing changes, we will rely less on these traditional large premium sales and more on alternative large case strategies to help support our business. Todd Mason, Colonial Life: The low interest rate phenomenon is the single greatest challenge facing the industry. These low rates will continue to put pressure on financial service companies and the interest-sensitive financial products they issue, including life insurance. All life insurance products are affected to varying degrees, but long-term contracts that rely heavily on earned interest, such as whole life and universal life, are especially affected. All life insurers will be challenged to make product adjustments in order to manage lower investment income and profitability in the environment. Speaking of Life Insurance Customers, Are There Certain Niches or Age Groups That Brokers Should More Of A Focus On?  Eric Henderson, Nationwide Financial: We feel that the middle market presents a growth opportunity for brokers. The tendency to focus on high net-worth clients in the financial services industry has left a large portion of the market underserved. Life insurance plays a crucial role in protecting the futures of all families as their primary source of income replacement. There is substantial opportunity for brokers who help people understand how affordable that protection is. Our research shows that 98% of consumers who are married, partnered, or have dependents lack enough insurance to replace their income. Of those surveyed, the average person will earn approximately $1.5 million before they retire and holds about $300,000 in life insurance coverage, leaving them about $1.2 million short of replacing their income with life insurance. However, they are also willing to pay enough for life insurance to reduce this income replacement gap. Consumers surveyed said they are willing to pay $99 per month on average to ensure that their family can maintain its standard of living indefinitely following the death of a breadwinner. Advisors and insurance agents may be able to motivate clients by helping them understand the implications of their income replacement gap. We know that consumers don’t respond well to scare tactics, but they may be relieved to learn that the solution is not as scary as they may expect. Even if they don’t feel compelled to buy enough life insurance to replace all of their income, most consumers can afford enough to put a significant dent in their income replacement gap. That’s at least a step in the right direction. Thom Freismuth, Hub International: The younger working family member who no longer has an agent calling on them to sell them life insurance still has a need for the product, so that is one of the reasons that voluntary life insurance options through the employer have increased. Historically many insurance carriers marketed directly to them, which is a thing of the past. The other area is the more affluent high income earners who would like to defer some of their income into corporate on life insurance policies to fund non qualified deferred compensation plans. Dave Donchey, CLU, Leisure Werden & Terry: The debate continues between a producer who trying to grow clientele while trying to make a living. Older, wealthier people provide for more lucrative sales, but will have less longevity as a client. Younger, less affluent clients will provide for easier and less lucrative sales, but will present greater income potential down the line. The best game plan is to achieve a balance between the two, but know that sales to older and more affluent people will keep the producer in the game. What Are Some Of The Common Characteristics Of Your Most Successful Life Insurance Producers?  Barron Dorf, senior market manager at Unum: An individual producer typically understands all the tax laws and uses life insurance as an investment vehicle for planning purposes. Employee benefit producers really understand the voluntary business and buying trends of different age groups, income brackets, and industries. Eric Henderson, Nationwide Financial: Common traits of successful life insurance producers include a lifelong commitment to learning and a focus on client needs. For example, good producers will observe a trend, such as the lack of consumer understanding about the true cost of long-term care in retirement, and then position themselves with clients as someone who can help them chart a path to address this challenge. Dave Donchey, CLU, Leisure Werden & Terry: The two common characteristics of our most successful life insurance producers would be first, the ability to network with the right people to gain the benefit of the greatest number of people from which to prospect on a favorable introduction basis. This would include key centers of influence. Second, each top producer has an overwhelming desire for their next case and leaves no stone unturned in pursuing it. They believe in their product and almost make it their life’s mission to provide it to others. Todd Mason, Colonial Life: We strongly believe in the value of one-to-one, personal benefit counseling sessions to help employees understand their needs and options to create an effective financial safety net for themselves and their families. So our most successful life insurance producers are those who are not only experts in product knowledge, but who also excel at this customized counseling approach. They create trust and credibility, as well as long-term relationships. They’ll be back in the same account next year and the year after, talking to the same employees, whose needs are likely to change. q –––––––– Leila Morris is senior editor of California Broker Magazine.   ... Continue Reading →
PrivateExchanges

Private Health Exchange Survey 2014

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

Employer-Sponsored Family Health Premiums Rise a Modest 4%
by Leila Morris – 9/3/14

Annual premiums for employer-sponsored family health coverage reached $16,351 in 2013, up 4% from in 2012, with workers paying an average of $4,565 toward the cost of their coverage, according to a report by the Kaiser Family Foundation/Health Research & Educational Trust. The rise in premiums is moderate by historical standards. Since 2003, premiums have increased 80%, nearly three times as fast as wages and inflation. “We are in a prolonged period of moderation in premiums, which should create some breathing room for the private sector to try to reduce costs without cutting back benefits for workers,” said Kaiser President and CEO Drew Altman, Ph.D. Firms with many lower-wage workers (at least 35% earning $23,000 or less annually) required workers to pay $1,363 more toward family premiums than did companies with fewer lower-wage workers ($5,818 versus $4,455 annually). The lower-wage firms offered less costly coverage too, creating a big disparity in the share of the premium that their workers pay (39% versus 29%). In 2013, 78% of all covered workers had an annual deductible, up from 72% in 2012. Typically, workers pay this deductible before most services are covered by their health plan. The average deductible for worker-only coverage was $1,135 in 2013, similar to the $1,097 average deductible in 2012. In 2013, 38% of all workers had a deductible of at least $1,000 or more compared to 58% of workers at small firms. In fact, 31% of workers at small firms had a deductible of at least $2,000 in 2013, up from 12% in 2008. In 2013, 35% of employers said that wellness plans are very effective in controlling costs compared to 22% who cited disease management, 20% who cited consumer-driven health plans, and 17% who cited higher cost sharing. Nearly all large employers (at least 200 workers) offered at least one wellness program. Thirty-six percent of large employers that offered wellness programs provided financial incentives for participation, such as lower premiums or deductibles, a larger contribution to a tax-preferred savings account, gift cards, cash, or other direct financial incentives. Fifty-five percent of large firms that offered health benefits also offered biometric screenings, and 11% rewarded or penalized workers financially based on whether they achieve biometric outcomes. The Affordable Care Act (ACA) includes provisions that allow broader use of financial incentives to encourage workers to improve their health status and outcomes. “This will be an important issue to watch next year, as employers will have more flexibility and could ask workers to pay more because of their lifestyles and health conditions,” said KFF vice president Gary Claxton. Thirty-six percent of covered workers were in grandfathered plans, down from 48% in 2012. The slow growth in premiums also means that fewer employer plans will be subject to the ACA’s high-cost plan tax that takes effect in 2018. The Congressional Budget Office recently reduced its estimate of the number of plans that would trigger the tax, and a continued low growth rate could further reduce the effect of this provision. In 2o13, 29% of employers with at least 5,000 workers were considering offering benefits through a private exchange. These jumbo firms employ almost 40% of all covered workers, so their interest could indicate a significant shift in the way many people get their health insurance. Fifty-seven percent of firms offered health benefits in 2013, which is statistically unchanged from the 2012 and 2011. Nearly all firms with at least 200 workers offered health benefits to at least some of their workers. Forty-three percent of the smallest firms (three to nine workers) offered health benefits in 2013 compared to 50% in 2012. Also, 23% of firms with a lot of low-wage workers offered health insurance compared to 60% of firms with few low-wage workers. For more information, visit http://kff.org/EHBS. Sluggish Economy, Not Health Reform, Drove Spending Slowdown The economic downturn can take the credit for about 70% of the recent decline in health care spending growth from 2009 to 2011, according to a study published in the August issue of Health Affairs. As the economy recovers, health spending is likely to increase at a faster pace. “The slowdown was mostly due to the sluggish economy, not to structural change in the health care sector. The Affordable Care Act may ultimately succeed at reducing costs, but it hasn’t done so yet,” said study co-author David Dranove of the Kellogg School of Management at Northwestern University. “There has been disagreement, over the years, as to whether health spending is recession proof. This study shows it’s not. The analysis, which focuses on privately insured people, highlights that the slowdown in health spending was not only caused by people who lost their jobs and employer-provided health insurance. Even people who retained insurance during the downturn reigned in their health spending. This demonstrates the broad effects of a recession on health spending,” said Co-author Craig Garthwaite, an assistant professor at the Kellogg School of Management. Health spending growth slowed 2.6% from 2009 to 2011. The authors predict that health-spending growth would have been 1.8% higher if the economy had not faltered in 2008.  Insured people living in the hardest hit areas experienced the smallest increases in health spending. Thus, they concluded that 70% of the decline in health care spending growth was the result of the stagnant economy.  For more information, visit http://www.healthcostinstitute.org/ -and-future-research-projects@healthcostinst. Higher Ed Employees Face More Cost Sharing Colleges and universities are passing more healthcare costs to their employees, according to a report by the College and University Assn. for Human Resources. Forty one percent have increased the employee share of premiums since the ACA went into effect. Additionally, 26% have increased in-network deductibles; 27% have increased out-of-pocket limits; 20% have increased the employee share of prescription drug costs; and 24% have increased the employee share of dependent coverage costs. Thirty-six percent of colleges and universities have adopted or expanded a wellness program; and 21% have adopted or expanded financial incentives to encourage healthy behaviors. The survey also reveals the following about colleges and universities: 50% of part-time staff and 80% of part-time faculty work less than 30 hours a week. The average annual premium was $6,501 for employee-only coverage and $17,484 for the employee plus family coverage for all four plan types (PPOs, HMO, POS plans, and HDHPs). 82% offer PPO plans; and 44% offer HDHPs — up from 17% in 2009. 60% offer healthcare benefits to same sex domestic partners or spouses (up from 46% five years ago). 42% offer healthcare benefits to part-time staff and 36% offer healthcare benefits faculty. Most of those also pay part of the premium. Colleges and universities that don’t offer healthcare benefits for part-time employees are not providing financial support for enrollment in a public exchange, and only 2% are considering doing so next year. Almost all colleges and universities provide basic life insurance, long-term disability, paid time-off, tuition assistance and retirement benefits. But only 64% offer short-term disability coverage. For more information visit www.cupahr.org/surveys/benefits.aspx. The Most Influential People in Health Care Modern Healthcare magazine released its 12th annual ranking of the 100 Most Influential People in Healthcare. Quite a few are in the insurance industry. The award honors people who are the most influential in the health care industry according to their peers and an expert panel. They are listed as follows: 1. Kathleen Sebelius, secretary of HHS, 2. Dr. John Kitzhaber, governor of Oregon 3. President Barack Obama 4. Stephen Hemsley, president and CEO of UnitedHealth Group 5. Marilyn Tavenner, CMS administrator 6. Mark Bertolini, chairman, president and CEO of Aetna 7. Richard Bracken, chairman and CEO of HCA in Nashville 8. Joseph Swedish, CEO of WellPoint 9. George Halvorson, outgoing chairman of Kaiser Permanente in Oakland, Calif. 10. Sister Carol Keehan, president and CEO of the Catholic Health Assn. 11. Kent Thiry, co-chairman and CEO of DaVita HealthCare Partners, Denver 12. Glenn Hackbarth, chairman, Medicare Payment Advisory Commission 13. Judith Faulkner, CEO of Epic Systems Corp. in Wisconsin. 14. Jan Brewer, governor of Arizona 15. Dr. John Noseworthy, president and CEO of the Mayo Clinic 16. Dr. Delos Toby Cosgrove, president and CEO of the Cleveland Clinic 17. Wayne Smith, chairman, president and CEO of Community Health Systems in Tennessee 18. Trevor Fetter, president and CEO of Tenet Healthcare in Dallas 19. Joel Allison, president and CEO of Baylor Health Care System in Dallas 20. David Cordani, president and CEO of Cigna 21. Maureen Bisognano, president and CEO of the Institute for Healthcare Improvement 22. Paul Diaz, CEO of Kindred Healthcare in Kentucky 23. Patricia Hemingway Hall, president and CEO of Health Care Service Corp. in Chicago 24. John Hammergren, chairman, president and CEO of McKesson Corp. in San Francisco 25. Michael Dowling, president and CEO of the North Shore-Long Island Jewish Health System in N.Y. 26. Dr. Gary Gottlieb, president and CEO of Partners HealthCare in Boston 27. Dr. Farzad Mostashari, outgoing national coordinator for health information technology of the ONC 28. Bruce Broussard, president and CEO of Humana 29. Richard Umbdenstock, president and CEO of the American Hospital Assn. 30. Kevin Lofton, president and CEO of Catholic Health Initiatives. 31. Dr. Gary Kaplan, chairman and CEO of the Virginia Mason Medical Center in Seattle 32. Drew Altman, president and CEO of the Kaiser Family Foundation in Menlo Park, Calif. 33. Chip Kahn, president and CEO of the Federation of American Hospitals 34. Lloyd Dean, president and CEO of Dignity Health in San Francisco 35. RoseAnn DeMoro, executive director of National Nurses United. 36. Sen. Max Baucus, Senate Finance Committee chairman (D-Mont.) 37. Ron Pollack, founding executive director of Families USA 38. Dan Wolterman, president and CEO of Memorial Hermann Health System in Houston 39. A. Barry Rand, CEO of AARP 40. Bill Carpenter, chairman and CEO of LifePoint Hospitals in Tennessee. 41. Dr. Susan Turney, president and CEO of MGMA-ACMPE 42. Pat Fry, president and CEO of Sutter Health in Sacramento, Calif. 43. Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention 44. Dr. Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation 45. Dr. Margaret Hamburg, commissioner of the FDA 46. Alex Gorsky, chairman and CEO of Johnson & Johnson 47. Susan DeVore, president and CEO of Premier in North Carolina 48. John Castellani, president and CEO of Pharmaceutical Research and Manufacturers of America 49. Dr. Charles Sorenson, president and CEO of Intermountain Healthcare in Salt Lake City 50. Dr. Jeffrey Drazen, editor-in-chief of the New England Journal of Medicine 51. Dr. Atul Gawande, professor of surgery and Harvard Medical School and professor of health policy and management at the Harvard School of Public Health 52. Cecile Richards, president of Planned Parenthood 53. Alan Miller, chairman and CEO of Universal Health Services in Pennsylvania 54. Dr. Ardis Hoven, president of the American Medical Assn. 55. Margaret Peggy O’Kane, president of the National Committee for Quality Assurance 56. Dr. Glenn Steele Jr., president and CEO of Geisinger Health System in Pennsylvania. 57. James Skogsbergh, president and CEO of Advocate Health Care in Illinois 58. Dr. Georges Benjamin, executive director of the American Public Health Assn. 59. Jay Grinney, president and CEO of HealthSouth in Alabama 60. Dr. Mark Chassin, president of the Joint Commission. 61. Anthony Tersigni, president and CEO of Ascension Health Alliance in St. Louis 62. Alan Aviles, president and CEO of the New York City Health and Hospitals Corp. 63. Doug Hawthorne, CEO of Texas Health Resources 64. Richard Feinstein, former director of the Bureau of Competition for the Federal Trade Commission 65. John Bardis, chairman, president, and CEO of MedAssets in Georgia. 66. Mary Brainerd, president and CEO of HealthPartners in Minneapolis 67. Leah Binder, president and CEO of the Leapfrog Group in Washington 68. Daniel Levinson, inspector general of HHS 69. Jeffrey Romoff, president and CEO of UPMC in Pittsburgh 70. Bobby Jindal, governor of Louisiana 71. Suzanne Delbanco, executive director of Catalyst for Payment Reform in San Francisco 72. Dr. Christine Cassel, incoming president and CEO of the National Quality Forum 73. Dr. Francis Collins, director of NIH 74. Nancy Schlichting, CEO of the Henry Ford Health System in Detroit 75. Karen Ignagni, president and CEO of America’s Health Insurance Plans 76. Bill Gates, co-chair of the Bill & Melinda Gates Foundation 77. Sen. Charles Grassley (R-Iowa) 78. Dr. Jeffrey Cain, president of the American Academy of Family Physicians 79. Gail McGovern, president and CEO of the American Red Cross 80. Dr. Harvey Fineberg, president of the Institute of Medicine 81. Dr. James Madara, executive vice president and CEO of the American Medical Assn. 82. Scott Armstrong, president and CEO of Group Health Cooperative in Seattle 83. Deborah Bowen, president and CEO of the American College of Healthcare Executives 84. Scott Serota, president and CEO of the Blue Cross and Blue Shield Assn. in Chicago 85. Dr. Darrell Kirch, president and CEO of the Assn. of American Medical Colleges 86. Dr. Ralph de la Torre, chairman and CEO of the Steward Health Care System in Boston 87. Dr. Benjamin Chu, group president of Kaiser Permanente Southern California and Hawaii, Kaiser Permanente, Oakland, Calif.; and board chairman of the American Hospital Assn. 88. Mary Kay Henry, president of the Service Employees International Union 89. Kenneth Raske, president and CEO of the Greater New York Hospital Assn. 90. Dr. Eric Topol, chief academic officer for Scripps Health and director of the Scripps Translational Science Institute in San Diego 91. Eric Shinseki, secretary of the Veterans Affairs Department 92. Donald Fisher, president and CEO of the American Medical Group Assn. 93. Dr. David Blumenthal, president of the Commonwealth Fund 94. Dr. James Weinstein, president and CEO of Dartmouth-Hitchcock in N.H. 95. Alan Morgan, CEO of the National Rural Health Assn. 96. Val Halamandaris, president of the National Assn. for Home Care & Hospice 97. Dr. Bruce Siegel, president and CEO of America’s Essential Hospitals 98. Helen Darling, president and CEO of the National Business Group on Health 99. Dr. Brent James, chief quality officer and executive director of the Institute for Health Care Delivery Research for Intermountain Healthcare in Salt Lake City 100. James Hinton, president and CEO of Presbyterian Healthcare Services in Albuquerque Read the full article as published in the August 26 issue of Modern Healthcare at: http://bit.ly/1dir1Ys Top Trends in Medicare Part D Now in its ninth year of operation, the Medicare Part D program has had consistently high levels of plan participation, offering dozens of plan choices for beneficiaries in each region and broad access to generic and brand name drugs. But there are some sobering trends beneath the surface, according to a report by the Kaiser Family Foundation. Cost and access trends could pose challenges for Part D enrollees. Although premiums have been flat for several years, average premiums have increased nearly 50% from 2006 to 2014. Median cost sharing for brand-name drugs has also increased. Finally, many low-income beneficiaries are paying steadily higher premiums for coverage when they could be enrolled in premium-free plans. Sixty-two percent of Part D enrollees are in PDPs, but enrollment in MA-PD plans is growing faster, representing half of the net increase in enrollment from 2013 to 2014. About 6.5 million Medicare beneficiaries with drug coverage from their former employers now get that coverage through a Part D plan designed for that firm’s retirees. Enrollment in employer plans has quadrupled since 2006, partly due to changes in law that took effect in 2013. In 2014, three Part D sponsors account for half of all Part D PDP and MA-PD enrollees. UnitedHealthCare, Humana, and CVS Caremark have enrolled half of all participants in Part D, which is relatively unchanged from 2006. UnitedHealthCare and Humana have held the highest shares of enrollment since the program began while enrollment in CVS Caremark has grown through the acquisition of other plan sponsors. UnitedHealthCare has maintained the top position for all nine years of the program, and provides coverage to more than one in five PDP and MA-PD enrollees in 2014. Average monthly PDP premiums have been flat since 2010; premiums for some of the most popular plans increased for 2014; and premiums for other popular plans fell. On average, PDP enrollees pay premiums of $37.75 per month in 2014. However, PDP premiums vary widely even for plans with equivalent benefits. Premiums range from $12.80 to $111.40 a month for plans offering the basic Part D benefit. UnitedHealthCare’s AARP MedicareRx Saver Plus PDP, which was new in 2013, raised its premiums by 54% in 2014 (an average increase of about $8 per month). In contrast, WellCare’s Classic PDP lowered its premium by 38% (an average decrease of about $13 per month) in 2014. Part D enrollees in MA-PD plans pay lower premiums on average ($14.70) than those in PDPs. Cost sharing for brand-name drugs has been relatively stable in recent years, but has risen substantially since the start of Part D.  MA-PD plan enrollees generally have somewhat higher cost sharing than do PDP enrollees. Cost sharing for brands increased by about 50% from 2006 to 2014 for beneficiaries in PDPs and about 70% for those in MA-PD plans. Median cost sharing in a MA-PD is $45 for preferred brands and $95 for non-preferred brands plans. Median cost sharing in a PDP is $40 for preferred brands and $85 for non-preferred brands. Seventy-six percent of PDPs and 75% of MA-PDs use five cost-sharing tiers including preferred and non-preferred tiers for generic drugs, preferred and non-preferred tiers for brand drugs, and a tier for specialty drugs. Four-tier arrangements were most common until 2012 when plans began shifting toward the five-tier cost-sharing design. Part D plans typically use specialty tiers for high-cost drugs and charge coinsurance of from 25% to 33% during the benefit’s initial coverage period, as in previous years. These initial high out-of-pocket costs may create a financial barrier to starting use of specialty drugs, which are expected to be a significant cost driver for Medicare. Users are likely to reach the benefit’s catastrophic threshold in a short period, and see their coinsurance reduced to 5%. The number of Part D stand-alone drug plans with a preferred pharmacy network grew from 7% in 2011 to 72% in 2014. Enrollees have lower cost sharing with preferred pharmacies. However, in some plans, there is no preferred pharmacy within a reasonable travel distance, which could make it hard for enrollees to take advantage of the lower cost sharing. Only 5% of PDP enrollees are in plans with the highest star ratings (four stars or more out of five). More than half are in plans with 3.5 stars. Nearly one-fourth of are in plans with fewer than three stars; plans at this level for three years in a row can be removed from the program. For more information, visit www.kff.org. HIV Medical Organizations Challenge Insurer Restrictions The American Academy of HIV Medicine (AAHIVM) and the HIV Medicine Assn. (HIVMA) are challenging new health plan policies that bar many HIV care providers from prescribing certain medications to treat hepatitis C (HCV). “Thanks to the treatments available today, most of our patients with HIV do not die from AIDS-related illness, but from other conditions including liver disease. Many people co-infected with HIV and HCV have been waiting a long time for more effective and tolerable HCV treatment. Now that a cure is available, it is unconscionable to deny them access to medical providers who are well qualified to administer and manage this treatment,” said Joel Gallant, MD, MPH, FIDSA, chair of HIVMA. A new drug approved for the treatment of HCV earlier this year offers a significantly improved cure rate over older treatments. “Of the 1.1 million Americans living with HIV, approximately 30% are co-infected with HCV. Many of these patients are being successfully cared for by an HIV practitioner. Yet some insurers are now enforcing policies to limit or remove HIV care providers’ ability to prescribe new HCV medications. These restrictive insurance policies exclude HIV providers who are not trained as gastroenterologists, hepatologists, or infectious diseases specialists from prescribing some medicines to treat HCV, and create other barriers to providing the best available care to patients with HCV infection. There is no medical rationale for excluding some HIV providers from prescribing HCV medications,” said Donna Sweet, MD, AAHIVS, chair of the AAHIVM Board of Directors.She added, “HIV providers who have been treating HCV/HIV co-infected patients for years are uniquely qualified to manage potential drug toxicities and side effects stemming from combining treatment… These restrictive policies not only limit access to the new HCV treatment for many people with HIV, but could also lead to treatment disruptions and other serious adverse health consequences for patients.” AAHIVM and HIVMA have sent letters to insurers urging them to reevaluate and discontinue these policies immediately. For more information, visit www.aahivm.org. Medical Tourism Webcast The Medical Tourism Assn. is hosting a webcast tomorrow at 7:00 AM. For more information, visit www.MedicalTourismAssn.com. NEW PRODUCTS Self-Service Enrollment Navera is offering employers and brokers a suite of educational and decision support software for self-service enrollment in Humana’s workplace voluntary benefits. Humana Inc. and Navera will include education and decision support software for other Humana benefits, including medical, dental, and vision products. For more information, visit www.humana.com. Health Exchange Aon Hewitt is expanding coverage options under the Aon Active Health Exchange for 2015. Employers can offer a wide range of elective benefit plans during this fall’s annual enrollment season. The following elective benefits that can be offered on the Aon Active Health Exchange for coverage beginning January 1, 2015: • Critical Illness • Accident • Hospital Indemnity • Life • Long-term Disability • Identity Theft • Legal • Home/Auto • Pet Insurance For more information, visit http://exchangesolutions.aon.com/our-exchange-portfolio. Education on Fiduciary Risks The Guardian launched The Fiduciary Awareness Quiz to help plan sponsors understand their fiduciary obligations. For more information, visit http://exchangesolutions.aon.com/our-exchange-portfolio. Global Health Budget Tool The Kaiser Family Foundation has launched an interactive tool that provides the latest data on the U.S. government’s global health budget in an easy-to-access form. The U.S. Global Health Budget Tracker lets users follow the budget from the President’s budget request through the appropriations process in Congress, and see trends over time. The Foundation will host an interactive web briefing on the new tool on Thursday, September 11 at 10:00. To view the tool, visit http://kff.org/interactive/budget-tracker/landing. To register for the briefing, visit https://cc.readytalk.com/cc/s/registrations/new?cid=udvgjeuo8nhi. CALIFORNIA Court Clarifies Definition of Independent Contractors The Ninth Circuit Court of Appeals ruled that 2,300 people working for FedEx Ground were misclassified as independent contractors instead of employees. As a result, FedEx may owe its workforce of drivers hundreds of millions of dollars for illegally shifting to them the costs of such things as the FedEx branded trucks, FedEx branded uniforms, and FedEx scanners, and missed meal and rest period pay, overtime compensation, and penalties. The case, known as “Alexander v. FedEx Ground,” covers employees in California from 2000 to 2007. The ruling can be found on the Leonard Carder website at leonardcarder.com. The court’s findings could influence the outcome in over two dozen cases nationwide in which FedEx Ground drivers are challenging the legality of their independent contractor classification.  FedEx requires its so-called contractors in California to hire a secondary workforce of FedEx drivers, who do the same work as the plaintiffs under the same contract. The Alexander decision calls into question FedEx’s strategy of making plaintiffs the middlemen between the secondary workforce of drivers and FedEx. Background on the everyday experience for FedEx Ground drivers includes the following: • FedEx Ground drivers were required to pay out of out of pocket for everything from the FedEx Ground branded trucks they drove (painted with the FedEx Ground logo) to fuel, various forms of insurance, tires, oil changes, maintenance, etc. and their uniforms, scanners and even workers compensation coverage. • In some cases, workers were required to pay the wages of employees who FedEx Ground required them to hire to cover for them if they were sick or needed a vacation, to help out during the Christmas rush, and in some cases to drive other FedEx Ground trucks. • After paying these expenses, a typical FedEx driver makes less than employee drivers at FedEx Ground’s competitors like UPS, and gets none of the employee benefits, like health care, workers compensation, paid sick leave and vacation, and retirement. • In addition, their employment was subject to the whims of FedEx management and FedEx Ground’s decisions on staffing and routes left the employee drivers stuck with expensive long-term truck leases on FedEx branded trucks. The drivers’ attorney Beth Ross added, nationally, thousands of FedEx Ground drivers must pay for the privilege of working for FedEx 55 hours a week, 52 weeks a year. These workers were granted rights and benefits entitled to employees under California law. To be clear, the Ninth Circuit exposed FedEx Ground’s independent contractor model as unlawful. For more information, visit http://www.leonardcarder.com/   California and Virginia join international information exchange agreement Insurance supervisors of California and Virginia have joined an international supervisory cooperation and information exchange agreement. There are now 42 jurisdictions admitted as signatories to the IAIS Multilateral Memorandum of Understanding (MMoU), representing nearly 60% of worldwide premium volume. MMoU, supervisors exchange relevant information and provide assistance to other signatories in order to promote  financial stability and sound supervision of cross-border insurance operations. California Insurance Commissioner Dave Jones said, “The MMoU is an essential regulatory tool, not only in crisis situations, but also on a day-to-day basis for supervisors to foster safer and more stable insurance markets.” For more information, visit www.iaisweb.org. LONG TERM CARE Motivating Clients to Plan for Long Term Care ACSIA Partners has introduced the concept of “empowered living,” which it hopes will catch on to help solve a big national problem: the lack of planning for long-term care. Denise Gott, CEO of ACSIA said, “It used to be that long-term care was a rather passive and dreary thing. People ended up in a nursing home or relative’s spare bedroom…But the care scene has changed, and will change even more in the years ahead…With good financial planning, you can look forward to years of rewarding, self-empowered living in spite of needing care.” A variety of senior and assisted-living communities have sprung up. They’re a far cry from yesterday’s nursing homes, and they’re transforming the quality of our later years. Some are plush and many offer amenities such as libraries, recreational facilities, support for business and professional pursuits, and cultural events such as lectures and concerts. Some operate with universities, providing rich cultural opportunities. One’s own home can be made care-friendly, she said. Retrofitting homes for people needing care is now a big business. Gott explained that Middle-aged Americans tend to associate needing care with becoming passive, losing control, declining, being  dependent, and being a burden on others. They sometimes even feel shame, fear, or repulsion just thinking about it. So they put it out of mind. Today’s 40-somethings and 50-somethings most need to think about LTC insurance because they’re usually fit enough to qualify for it and can get the best rates, she added. “They just need to look at it positively, from the upbeat perspective of empowered living, and then make a plan. Our belief is that many more will do that if we paint the right picture. One’s care years can be an upbeat stage of life — a period under their complete control, full of fresh, rewarding activity, interaction, and effectiveness.” For more information, visit .http://www.acsiapartners.com. FINANCIAL PLANNING Making Financial Plans for Pet Care Forty-four percent of pet owners surveyed by Securian Financial have made plans for their pets’ future care. For one-fifth of those owners, those plans are financial. Michelle Hall, manager of Market Research for Securian Financial Group said, “Pets may provide opportunities for financial advisors whose clients consider their pets members of the family and spend large sums on their care. The American Society for the Prevention of Cruelty to Animals urges owners to plan for their pets’ care. Forty-six states have passed pet trust laws. Pet protection agreements, wills, powers of attorney, and letters of instruction are also available. The pet industry has more than tripled from $17 billion in 1994 to $59 billion in 2014, according to the American Pet Products Assn. Sixteen percent of pet owners say they would spend $10,000 or more to save a pet’s life while 29% would spend $2,000 to $5,000. Nearly 60% now spend up to $1,000 a year on food, grooming, toys, etc.; three-fourths spend up to $1,000 a year on veterinary bills; and 18% say their largest single pet-related expense was $2,000 or more. These costs add up to many thousands of dollars over the years, especially for long-lived pets. If the owner  dies suddenly or becomes disabled, the person who inherits the pet may not be financially prepared for ongoing care or life-saving procedures. Thirty-eight percent added the pet’s future caregiver as a beneficiary to a life insurance policy; 35% added more coverage to their life policies; and 13% purchased annuities naming the pet’s caregiver as the beneficiary. Margaret.jensen@securian.com ... Continue Reading →
money

Greater Insurer Competition Found To Lower Health Care Premiums

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

9 of the 100 Most Influential People in Healthcare are Californians

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

You Know the Drill! Our Annual Dental Survey

Welcome to California Broker’s 2014 Dental Survey. We’ve asked the top dental providers in California to answer 28 crucial questions to better help you, the agent, understand their benefits, features, and services.  California’s top dental providers answer crucial questions about their benefits, features and services. 1. What types of plans do you offer? Aetna: We offer the following dental plans: • Aetna Dental Maintenance DMO plan, PPO, PPO Max. •Freedom-of-Choice Plan Design (offering members their choice of two dental plans). •Aetna Dental Preventive Care, Aetna DMO Access, Aetna Dental Care Reward, Aetna •DentalFund (our consumer-directed dental plan), indemnity, Vital Savings by Aetna, a dental discount program. •Aetna ValuePass Card. Aflac: Aflac Dental – voluntary insurance policy – has the simplicity of a Voluntary Individual Table of Allowances plan that pays a fixed benefit amount for each procedure, regardless of what the dentist charges. Ameritas: We have the following types of dental plans available nationwide:  PPO, indemnity, voluntary, non-voluntary, groups from two lives and up, individual, consumer driven and cost containment plans. Anthem Blue Cross: Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company offer a comprehensive line-up of dental plans and products that include: PPOs and DHMOs for individuals, small groups, large groups and national accounts. We offer voluntary dental plans for small and large groups. BEN-E-LECT: BEN-E-LECT offers fully insured PPO, EPO, high deductible, pre-paid and self-insured dental plans for the group market. Employer-paid and voluntary plans with multiple network and out-of-network options down to the employee level are available to groups with as few as two lives. BEST Life: In California, we offer employer-contributory PPO, and indemnity dental plans to groups with two or more employees enrolling. Voluntary PPO/indemnity dental plans are available to groups with five or more employees enrolling. Custom dental plans can be offered for groups with 100 or more employees enrolling. Group term life and vision coverage. Blue Shield: Blue Shield provides a wide range of affordable and comprehensive dental products to meet our clients’ needs. From dental PPOs, to in-network only (INO) and HMO plans, our plans offer members a wide variety of plan designs and networks that fit their budget. For individuals/families, we offer a unique dental PPO plan that provides member copayments instead of the usual coinsurance percentages. Our dental HMO plan offers comprehensive benefits with pre-determined member copayments. Finally, our Duo plan offers members dental and vision coverage at a single price. Our plans can be sold with medical plans or on a standalone basis.. For senior members, we offer two comprehensive dental PPO plans for Medicare supplement plan members. There is also a dental plus vision plan package option for Medicare supplement plan members. For groups, our dental PPO, INO and HMO plans are available on a contributory or voluntary basis, can be sold with or without Blue Shield medical plans and are  UCR- or MAC-based. BRIGHTER: Brighter offers two unique dental solutions: 1) An administrative services only (ASO) solution that utilizes revolutionary technology to reduce costs for self-funded employers; and 2) a savings-only plan for employees not wishing to purchase traditional coverage. Cigna: We offer a full spectrum of dental solutions, including the Cigna Dental Care® (DHMO) plan, Cigna DPPO plan, Cigna DEPO plan, Cigna Traditional indemnity plan, and Cigna Dental Shared Administration. We also offer product features like Cigna Dental WellnessPlus®, Cigna Dental Waiver Saver®, and CignaFlex Advantage® that enhance our plans. We also offer CignaPlus Savings®, a discount dental program for retirees, part-time or seasonal employees, or anyone else not eligible for insurance coverage. All plans are available on a stand-alone basis. All plans except the discount card are also available alongside medical and/or vision plans. Cigna also has three WellnessPlus features, which can be paired with DPPO, DEPO, or dental indemnity products. Individuals who get any preventive care in one plan year qualify for increased benefits in the following plan year. All plans are available on a contributory or voluntary basis. In addition to WellnessPlus, Cigna offers Cigna Dental Waiver Saver, where customers Class 1 (preventive) services can be waived for maximums and deductibles, providing an incentive for customers to seek preventive care. Delta Dental: Managed fee-for-service, PPO, and DHMO group dental plans; individual DHMO dental plans and group HMO vision plans. Also, in response to the Affordable Care Act, Delta Dental of California and its affiliated companies now offer pediatric and adult dental benefit plans in 27 health exchanges around the country, covering more than 300,000 new enrollees since the inception of the ACA. This required us to design pediatric and family dental plans based on different sets of rules for the federal and state exchanges, for stand-alone versus bundled scenarios, and for differing market conditions. Dental Health Services: Dental Health Services offers high-quality, affordable prepaid (D-HMO) dental benefit solutions for large & small employer groups and individuals. Other plans are also available, including PPO, EPO, indemnity (reimbursement) products for groups of all sizes, and ASO services for self-funded groups. Guardian: Dental PPO (active or passive), Prepaid/DHMO, and Indemnity plans are available on a voluntary or employer-sponsored basis.  Dual and Triple Choice, Monthly Switch (between a DHMO and PPO), and Administrative Services Only plans are also available.  Guardian specializes in customized plans based on the needs and price points of the employers and employees. Health Net Dental: Health Net Dental HMO (DHMO) plans and dental PPO plans offer robust benefits covering most dental procedures. Dental plans may be purchased with a Health Net medical plan or on a stand-alone basis. In addition, the dental plans may be purchased as dual choice. Contributory and voluntary plans are also available. HumanaDental: PPO, prepaid/DHMO, traditional preferred, and preventive plus plans are available on a voluntary or employer-sponsored basis. Humana also has a robust ASO dental plan available in California. Principal Financial Group:  We offer both employer paid and voluntary plans, including PPO, EPO and POS.  We also offer a choice between our plans and dental HMO plans through marketing alliances. Securian Dental: Group Dental PPO and indemnity United Concordia: United Concordia offers flexible fully insured preferred provider organizations (PPOs) and dental health maintenance organizations (DHMOs) plans, as well as an individual product, iDental. ASO funding arrangements are available based on client size. Most plans are offered on an employer-sponsored or voluntary basis. Western Dental: Western Dental offers DHMO mixed-model provider panel comprised of (a) contracted independent, general dentist and specialists, along with (b) Western Dental employee dentist and specialists, who work in the company-owned Western Dental Centers. Western Dental currently operates general dentistry and orthodontic offices throughout Calif., Ariz., and Nevada. 2. How do plans you offer for the individual and/or small group compare in rates and benefits to the large-group plans? Aetna: The key difference between Aetna small group plans and larger group plans is that small group plans are pre-packaged plan designs. While larger groups can select from an array of benefits, the packaged small group plans are comprehensive, yet price sensitive and make it easy for our customers to choose from plans that are competitive in the market. Aflac Dental rates and benefits do not vary based upon the size of the account. Ameritas: Ameritas’ small group and one-life group plans are rated by industry and are pooled in full or in part. Large groups’ experience is rated and includes lower rates in most cases. Ameritas offers a wide variety of plan designs, regardless of group size, to meet the needs of our customers. The pricing of our nongroup individual plans will be higher than group individual because of the nature of the risk. Anthem Blue Cross:  There are different underwriting considerations for each business segment depending on the product offered. With our Dental Prime and Dental Complete plans, both small and large groups can customize benefits to fit their employees’ needs. BEN-E-LECT: The majority of BEN-E-LECT’s plans compete very well in the large group market. The benefit design and structure of these plans remain consistent across the small and large group markets. BEST Life: Rates vary by plan design, group size and employer contribution. Typically the larger the group, the lower the rates. However, we offer a lot of plan design flexibility for groups with 10 or more enrolling.  Waiting periods for major and ortho services are waived for groups with 10 or more employees enrolling – regardless of employer contribution. Some benefits are standard regardless of size.  We offer a dental supplemental accident benefit on all of our dental plans. A child vision benefit is also standard on plans with orthodontic coverage.. Blue Shield: There are different underwriting considerations for each business segment. Our ability to customize offerings for groups with more than 300 employees typically results in lower rates and more choices to meet the employer’s needs. Group plans come in a range of deductibles and annual benefit maximums. Our individual, family and Medicare Supplement dental plans may vary in waiting periods, deductibles, and annual benefit maximums based on the plan selection. All dental plans include generous benefits, competitive premiums, and strong California and national provider networks that are available to all members; we don’t differentiate our provider network for small groups or individual or family markets. BRIGHTER: Our small group plans enable employees to reduce dental expenses for their families by an average of 30 – 50% without paying high dental premiums. So, in any given year they can often receive the same amount of care that they would through a large group plan, and do so at a fraction of the cost they would have otherwise paid through premiums, deductibles & co-insurances. Cigna: Dental plan designs and rates for small groups are similar to those of large groups. There are a series of standard DHMO plan designs and DPPO/indemnity plan designs. Cigna offers an individual plan in the state of California, available as a buy-up option to our medical plan offering. That plan is a DPPO offering, very similar to our group plans aimed at businesses trying to control costs while offering a broad network. Larger groups generally want more robust and flexible plans, while smaller groups gravitate toward standard offerings. We can custom-fit DPPO plans to offer a variety of cost-savings options for employers that want to keep claims costs low, such as missing tooth limitations, class shifting, low maximums, varying coinsurance, deductibles, waiting periods, etc. Our DHMO plans start with basic coverage, specialty discount, split copays, and other cost savings mechanisms and go up to very rich, low-copay plans at the higher end of the cost spectrum, including plans with coverage for surgical implants and related procedures. Cigna can also deliver solutions for the smaller employer segment through the Cigna Voluntary limited benefit dental plan as well as leveraging the small segment capabilities of the former Great West distribution channel. Delta Dental: While benefits offered to smaller groups are comparable to those offered to larger groups, larger groups have more options in terms of plan designs. Rates can be slightly higher for smaller clients and individuals, but Delta Dental strives to be competitive while balancing our financial risk. With individual DHMO plan benefits, we offer three different plan options – two for individuals and families and one customized for seniors. The individual and family plans offer a wide range of covered services. The senior plan is designed to offer services most utilized by this particular population. Dental Health Services: Dental Health Services works with its group clients on customizing dental benefit solutions that meet their needs. All individual plans offer the same high-quality benefits and services at competitive rates. Guardian: Guardian offers nearly the same plan options to small group employers as to large employers, plus an array of cost-reducing options.  We also offer dental benefits through the California state exchange. Health Net Dental: DHMO plans offered to individuals provide a comprehensive schedule of benefits at a monthly fee that is slightly higher than rates quoted for groups. Small groups (two to 50 employees) have two comprehensive Health Net Plus DHMO and 3 DPPO plans from which to choose. Mid-market groups (51 to 250 employees) may choose from five DHMO plans and 15 new DPPO plans. Mid-market rates are based on location, benefit plan chosen, employer contributions, and participation. Individual and small group rates are based on book rates. Risk evaluation is taken into consideration when underwriting larger groups (over 250 eligible employees). HumanaDental: We offer flexible plan designs with a range of deductibles, co-payments, and out-of-pocket expense limits to meet the needs of small to large groups. We also offer large groups the additional flexibility to customize plan options. All our dental plans provide employees with incentives for preventive dental care, which promotes their overall health. Customers who see dentists participating in the HumanaDental PPO Network receive deep discounts. A vision discount program is included with all HumanaDental plans. Principal Financial Group:  We do not have individual dental plans.  The only significant rating difference between our small and large group rates pertains to experience rating which is used on groups with 150+ employees. The benefits are the same for small and large groups. Securian Dental: Small group rates are developed on a pooled basis.  Large group rates are developed on a custom basis. United Concordia: While larger clients have more flexibility in customizing benefit options than smaller clients, United Concordia offers an array of standard client products and options that provide small businesses and individual consumers with cost-effective, quality choices. To keep the small client premiums comparable to those found in larger clients, slightly higher deductibles, lower coinsurance percentages and lower maximums are more commonplace within this market segment. Western Dental: Our individual and small group rates are a little higher for standard benefit plans. Customized benefits plans are available for large groups. 3. Is your plan(s) better than previous incarnations? If so, how? Aetna: We continuously review which services should be covered based on major dental studies, new clinical advances, recommendations from the leading health and dental organizations, consultations with academic leaders on the latest technology and techniques now taught in dental schools. We offer the following: • Freedom-of-Choice Plan Design — packages our DMO plan with one of our indemnity or PPO plan options. Members pay one rate and can switch between the plans as often as monthly. It can be a lower cost alternative to a PPO plan. • Aetna Dental Preventive Care — a low-cost PPO or indemnity plan covers preventive and diagnostic procedures from 70% to 100%. Members may also get reduced fees from dentists who participate in Aetna’s PPO network for non-covered services like fillings, adult orthodontia, and cosmetic tooth whitening. • Aetna DMO Access — a fixed-co-pay DMO plan offers broader network access at a lower cost. There are no out-of-pocket deductibles for the member to pay and no claim forms to file. It also includes the Aetna Dental Access discount network, which gives members access to more dentists and discounts of 15% to 50% for non-covered services like bleaching. • Aetna Dental Care Reward — By going to the dentist for preventive services in one plan year, Aetna will cover a greater percentage of coinsurance and/or annual maximum next plan year. Aflac: Employers are seeking ways to shift costs and employees are looking for more value. The Aflac Dental plan is designed to increase the policy year maximum, which will satisfy both employers and employees. Ameritas: We are known for our flexibility and expertise in dental.  We listen to employers all over the country to learn about their needs.  Our plans are updated constantly to meet those needs. We have released several industry firsts including a rollover maximum product; fully insured LASIK eye benefits; dollar reimbursement plans; combined dental/vision deductible,frequency and maximum plans; shared family maximum plans; $5000 maximum plans, and stand-alone hearing care benefits.  Our newest individual plan release, vision, is very popular across the nation. Anthem Blue Cross: Yes, our plans are significantly better than previous incarnations.  Our Dental Prime and Dental Complete plans are open-access models that include the freedom to see any dentist — with lower out-of-pocket costs at in-network dentists.  These plans are better than previous incarnations because they (a) incorporate evidence-based benefit designs and claims processing guidelines, for greater savings and consistency with clinical oral health science, (b) include a more robust California provider network and (c) automatically include access to the national Dental GRID, one of the nation’s leading dentist networks, with dentists in all 50 states. The GRID is exclusively for customers of participating Blue Cross and Blue Shield plans.  In short:  our new plans have better benefit designs and a larger network locally and nationwide. BEN-E-LECT: BEN-E-LECT plans offer more employer and employee options than any other dental plan in the market. They can be written stand-alone or the employer may combine various BEN-E-LECT plans for a complete package offering PPO, DHMO and fully self-funded options BEST Life: Our current dental plans offer a lot more options compared to the dental plans we’ve offered in the past. We offer a MAC reimbursement option and all of our dental plans can be tailored to offer rich or lean benefits, depending on a company’s needs. We continually evaluate our dental plans to ensure the competitiveness of the benefits, and our underwriting guidelines. Blue Shield: Yes, we are always looking to enhance our plans and provide richer benefits. For 2014, we are introducing four new group dental HMO plans and four new dental INO plans with a $1,500 calendar year maximum. Compared to our existing dental HMO plans, our new dental HMO plans offer lower copayments to deliver a richer benefit to our members. The new dental INO plans offer a lower price alternative to our INO plans with $2,500 calendar year maximums. In addition to new plan designs, all BSC plans include oral cancer screening coverage as a value-added benefit, which comes at no out-of-pocket cost to the member. We also offer enhanced dental services for pregnant women to all dental PPO plans. Pregnant women receive one additional routine adult prophylaxis, and/or one course (up to four quadrants) of periodontal scaling and root planing, and/or periodontal maintenance if warranted by a history of periodontal treatment. Treatment is payable at 100% of the allowable amount for  in and out of network. BRIGHTER: Brighter has introduced the industry’s first Proactive Remittence Organization (PRO) which is a dental care system enabled by our cloud-based platform that streamlines the interactions amongst members, providers and payers to lower claims costs through new efficiencies in benefits payments, network fee schedules, utilization review and group plan designs. Cigna: The new Cigna Dental Care® DHMO 09 Series of patient charge schedules (PCSs) includes many features and options from which to choose. This series provides a spectrum of schedules with multiple copay structures, so we can design the plan that meets our clients’ needs.  Below is a summary of new features and enhancements that only apply to the 09 Series of schedules: • Surgical Placement of Implant Coverage – We are one of the few DHMO carriers to offer coverage for surgical placement of implants and related procedures such as sinus augmentation, bone grafting, and cone beam CT x-rays. • Same Day, In office Services – Members are able to take advantage of upgrading certain procedures which require material fabrications (veneers, crowns, inlays, onlays, and post and core) to same-day, in office service using CAD/CAM technology for a fixed copay. • Temporomandibular Joint (TMJ) Coverage – TMJ coverage is now standard on our plans and coverages, and includes an exam, diagnostic cone beam CT x-ray, and an orthotic occlusal devise to treat TMJ. • Expanded Periodontal Maintenance Coverage – We have expanded coverage for periodontal maintenance cleanings to four per year to increase our focus on prevention. Additional Application of Fluoride and Fluoride with Varnish – At a minimal copay, we now allow additional applications of fluoride for those members who may need them. Delta Dental: Most mid- to large-range plans offered by Delta Dental are customizable within basic parameters, and we incorporate changes in treatment standards and technology as they evolve. Dental Health Services: Yes. Dental Health Services’ plans are better than previous incarnations. The company frequently performs comprehensive evaluations of its plans to ensure covered benefits, monthly premium rates, and copayments for services are appropriate and competitive. Guardian: The key is flexibility, especially in today’s market as employers and employees are trying to balance costs with benefits. Guardian offers customized options to fit each employer’s needs and budget. Our recent focus has been on innovative plan designs with flexible solutions, options like Guardian FreedomSM, which is a new lower cost dental option that gives members a choice of networks with access to providers in Guardian’s premier PPO network, DentalGuard Preferred, or in Guardian’s DentalGuard Alliance PPO, which offers even greater claims savings  through a select pool of dentists. We also are focusing heavily on developing more voluntary options, a market we see poised for tremendous growth particularly with the legislative changes on the horizon. Health Net Dental: Health Net offers DPPO plans for small and mid-market groups. All of our DPPO plans include extra services for pregnant women in their second and third trimesters, including extra cleanings, scaling and debridement covered at 100% in and out of network and not subject to the plan’s deductible. Our Mid Market Classic Plus DPPO Plans include MaxAdvantage, our rewards program that allows members to carry over a portion of their calendar year maximum into the next calendar year. Our Basic DPPO is a unique plan offering in- and out-of-network coverage for preventive, diagnostic and restorative procedures (oral surgery, endodontics, periodontics, major services and orthodontia not covered). HumanaDental: Yes, we continually explore ways to offer more choices and flexibility for our customers. Please see next response. Principal Financial Group:  Our current plan offers significant flexibility in plan design, optional coverage for cosmetic services, TMJ treatment, dental implant coverage, accident coverage, employee choice options and multiple price points.  Employers can design any combination of plan options to meet their needs.  In addition to our Maximum Accumulation feature which allows members to carry over a portion of their unused annual maximum for use in future years, we also have a Preventive Passport feature.  This feature allows for preventive charges to not accumulate towards the annual maximum. Securian Dental: Yes, we have added greater flexibility. United Concordia: In recent years we have done the following: • Introduced more voluntary plan options and added optional coverage for posterior composite restorations and implants to clients with 10 or more enrollees. • We launched Preventive Incentive, which covers diagnostic and preventive services without counting them toward the member’s annual maximum. • Enhanced our employee oral health educational offerings. • Launched a series of plan designs through iDental, our dental product for individuals and families without coverage elsewhere. • New for 2014, we are introducing a value suite of products to include lower premium options, greater discounts on non-covered services and a lean product option. • Launched a dental discount program for Individuals through DentalPlans.com. • Introduced the UCWellness Oral Health Rider in 2012, which offers enhanced coverage for members with diabetes and other diseases to clear away concerns they may have on the cost of treatment. UCWellness also provides oral health education and program details for all members and targeted messaging to motivate those eligible for UCWellness benefits. Western Dental: Western Dental Benefits Division recently launched the DHMO Series 7 dental plans. Our new plans offer an increase of covered procedures to include the availability of cosmetic alternatives and more orthodontic options for children and adults 4. What have been the most recent changes in your plan(s)? Aetna: New DMO fixed co-pay plans that cover Implants were added. Aflac: Along with an increased policy year maximum, Aflac Dental continues to provide a simple, no direct-cost option for employers to enhance employee benefits offerings. The Aflac Dental plan provides the ease of administration without the hassle of network restrictions, deductibles, precertification for treatment, or annual premium reviews. Ameritas: Ameritas developed ACA-certified plans that are offered in most states. We also have developed our new Better Benefit product, through which certified pediatric dental benefits can be added to traditional dental plans. Pediatric dental claims are processed through both their traditional plan design and the ACA-certified design, and Ameritas pays the better of the two.. Anthem Blue Cross: We revised our Dental Net DHMO. Our new Dental Net DHMO plans cover approximately 300 procedures — approximately 62 percent more procedures than our existing Dental Net plans. In addition, our Dental Net network includes more than 8,000 general dentist and specialist access points in California. And, we still have our Dental Prime and Dental Complete products, which include modernized benefit designs, lower premiums, and a more robust dentist network locally and nationally.These plans include benefits, such as dental implants, annual maximum carryover and composite fillings on all teeth. Plus, there are more options for out-of-network reimbursement, including the 90th percentile of FAIR Health. Voluntary plans are available with a minimum of five enrolled employees. BEN-E-LECT: BEN-E-LECT has evaluated its Freedom PPO benefits portfolio and narrowed it down to four plans that have proven to be most beneficial to its members. By focusing on development of those four plans, BEN-E-LECT is now more able to create sustainable rates for its groups taking into account size and location. BEN-E-LECT has also eliminated the waiting period for groups and new hires on its employer-paid plans for added convenience. We have also added an EPO option to our portfolio which allows for even more cost savings and offers one of the strongest networks available. BEST Life: Beginning in 2015 we will offer certified-pediatric plans that meet or exceed ACA standards to complement our product offerings. So the great Dental solutions from BEST Life continue to meet the changing needs of our groups in California. Blue Shield: For 2014, we are introducing two new dental PPO plans in our small group portfolio designed to fill a gap in the upper end of the benefit spectrum. BRIGHTER: Brighter has introduced the industry’s first Proactive Remittence Organization (PRO) which is a dental care system enabled by our cloud-based platform that streamlines the interactions amongst members, providers and payers to lower claims costs through new efficiencies in benefits payments, network fee schedules, utilization review and group plan designs. Cigna: Cigna Dental Oral Health Integration Program® We developed the Cigna Dental Oral Health Integration Program® in 2006 to reinforce the importance of good oral health in relation to overall health. We continue to stay abreast of new clinical research showing associations between oral health and certain medical conditions and as a result, we have enhanced the program to reflect the latest medical and dental research. The new program includes the following list of clinical conditions: • cardiovascular disease • cerebrovascular (stroke) • maternity • diabetes • chronic kidney disease • head and neck cancer radiation • organ transplants The program also provides 100 percent reimbursement of copays and coinsurance on certain dental procedures associated with treating gum disease. In April of 2014 we enhanced our customer experience with this program.  Previously, customers submitted a reimbursement form each time an eligible service was performed.  Now, customers only need to register once (for each eligible condition) and their coinsurance/copays for qualifying procedures will automatically be reimbursed within 2-3 weeks from when we receive the claim from their dentist. We have made several enhancements to our DPPO products to provide additional benefit flexibility including cost saving capabilities with our dental code classification process thru improved class shifting functionality. Delta Dental: To help make dental plan administration even easier for our network fee-for-service dentists, Delta Dental launched new online Provider Tools — a suite of helpful services that enables real-time processing of certain claims and pre-treatment estimates (those that don’t require clinical review, for example). With real-time processing, dentists and patients can see the patient’s payment portion and what Delta Dental will pay within moments. Provider Tools also gives dental offices other useful features, including a list of their Delta Dental patients and eligibility and benefits details, access to the status of submitted claims, a reference library, a list of Delta Dental’s payments and more. Provider Tools are fast, friendly, free — and an easy way to reduce paper use, too. In addition, Delta Dental recently introduced a new online health risk assessment tool that provides a structured set of questions that produces a risk assessment score that identifies specific issues related to the individual’s oral health. The tool’s risk assessment form is meant not only to inform the respondent as to likely risks of oral disease, but also to serve as a discussion piece with the individual’s dentist. The risk assessment form can be printed and shared with the patient’s dentist at their next appointment. The intent of this risk assessment tool is to inform the patient and their dentist of specific risk factors for oral disease and help guide preventive measures. Dental Health Services: Dental Health Services now offers dental implants as a covered benefit. Specialized crowns and upgrades are also now available. Guardian: Guardian constantly develops new, innovative ideas in order to meet our customers’ needs by helping keep their teeth healthy and saving them money. Guardian Freedom allows members to choose between networks, and members are still free to see out-of-network dentists. We also offer dental benefits through the California state exchange.  Members can easily access an electronic ID card or find a dentist near them (in English or Spanish) at www.GuardianAnytime.com or on their smart phones with GuardianAnytimeSM Mobile. Health Net Dental:  All of our Classic Plus, Classic, Essential and Basic DPPO plans include extra benefits for pregnant members in their second and third trimesters. HumanaDental: Plans in our new generation of products are available as voluntary plans, and to groups with as few as two employees. Our new plans offer an extended maximum benefit, in which members get 30% coinsurance on services rendered after they reach their annual maximum (implants and orthodontia excluded). In addition, no waiting periods for major services for voluntary groups with 10 or more enrolled, open enrollment options, and orthodontia benefits. Updates include reimbursement options for out-of- network reimbursement: maximum allowable fee, or based on in-network fee schedules. Additional deductible choices, implant coverage, and acrylic filling coverage have also been added. Due to the connection between oral health and overall health, we have added, free of charge, oral cancer screenings to all of our products, excluding DHMO/prepaid plans. Principal Financial Group:  Our current plan offers significant flexibility in plan design, optional coverage for cosmetic services, TMJ treatment, dental implant coverage, accident coverage, employee choice options and multiple price points.  Employers can design any combination of plan options to meet their needs.  In addition to our Maximum Accumulation feature which allows members to carry over a portion of their unused annual maximum for use in future years, we also have a Preventive Passport feature. Securian Dental: Enhanced benefit plans. Escalating Annual Maximum and Lifetime Deductible options where available. United Concordia: In recent years we have done the following: •Expanded our PPO network by 12,000 dentists, to create our Alliance network. ?? not exactly sure of the final #s, but something to this effect. • We re-credentialed our PPO network of dentists, and now more than 8X% accept our discounted allowances for non-covered services and services over the annual maximum.  Members can find which dentists have agreed to this cost saving measure, by looking at our website. The dentists are clearly noted. • We launched Preventive Incentive®, which covers diagnostic and preventive services without counting them toward the member’s annual maximum. • Enhanced our employee oral health educational offerings. • Introduced Smile for Health – Wellness®, which offers enhanced coverage for members with diabetes and other diseases to clear away concerns they may have on the cost of treatment.  This coverage is now standard with all plans.  Smile for Health – Wellness also provides oral health education and program details for all members and targeted messaging to motivate those eligible for Smile for Health – Wellness benefits. Western Dental: Our Series 7 plans cover more procedures and now include Implants, veneers and external bleaching. 5. Can an insured use their own dentist even if they are not on your participation list? Aetna: PPO — We offer a national network of dentists. Each covered family member can visit any licensed dentist for covered services. When members visit dentists who participate in our network, their out-of-pocket costs are generally lower. Aetna: DMO — Members must seek care from a participating DMO provider unless a state allows a member to seek out of network care. We make this easy by consistently offering the largest DMO network in the industry. Ameritas: Insureds can use any provider, but they may incur additional out-of-pocket expenses. Anthem Blue Cross:  Members of our Dental PPO plans, including Dental Prime and Dental Complete, can see any dentist they want. However, members who choose a network provider generally experience lower out-of-pocket costs.  Plus, members never need to file a claim when they see one of our in-network ­providers — the dentist files the claim for them.  The DHMO plans are in-network only. Aflac: Policyholders may use any dentist they choose since Aflac Dental does not have network requirements. Anthem Blue Cross: Yes, they can with all of our PPO plans. Members who choose a provider, within the Dental Blue network, get the most savings in their dental costs. However, members can choose a non-Dental Blue dentist, but their out-of-pocket costs may be higher. The same is true for our traditional Prudent Buyer PPO dental plans. The DHMO plans are in-network only. BEN-E-LECT: Yes, BEN-E-LECT’s plans offer in and out-of-network coverage with multiple options for coverage and benefits. The members maintain complete control over the dentist they choose to utilize. BEST Life: Yes, group and individual products allow members to visit any dentist of their choice and receive coverage for services. Blue Shield: Yes, dental PPO plan members can choose to go to any dentist, although their benefits will be covered at a higher percentage when choosing a network dentist, with less out-of-pocket expense. BRIGHTER: Yes Cigna: Insureds can use their own dentist in the DPPO and dental indemnity plans. However, there are no out-of-network benefits with DHMO, CignaPlus Savings dental discount plans (not insurance) or with DEPO. Individuals can nominate their dentist to join our plan and if the dentist wants to participate and meets our criteria, he/she will be credentialed and added to the network. Additionally, DPPO and DEPO plans may include savings on most non-covered services (in states where allowed by law). Most of our DPPO network dentists offer their negotiated contracted fees to customers and their covered dependents for most non-covered services (in states where allowed by law). And the savings also apply to covered services when an individual exceeds his or her annual maximum or other plan limitations, such as frequency, age or missing tooth. We are continuously expanding our network to meet the needs of current and potential clients. Delta Dental: Delta Dental Premier enrollees can visit any licensed dentist for care, although there are advantages to visiting one of more than 48,000 dentist locations for Delta Dental Premier dentists in California. Enrollees can go to any dentist, but they are only guaranteed to get in-network benefits and avoid balance billing when visiting a Delta Dental dentist. Delta Dental PPO enrollees also have freedom of choice, but can benefit from the protections associated with selecting one of more than 31,000 dentist locations for Delta Dental PPO dentists in California. PPO enrollees have access to  Delta Dental PPO and Premier dentist networks with different levels of savings. DHMO enrollees must use a participating general dentist or approved specialist, except for emergency care. There are more than 5,100 dentist facilities for DeltaCare USA in California. Dental Health Services: Members of Dental Health Services’ prepaid (D-HMO) and EPO plans choose their dentist from the company’s exclusive Quality Assured network. Participating dentists on all prepaid (D-HMO) plan networks are subjected to credentialing, background checks and a 107-point quality checklist. They are also regularly monitored by the company’s Professional Services staff, and plan benefits are only available at these Quality Assured dentists. The company’s PPO and reimbursement plans allow members to receive treatment from any dentist Guardian: Members covered under our PPO plans can visit any dentist; however, benefits may be paid at a lower coinsurance rate for non-participating dentists.  DHMO members must choose a participating primary care dentist. Health Net Dental: Our dental PPO plans offer members freedom of choice; members may receive services from any licensed dentist, but we will reduce their out-of-pocket costs by receiving services from a participating PPO dentist. Under Health Net Dental DHMO plan, members must use a participating dentist to receive benefits. HumanaDental: PPO members can visit the dentists of their choice. Out-of-pocket savings are greater when members visit participating network dentists. Principal Financial Group:  Yes, our members can see any dentist even if the dentist is not on the “participation” list if they are enrolled in either our PPO or POS design.  If a member is enrolled in our EPO design, network dentists must be seen for services in order to receive benefits under the plan. Securian Dental: Yes. United Concordia: Our FFS and PPO plans allow members to visit any dentist. However, out-of-pocket costs are lower when visiting a participating network provider. DHMO members must use network dentists. Western Dental: Through the DMO plans, the member must use a dentist who participates in our network in order to have coverage. 6.  If the dentist bill exceeds U&C, can the dentist bill the patient for the difference? Aetna: For covered services, network dentists are contractually prevented from balance billing above the negotiated rate. Non-covered services are also available for a discount in some states. Dentists who are not in our networks may balance bill members. Aflac: Aflac Dental pays benefits based on a Table of Allowances and not on UCR. If the dentist’s charge exceeds the benefit amount paid, the dentist may bill the patient for the remaining balance. Ameritas: Ameritas PPO/First Dental Health (FDH) Networks — Ameritas PPO dentists and FDH PPO dentists are bound by contract not to balance bill the difference between their normal charge and PPO maximum allowable charges. Anthem Blue Cross: No, not when visiting an in-network dentist with our PPO plans, including Dental Prime and Dental Complete.  Anthem Blue Cross participating provider contracts include negotiated fee agreements that prohibit balance billing. A participating dentist may not balance-bill members for amounts that exceed the negotiated and contractually agreed on fee. Members are not responsible for amounts in excess of negotiated rates. However, if a member visits an out-of-network provider, there is no contract and the provider can bill the patient for the difference. With our DHMO plans, the patient is only responsible for co-payments and non-covered services when accessing services through their participating dental provider. BEN-E-LECT: The member does have the option to choose this method upon enrollment. BEST Life: Members will not be balanced billed if they receive treatment from a contracted PPO provider. All our dental PPO plans offer a regional and national PPO network. Members can access their in-network benefits anywhere in the country and will not be balance billed. Blue Shield: No, in-network providers cannot bill members for fees that exceed the negotiated rate. Non-network providers, however, may bill for charges that exceed the plan’s allowed amount. BRIGHTER: Not if the dentist is participating on our platform. Cigna: DHMO. Network general dentist and specialist contracts contain clauses that prohibit dentists from charging members any additional fee, surcharge, or other cost for services, other than applicable patient charges as defined in the patient charge schedule (PCS) or contract payment schedule for covered procedures. For services we do not cover, dentists may charge their usual fees. For certain orthodontic procedures, network dentists may charge incremental costs associated with optional/elective materials, including, but not limited to ceramic, clear, lingual brackets, or other cosmetic appliances. DEPO/DPPO. Cigna’s network dentists’ contracts include language to ensure that members are only charged in accordance with the contracted fee schedule amounts. They are prohibited from balance billing members. Network fee schedules apply for covered services even after members have reached their annual maximums or exceeded frequency limitations, or if the applicable dental plan imposes missing tooth limitations or other similar limitations. For noncovered services, members are responsible for paying the dentist’s usual fee or contracted fee for that procedure. Since the DEPO plan does not cover out-of-network services, members are responsible for the out-of-network dentist’s usual fees for any treatment received out-of-network. Out-of-network dentists may balance bill the difference between the DPPO plan’s payment and their usual charges. Indemnity. We do not prohibit balance billing for our traditional indemnity plan coverage; dentists may balance bill the difference between the plan’s payment and their usual charges. Members pay dentists at the time services are rendered and then submit claim forms to us, or dentists submit the claim forms directly to us for payment. Delta Dental: Contracted dentists agree not to balance bill patients for services covered under the program for which the dentist has contracted service fees. Delta Dental holds its Delta Dental PPO and Premier dentists to their contracted fees when providing services to eligible enrollees. DHMO enrollees do not pay more than their set copayment for covered benefits under the DeltaCare USA plan. Specialists are paid the difference for charges exceeding the enrollee’s copayment for all preauthorized services. When an enrollee chooses a more costly procedure not covered under the plan, the enrollee is responsible for the difference in cost between the network dentist’s usual fees for the covered procedure and the optional treatment, plus applicable copayment for the covered procedure. Dental Health Services: No. Dental Health Services guards against balance billing for specialty claims and also has separate safeguards in place to protect your clients’ members from other types of overcharging. Dental Health Services contracts with participating specialists who specifically prohibit balance billing. The specialist can only charge the agreed-upon fee for a particular service. This and other proactive initiatives designed to advocate for members have resulted in Dental Health Services’ 97% retention for satisfied group clients and their members. Guardian: Guardian’s PPO dentists are prohibited from billing members for any difference between the billed fee and the contracted fee schedule amount, less applicable deductibles and coinsurance. Health Net Dental: When receiving services from a participating PPO dentist, members cannot be billed any charge in excess of the maximum allowable charge established by the plan. If the member goes to a non-participating dentist, the dentist can bill the patient for the difference between the allowed amount for the plan benefit and the dentist’s submitted charge. HumanaDental: Members are encouraged to visit in-network providers to experience lower out-of-pocket costs. In-network providers have agreed to accept the amount listed on their PPO fee schedule as payment in full, less all copayments, coinsurance, deductibles and non-covered services.  They may not balance bill for amounts that exceed their PPO fee schedule. Out-of-network members are responsible for any charges that exceed the maximum amount that Humana will reimburse for a specific service. Principal Financial Group:  Dentists cannot bill over the UCR/fee schedule allowance amount if they are part of our PPO or EPO networks.  If the dentist is not a part of one of our networks, he/she can bill the amount over UCR. Securian Dental: If the dentist is part of our network – no.  If the dentist is not part of our network – yes. United Concordia: Contractually, United Concordia participating dentists agree to accept our allowances as payment in full for covered services (less any deductibles and coinsurances or co-payments). Western Dental: Since this is a managed care plan, members pay only the applicable co-payment listed on their benefit schedule. Members are financially responsible for non-covered procedures at a discount. 7. How does the dental plan protect against over billing or waiver of co-payments? Aetna: Our explanation of benefits shows the member’s out of-pocket responsibility. Additionally, the vast majority of our network dentists accept the contracted amount for non-covered services and any services over the annual maximum a copy is sent to  member and provider. If necessary, the provider relations area helps resolve any issues whether related to over billing, waiver of co-payments, or other issues. Aflac: Aflac Dental does not have network requirements. If the dentist’s charge exceeds the benefit amount paid, the dentist may bill the patient for the remaining balance. Ameritas: The explanation of benefits automatically calculates the insured’s portion of the bill to prevent these kinds of problems. Anthem Blue Cross: With our Dental Prime and Dental Complete plans, we protect members against inappropriate billing through our provider contracts, claim review, and our continuous analytic monitoring of the treatment and claim submission patterns of each dentist that submits claims to us.  For our DHMO programs, our quality assurance teams assess claims and providers regularly to ensure our DHMO members are getting the highest level of service and satisfaction. BENELECT: Provider network discounts are applied automatically when a claim is submitted. We also make pre-determination services available to inform members what their charges will be prior to receiving service. The members also receive an explanation of benefits which clearly illustrates network savings and patient responsibility. BEST Life: We do this in several ways: 1) Provider network discounts are applied at the time a claim is processed; 2) Predetermination services are available to inform members what their charges will be prior to receiving service, 3) We provide easy-to-understand EOBs that clearly illustrate network savings. 4) We have educational flyers that inform members on how their dental plan works and why they should go to a network provider. Blue Shield: We prohibit network dentists from balance billing a member for the difference between billed amount and the amount received. Members are only charged the applicable copayment or coinsurance. We monitor and address any network dentist who attempts to bill for this difference. BRIGHTER: We track all utilization of the plan to ensure both the members and sponsor are billed appropriately. Cigna: Balance billing for covered procedures is strictly prohibited. We counsel network dentists who do not comply. Continued balance billing may be referred to our Credentialing Committee for review of future participation in the network. Cigna monitors allegations of overcharging through enrollee feedback, surveys, and the dental network management staff. For DHMO plans, the collection of copays is between the patient and the dentist. We encourage dentists to collect copays at the time treatment is rendered. For DPPO/Indemnity plans, it is illegal in some states for dentists to routinely waive deductibles. Since our group contracts indicate that Cigna is not responsible for any charge the patient is not required to pay, we may reduce our claim payment by the copay amount waived by the dentist. Our Special Investigations Unit may also contact the dentist and the patient for further information and has the ability to review claims on an ongoing basis. Delta Dental: Delta Dental Premier and PPO dentists contract with us to establish acceptable fees as well as formally agree to certain protections for Delta Dental enrollees. Protections include no balance billing — contracted dentists cannot charge enrollees for the difference between their contracted Delta Dental fee and their submitted charge for a service, and they may only collect the patient portion (copayment plus any deductible and/or amount over the annual maximum) at the time of service. Delta Dental dentists also agree not to unbundle a procedure that is on file with Delta Dental as one procedure. Waiver of plan copayments and deductibles is considered fraudulent and is handled by notifying the dentist of the violation and possible network termination. DHMO network dentists agree to be paid by Delta Dental on a guaranteed capitation basis. They also contractually agree to accept enrollee copayments as payment in full for covered dental procedures and not to seek additional fees. If a dentist consistently demonstrates a disregard for their contractual obligations with Delta Dental, their participation may be restricted or terminated. Dental Health Services: Dental Health Services’ Professional Services Staff regularly audits the company’s participating dentists’ charts on-site to ensure dental care and treatment provided to members meet the company’s quality standards and policies. In addition, plan members receive extensive patient education and tools to help them understand their plan benefits so they can question charges that may not be in compliance with plan benefits. Members are encouraged to contact the plan for assistance if they feel they are being overcharged. Guardian: Guardian’s PPO dentists may only charge members for any covered charges other than the deductible or coinsurance that may apply to the discounted fee schedule amount.  Explanation of benefits statements sent to members specifically identifies the discounts taken and the member’s responsibility. Health Net Dental: Under our DPPO and DHMO plans, participating dentists are contractually prohibited from balance billing a member more than the maximum allowable charge or the contracted copayment amount. Practices are in place to discipline network dentists who attempt to bill members more than these contracted amounts. If it is determined that a participating dentist has overcharged a member, our Customer Service team will contact the provider on behalf of the member to confirm benefits and re-educate the office about proper plan collection from a member. If the provider refuses to comply with the plan design, the issue is escalated to the Professional Relations Department for follow-up with the provider. Depending on the circumstances, the issue could be escalated to our Quality Management Team, which follows state mandates for a full investigation, including the request for patient records from the office and a review by a dental professional. These investigations must be completed within 30 days and written communications are sent to  the member and provider. If the provider still refuses to comply, our legal department would be contacted and steps may be taken to terminate our relationship with the provider. In these rare instances, it might become necessary for the plan to reimburse the member or provider depending on the circumstances and to ensure a positive member experience. HumanaDental: The dentist and the patient get an explanation of benefits to ensure that the dentist does not overcharge or omit fees. The claims processing systems adjudicate the claim based on the contracted fee schedule. Waiving co-payments does not apply under a PPO. Principal Financial Group: Provider utilization patterns are studied and issues are addressed as uncovered. Securian Dental: We systematically check every submitted claim. United Concordia: United Concordia participating dentists contractually agree to only bill members for applicable deductibles, coinsurance, or amounts exceeding the plan maximums. In addition, members receive explanations of benefits that clearly describe the services received and their financial responsibility. Members can also access the My Dental Benefits tool on our website (UnitedConcordia.com) to view their benefits and eligibility information, claim details, procedure history, maximum and deductible accumulations and more. Plus, United Concordia’s responsive customer service representatives are available to assist members with questions regarding their benefits. Our Utilization Review area also analyzes thousands of claims each year to ensure the acceptability of treatment and quality of services. Our dental advisors and consultants also continuously review dentists’ fees and practice patterns for statistical variation from their peers. Dentists who fall outside of the norm are targeted for education and additional monitoring. Western Dental: Providers are bound by contract to accept the member’s schedule of benefits. Members can also access the My Dental Benefits tool on our website (www.UnitedConcordia.com) to view their benefits and eligibility information, claim details, procedure history, maximum and deductible accumulations, and more. Plus, United Concordia’s responsive customer service representatives are available to assist members with questions regarding their benefits. Our Utilization Review area also analyzes thousands of claims each year to ensure the acceptability of treatment and quality of services. Our Dental Advisors and consultants also continuously review dentists’ fees and practice patterns for statistical variation from their peers. Dentists who fall outside of the norm are targeted for education and additional monitoring. 8. How many provider locations do you have? Aetna: As of 6/1/14: DMO over 11,000 dentist locations nationally and 98,000 in California, PPO: over 225,000 dentist locations nationally and 37,000 in California. Aflac: Aflac Dental does not have network requirements. Policyholders may visit any provider they choose. Ameritas: Ameritas/FDH Network: 79,516 California provider access points, (54,542 Ameritas; 24,974 FDH); 19,172 California locations, (12,582 Ameritas; 7,090 FDH) Anthem Blue Cross: We’ve had a lot of growth in our dental networks the last couple of years. Dental Complete members have access to more than 16,600 unique dentists and nearly 40,000 access points in California alone — and more than 96,000 unique dentists and 228,100 access points nationwide. That’s 75% more dentists nationwide than we had in 2011. Our Dental Net DHMO network includes nearly 10,000 provider locations in California to choose from.  Additionally, all Anthem dental members have access to our international emergency dentist network, with 24/7 assistance with locating an English-speaking provider for dental emergencies in approximately 100 countries worldwide. Services received through this program do not count toward the member’s annual maximum if their plan has one. BEN-E-LECT: BEN-E-LECT’s dental plans utilize the Health Smart (Interplan), First Dental Health, Dentemax, PPO USA and Western Dental networks, which contain thousands of offices statewide. BEST Life:  We offer access to a regional and a national PPO networks — First Dental Health (FDH) and DenteMax. Our California network has over 68,672 access points and an additional 9,593 provider locations throughout the state. Our national network has over 285,000 provider locations, which offers our members network access when they are outside of California. Blue Shield: Members have network access to over 16,000 dental HMO and 25,000 dental PPO providers in California, and more than 218,000 providers nationwide. These are two of the largest statewide provider networks in the industry. BRIGHTER: While Brighter can be used at any dentist, with discounts at over 190,000 Access Points nationwide, it currently is only available to employers with a significant portion of their employees located in Southern California as that is where we deliver the greatest savings and member experience. Cigna: Across all specialties, Cigna has over 131,300 unique DPPO dentists nationally and over 20,500 in California.  For DHMO, Cigna offers access to 19,200 offices across the country, with 5,020 DHMO offices in California. Delta Dental: Our networks offer access to more than 48,000 dentist locations for Delta Dental Premier, more than 31,000 dentist locations for Delta Dental PPO and more than 5,100 dentist facilities for DeltaCare USA in California. Dental Health Services: Dental Health Services’ exclusive, Quality Assured dental network consists of 927 general practice offices with 4,354 participating dentists and an additional 1,924 specialists. Guardian: There are over 244,321 PPO dentist locations across the country and more than 34,882 in California. We are one of the largest PPO networks in the state based on unique dentists.  The DentalGuard Alliance PPO network has over 5,803 dentist-locations in California.   For the DHMO, there are 14,367 locations across the country and 7,093 in California.  Guardian’s PPO network now includes more than 56 dental offices in Mexico.  International Assist, a value-added service available, provides dental members with access to dental care if needed while traveling outside of the U.S.  Also, a supplemental listing of out-of-network dentists, Out-of-Network Plus, provides Guardian members greater selection in finding an affordable dentist. Health Net Dental: As of May 2014, our California PPO network includes 40,722 access points in 11,367 locations. Our California DHMO network includes 2,382 locations. HUMANA Dental: Nationally, Humana has more than 215,000 provider locations. In California, we have approximately 30,000 provider locations. Principal Financial Group:  We have approximately 48,000 PPO provider locations and 25,700 EPO provider locations. Securian Dental: More than 190,000 dentist access points. United Concordia: To support our diverse product portfolio consisting of fee-for-service, DHMOs and PPOs, we maintain some of the largest dentist networks in the nation. Our largest network provides access to 92,500 dentists at almost 235,000 access points. In California alone, we have 15,800 providers at 37,833 access points. Our DHMO network includes more than 2,600 primary dental offices and almost 1,700 specialists nationwide, with over 1,657 primary dental offices and 776 specialists in California. 9. Can Insureds change providers easily if they are unhappy? Aetna: Yes, members in our PPO/indemnity plan can change any time and do not need to notify us. Members in our DMO plan can choose a new provider as often as once per month through Navigator, our online web tool for members, or by calling the toll-free telephone number on the back of their ID card. Aflac: Yes. Policyholders can change providers at any time. Ameritas: Ameritas PPO and the FDH Networks – Insureds can choose any provider at any time for procedures. Anthem Blue Cross: Yes.  Our PPO networks, including Dental Prime and Dental Complete, are open-access models:  The member does not have to pre-select a dentist and can always see the dentist of his/her choice. DHMO members can change providers once a month. BEN-E-LECT: Yes. Members may change providers at any time by selecting to use another provider. No further documentation or process is necessary. BEST Life: Members may choose any dentist they desire without calling BEST Life to switch providers. We also provide immediate access to customer service, who can assist members with selecting a provider. Blue Shield: Yes. Dental PPO plan members have the flexibility to see in-network or non-network providers while dental INO members can only see network providers. However,  dental PPO and dental INO plan members may change providers at any time without notice; Dental HMO plan members may change their primary care dentist as needed; changes will be effective the first of the following month. BRIGHTER: Brighter members can choose the best dentist that matches their needs. Using our online dental shopping platform, members choose dentists based on location, ratings or price. Cigna: DHMO – Members may transfer to a new dental office once a month and for any reason, as long as the member has paid his/her account, in full, at the current office. Members can call our customer service department to speak with a representative, transfer using the online Dental HealthCare Professional Directory on myCigna.com or use our automated transfer option which can process transfers 24 hours a day. Transfers are effective the first of the following month. We suggest that members complete any dental treatment-in-progress before transferring to another dental office. DPPO — Cigna DPPO members have the freedom to visit either a network dentist or any licensed dentist at any time. However, we do recommend that they complete any treatment-in-progress and pay outstanding balances full before changing dentists. DEPO — Cigna DEPO members may seek care from any ­network dentist; however, we do recommend that they complete any treatment-in-progress and pay outstanding balances in full before changing dentists. Indemnity Cigna Traditional indemnity members have the freedom to visit any licensed dentist at any time. Delta Dental: Fee-for-service enrollees can change dentists any time without notifying us. DHMO enrollees can change their contract dentist by contacting customer service or online at www.deltadentalins.com. Requests submitted prior to the 21st of each month are effective the first of the following month. Dental Health Services: Yes. Member satisfaction is Dental Health Services’ top priority, which is why members can change their dentist at any time by contacting their Member Service Specialist or by simply visiting the Dental Health Services website at www.dentalhealthservices.com. Guardian: Members covered under Guardian’s PPO plans can change dentists at will, regardless of whether the dentists are participating or non-participating. Members covered under our DHMO plan may change dentists by using our on-line web tool, GuardianAnytime.com, or by calling our toll-fee number.  We also offer a dual choice monthly switch plan which enables members to switch between the DHMO and PPO as often as desired on a monthly basis. Health Net Dental: With our PPO plan design, there is no need to select a primary care dentist or to obtain referrals for specialty care. Under our DHMO plans, members may change their primary care dentists once a month by calling Health Net Dental Member Services or via our on-line Web portal. The change is effective the first of the month, provided that the request is made by the 20th of the previous month. HumanaDental: With the PPO plan design, the member can change dentists without notifying the dental plan. Principal Financial Group: Yes Securian Dental: Yes. United Concordia: Yes, members can change PPO providers at any time without notice. DHMO participants may change dentists by writing or calling our customer service department and requesting a new DHMO provider, as long as there is no existing balance due to the current dentist or treatment in progress. Western Dental: Our membership can change providers, on a monthly basis, by phone or in writing. 10. How do you ensure that your dentists are aware of the benefits of your plan(s)? Do you have a way of knowing if the dentists are soliciting or recommending services that are not compensated for by your plan? Aetna: Participating dental offices receive our helpful Dental Office Guide, which provides clear information about plan designs, policies, and procedures. We also offer a website specifically designed for dentists. The site includes real-time eligibility and benefits information, a 24/7 speech recognition system called “Aetna Voice Advantage.” Also, our dental solutions team is trained to know what is important for provider service. Unusual treatment patterns may be discovered during our review of utilization reports. This usually results in an office audit that includes a review of patient files and general office practices. We talk with the dentist about the findings and develop recommendations for improvement where needed. Aflac: Aflac has materials that may be provided to dentists with information on how to file claims and access online materials. A dedicated section on aflac.com provides dentists with claim forms and instructions, as well as online access to verify policy benefit amounts. If the dentist has any additional questions, he or she may call Aflac’s Customer Service Center toll-free -1.800.99.AFLAC. Ameritas: Providers can access individual plan information using the toll-free voice response system, the fax-back system, or our online benefit Website.  We hope this educates both the provider and insured about covered benefits.  If not, periodic surveys and automated utilization review mechanisms help provide a way to monitor issues regarding plan coverage misunderstandings. Anthem Blue Cross: We inform participating dentists of plan benefits through a variety of communication vehicles. Dentists can access updated information on our Website, through our interactive voice response system, directly from our provider relations and customer service representatives, and through our provider mailings. Practice patterns of participating providers are monitored continuously and reported through monthly utilization reports and claims experience. We involve our dental director when we suspect over- or under-utilization patterns. In such cases, our dental director contacts the dentist to discuss findings along with a plan of action to help bring the practice within the standard. BEN-E-LECT: The members are given material specific to the dentist to ensure benefits are understood. BEN-E-LECT also offers extended customer service hours with a department dedicated to assisting dentists with benefits information. BEN-E-LECT also has regular outside auditors review claims for this information in addition to scrub during time of payment. BEST Life: Dentists may contact BEST Life for information about member benefits by calling 800-433-0088. All calls are answered by a live person, every time, no exception. We also have a fax back line dentists can use to obtain benefit information. Blue Shield: We strive to make it easier for dentists to participate in our network by automating as many administrative processes as possible. Because administrative capabilities vary among dental offices, multiple approaches exist to facilitate dentist communication-from web-based applications to direct telephone contact-to ensure that all offices have access to critical dentist information and support. Communication channels available 24 hours a day, seven days a week, include: • The Interactive Voice Response (IVR) system offers real-time eligibility verification and claims status inquiry. The IVR also provides fax-back capability for hard copy eligibility verification. • A website enables eligibility verification, benefit confirmation and claims status inquiry. • Electronic Claims Filing — we contract with a number of clearinghouses or trading partners to receive electronic claims submissions. • Electronic Claims Payment — The capability exists to pay our providers electronically if they so choose. Claims are paid on a daily basis (Sunday-Friday). Network dentists can control costs and increase efficiency by submitting data electronically, using our website and interactive voice response (IVR) system. BRIGHTER: Our dentists utilize our simple online platform to process interactions with our members so mistakes are minimized. This also empowers us to track all recommended treatments and proactively remove providers that are over-utilizing (recommending unecessary services) from being seen by our members. Cigna: Our Internet-based platform allows contracted dentists the ability to conduct transactions over a secure website directly linked to Cigna. This website provides one-stop online access to information that the dental offices will find helpful to manage day-to-day operations and increase operational efficiency. Our website at www.cigna.com also provides an easy way for dental offices to access information about participating in the Cigna Dental Care or Cigna DEPO/DPPO network. The network management staff communicates regularly with dental office personnel by phone, periodic newsletters, site visits to provide information about regulations, practice management, patient satisfaction, policies, procedures, and high level news about Cigna. DHMO –The Cigna Dental Care Reference Guide, Patient Charge Schedules (PCSs) at a Glance and Specialty Referral Guidelines are provided to each network dental office on the plan. We produce a periodic newsletter to communicate information about regulations that affect dentists, nationwide and state-specific policies, procedures. This bulletin is mailed with monthly payment packages to the dental offices to which the information is applicable. DEPO/DPPO – The Cigna DPPO Office Reference Guide and fee schedules are provided to each network dental office on the plan. These documents describe the policies and procedures to administer the plan, assist members; contracted fee schedules for the dental office and the advantage of participating in the Cigna DEPO/DPPO network. In addition to the savings generated by our thorough and efficient claims and treatment plan review process, another key aspect of the utilization management program is the analysis of network dentist practice patterns (dentist profiling). Our utilization database containing millions of claims and encounters from more than 140,000 dentists across the country provides us with a comprehensive and statistically sound basis for establishing utilization norms. DHMO – When a dentist submits an encounter form, we enter and store in our database. We generate a statistical report monthly for each network dental office. This report provides a means to systematically evaluate each facility by presenting a clear profile of our dentists’ practice patterns. The report also includes state and regional normative data to facilitate the identification of outliers for each listed category, as well as the development of appropriate follow-up action plans. Based on the evaluation of the outliers by our dental directors, we initiate corrective action activity. If unacceptable practice patterns continue, we may end the network dental office contract. DPPO/DEPO – Cigna Dental uses our provider profiling application as part of our utilization review program. The application uses claims data to generate a report showing the practice profile for a given provider that can be compared with the average practice profile of his or her peers. The profiling report provides details on the following types of practice patterns: The database for any given period compares a single dental office with submitted procedures of over 400 American Dental Association (ADA) codes, with a frequency total of tens of millions of procedures. action. Through our utilization review and dentist profiling efforts, as part of our overall utilization management program, Cigna has been able to ensure network dentists provide adequate and appropriate care. Plus, we have saved our clients billions in the process. . Delta Dental: Detailed program information for all enrollees, including maximums, deductible and benefit levels, is available through a secure area of our website and through a toll-free telephone number. Additionally, Delta Dental issues a bimonthly newsletter to network dental offices, which covers Delta Dental policy, industry news, seminars, new Delta Dental clients, tips on submitting claims and other useful information. We issue a quarterly quality-related newsletter to participating dentists that provides useful information to help improve the quality and efficiency of the care they provide. In addition, Delta Dental holds regular seminars to keep dentists up to date. Regular enrollee surveys seek information on various quality issues, such as services rendered that are not covered by the program; services delivered as claimed; office cleanliness and appearance; and customer service. Dental Health Services: Dental Health Services regularly provides on-site training, auditing, and service visits for the company’s participating prepaid (D-HMO) dentists. Additionally, each dental office receives a manual that contains comprehensive information about Dental Health Services’ dental benefit plans. The company monitors all services and treatment received by its members through monthly utilization reports. Guardian: Dentists can access plan benefits online at www.GuardianAnytime.com or through their practice management system. All PPO dentists receive information about Guardian’s plans through local network recruiters as well as email newsletters or mailings of pertinent information. Our claim system tracks and monitors each dentist’s practice patterns for bundling, over-utilization, etc.  We consult with dentists who are not meeting our expectations, and if they are unable to do so, we may discontinue their network participation. All offices that join our DHMO network receive an orientation that fully explains the plan.  Additionally, our DHMO Regional Network Managers periodically visit the offices to review the plan.  Dental Offices submit encounter data of services provided to DHMO members which is reviewed quarterly by our Quality Assurance Committee. Health Net Dental:  We educate our providers about our administrative policies, including guidelines on appropriate care. Providers are encouraged to submit pre-treatment plans for review in order to learn what procedures would be covered under the member’s benefit plan and the level of reimbursement. In the process of reviewing pre-treatment estimates and in completed claims, we track and monitor each provider’s practice patterns. Providers with aberrant patterns receive focused review, including statistical analysis and record audits, which may result in appropriate corrective action plans. Our Professional Network Relations Reps meet with providers to counsel them and to answer any questions about planning care for members. Our Internet portals provide real-time information to providers and members on their benefits. HumanaDental: HumanaDental notifies dentists, according to their contract, of any new product 45 days in advance of introduction. Providers are encouraged to check eligibility and benefits prior to treatment. Through monitoring of member communications and through utilization review, we would become aware of any situation where a dentist may be recommending non-covered procedures on a routine basis. Principal Financial Group:  We provide online, telephone and fax service options for providers to verify benefits and eligibility.  We encourage pre-determinations to be performed for inlays, onlays, single crowns, prosthetics, periodontics and oral surgery. Securian Dental: Dentists can verify benefits by calling our toll-free customer service phone number or via our Web site. United Concordia: Dental offices can confirm benefit coverage information on our website via “My Patients’ Benefits,” through our telephone interactive voice response (IVR) system, or by speaking to a customer service representative. In some instances, we also inform dentists of important benefit changes through written communications, via our quarterly newsletter, through a stuffer included with dentist checks and/or with an automated telephone call. Dentists can also reference benefit information using our Dentist Reference Guide, available on our website. Professional relations representatives are also available to provide assistance when necessary. We identify abnormal practice patterns through a comprehensive quality assurance process. United Concordia reviews thousands of claims each year to ensure the acceptability of treatment and quality of services. Advisors and consultants also review dentists’ fees and practice patterns. Dentists who fall outside of the norm are targeted for education and additional monitoring. Western Dental: Each provider is trained and given training materials to ensure that they are knowledgeable about Western Dental programs. Western Dental Services also monitors customer service inquiries and grievances in addition to reviewing utilization data supplied by each provider.   11. How many provider offices have you lost over the past year? If asked, will you provide the names and phone numbers of at least three of these offices? Aetna: In 2013, we lost 1.9% or providers in our DMO network and 1% in our PPO network. This is the voluntary termination rate. We are not at liberty to provide specific dentist information, such as names and phone numbers. Aflac: Aflac Dental has no provider networks. Policyholders have the freedom to choose any dentist without restriction. Ameritas PPO: 12,171 provider access points were lost (Ameritas = 3,808, FDH = 8,363). Yes, we would provide names, if requested. Anthem Blue Cross: In the past 12 months, our Dental Prime and Dental Complete networks have grown significantly and less than 1 percent of dentists have terminated participation (primarily through retirement or death). Anthem does not make it a practice to provide names and phone numbers of dental offices that have left the network. BEN-E-LECT: For all plans combined, the turnover is less than 2%. Many offices have been terminated due to lack of meeting credentialing standards, retirement or death of the provider. BEN-E-LECT does maintain the information for these offices; however it is not common practice to release the information. BEST Life: (First Dental Health (FDH) and DenteMax: We have no control of this number. However, our provider locations have actually increased a total of 11,398 locations in the past 12 months. Less than 2.5% of providers have left our PPO networks in the past 12 months. The majority of these terminations are due to a provider’s retirement, death or the moving or closing of a practice. We maintain a clean and thorough network that involves regular network clean-ups. For the sake of privacy, our network does not share such information for the purpose of a general interview. Our networks also focus on growth. Our national network has added 249 access points in California in May 2014. Blue Shield: Dental PPO: For 2012, the voluntary turnover rate (excluding deaths, retirements and practice relocations) was less than 1%. Dental HMO: For 2012, the voluntary turnover rate (excluding deaths, retirements and proactive relocations) was 2%. If requested, Blue Shield can provide the names and phone numbers of at least 3 offices that have left our network within the past 12 months. BRIGHTER: Brighter maintains a high retention rate of 97% annually. Cigna: Cigna’s dental network turnover rates have been lower than published industry average data. Dentist and dental office information can be shared with clients and brokers if required. Delta Dental: Nationally, the dentist locations for our Delta Dental Premier network increased by 10.7%; our Delta Dental PPO network increased by 14.35%; and our DHMO network increased by 9.69% general dentist facilities. In California, there were 270 Premier terminations and 311 PPO terminations. Delta Dental does not release specific information on its contracted dentists. Dental Health Services: Although roughly 5% of participating dentists have been lost over the past 12 months, our overall network size has made up for this and has increased by 5% over the previous year through a focus on seeking out only the most qualified dentists while improving accessibility and availability. The names and phone numbers of all offices are available on request. Guardian: Guardian has a 97% network retention rate. Health Net Dental: In 2013, our DHMO turnover rate for voluntary terms was 0.67% and our PPO turnover rate was 0.25%. We do not release specific information on our contracted dentists. HumanaDental: In the past 12 months, there were 97 providers termed in California, including 5 due to not meeting our credentialing requirements. We do not provide the names and phone numbers of termed offices. Principal Financial Group: Less than 5%. Securian Dental: Very few providers choose to leave the DenteMax network. Less than 3 percent of our network dentists discontinue participation with DenteMax every year. The majority of these terminations are due to a provider’s retirement or death or the moving or closing of a practice. We would be willing to provide names and phone numbers of terminated offices upon request. United Concordia: In California, we grew our PPO network from 15,800 individual dentists and 37,833 access points to 16,240 dentists and 41,168 access points. In addition, our DHMO network of primary dental offices remains consistent with just over 1,652 primary dental offices. Yes, if requested, we can provide the names and phone numbers of dental offices that no longer participate in our network. Western Dental: Turnover is about 3% for the past year. Yes, we will provide the names and phone numbers for 3 of these offices, if requested. 12.What percentage of your network is closed to new enrollment? How many offices does this represent? Aetna: For California, approximately 4% of our DMO participating providers are closed to new patients. All of our PPO providers are open to new patients. Aflac: Aflac Dental has no provider networks. Policyholders may visit any dentist they choose. Ameritas PPO: Only 106 Ameritas Offices and 26 FDH Offices are closed to new enrollment. This represents approximately 0.2%. Anthem Blue Cross: Our Dental Prime and Dental Complete network model is open-access, and we do not contractually require providers to report on new-patient status. We have not heard reports of any members having issues with finding a participating dentist that is open to new patients. BEN-E-LECT: All of BEN-E-LECT’s dental PPO providers are accepting new patients. For the DHMO product, less than 3% of the offices are closed to new enrollment representing approximately 60 offices. BEST Life: All participating PPO dentists are accepting new patients. Blue Shield: In 2012, less than 1% of dental HMO plan network providers maintained closed practices; this represents approximately 30 offices. BRIGHTER: All Brighter dentists are accepting new patients. Cigna: DHMO — Our systems include data on dentist capacity and current and projected Cigna Dental Care member loads. Network managers regularly monitor capacity and projected growth. They contact dentists as necessary to discuss capacity expansion through staff increases or office hour changes. If these actions are not feasible, we will consider adding more dental offices. Nationwide, approximately 8 percent of the Cigna Dental Care network dental offices are closed or capped to new members. DPPO/DEPO — Network dentists do not cap or close their offices. Members are not required to select a primary network dental office Delta Dental: 0%. Under the PPO/Premier plans, enrollees are free to see any licensed dentist. Contracted dentists can close their practices to new patients but cannot close their practice exclusively to new Delta Dental patients; 2.92% DHMO dental facilities are closed to new enrollment. Dental Health Services: About 8% of network general practice dentists are closed to new enrollment (63 offices). No specialty offices are closed to new members. Guardian: In California, only 0.4% of our PPO network and 5.7% of our DHMO network is closed to new patients. Health Net Dental: As of April 2013, for DHMO, currently 3% of our General Dentist unique locations are closed to new enrollment. For PPO, currently 0.8% of our dentists’ offices are closed to new enrollment. HumanaDental: Under HumanaDental’s provider contract, participating dentists have payer differentials. Because this is a fee-for-service reimbursement program, closed practices are not common. Principal Financial Group: Less than 1% of the offices participating in our network are  closed  to new enrollment. Securian Dental: All of our network dentists are open to new enrollment. United Concordia: In California, more than 99% of our PPO dentist network is open to new enrollment, as well as more than 95% of our DHMO dentist network. Western Dental: Less than 3% of our network providers are closed to new enrollments – about 60 offices. 13. Do all of your contracted offices accept every benefit level sold by your company or do they have the option to pick and choose only the programs with co-payments they want to accept? Aetna: For California, approximately 4% of our DMO participating providersare closed to new patients. All of our PPO providers are open to new patients. Aflac: Aflac Dental has no provider networks. Ameritas: All providers accept patients from all plans sold through Ameritas Group Dental. Anthem Blue Cross: Anthem Blue Cross recommends all participating providers accept all plans offered. Providers cannot cherry pick DHMO plans, they either accept all DHMO plans under the specific contract, or they do not contract. Providers can choose to participate with Dental Prime and Dental Complete, or Dental Complete only; however as for plan or benefit designs under each product, providers cannot cherry pick which PPO design they will accept. BEN-E-LECT: All benefit levels are accepted and to date no offices have limited or requested to limit the programs they will accept. BEST Life: All contracted offices accept every benefit level. Furthermore, by contract, all providers will honor the PPO discounts on all procedures, including non-covered services. They must also honor a discount for members who are within a waiting period or who have exceeded their annual maximum. Blue Shield: Offices are not allowed to  pick and choose  which plan designs they accept. BRIGHTER: All contracted offices must participate in each benefit level we sell. Cigna: All contracted DPPO offices accept all of the insured benefit DPPO plan designs that we offer. All contracted DHMO offices accept all of the DHMO plan designs that we offer. For our discount dental programs, not all DPPO contracted dentists are required to participate. They may opt out of participation in these discount dental programs if they desire. Delta Dental: Delta Dental holds contracts with individual dentists for participation with each network (Premier, PPO and DeltaCare USA [DHMO]). Dentists can choose to participate only in those programs with copayments they wish to accept. Dental Health Services: All new dentists are contracted for all plans offered by Dental Health Services. Guardian: All contracted PPO and CA DHMO offices accept all of the plan designs that we offer. Health Net Dental: All participating PPO dentists accept all of our plan designs. Contracted DHMO providers accept all Health Net Dental DHMO plans. HumanaDental: The PPO contract is for all network-based programs, excluding DHMO, which requires a separate agreement. Dentists can opt-out of participation in the Medicare and Access (discount) programs, which are a subset of the PPO. Principal Financial Group: Providers can choose to participate in our PPO and/or EPO networks. Within each option, providers need to accept all benefit levels sold by our company. Securian Dental: Yes, they accept every benefit level sold by our company. United Concordia: All contracted PPO dentists accept all United Concordia PPO plans. All contracted DHMO dentists accept all United Concordia DHMO plans. Western Dental: The entire network accepts all of the new Series 7 plans. 14. Do you have a way to monitor the length of time patients have to wait in the doctor’s office? Aetna: We do not monitor average wait times in a dentist’s office. Aflac:  Since policyholders can choose any dentist without restriction, Aflac does not monitor wait times. Ameritas: We monitor patient wait time through random customer and patient surveys. Providers are contacted, if necessary, to discuss specific feedback. Anthem Blue Cross: Yes, we monitor this as a metric in our member satisfaction surveys. Through our complaint/grievance tracking processes, issues such as wait times are logged and monitored. Additionally, we monitor appointment wait times and emergency wait times through surveys conducted by our organization. BEN-E-LECT: This information is tracked closely for Freedom Pre-Paid Dental Plans. Surveys and questionnaires for the PPO products track this information. BEST Life: Network accessibility and wait times are included as part of the credentialing and ongoing monitoring processes. Blue Shield: Yes. We monitor and track wait times several ways. We document member complaints on this issue in our customer service workbench and track them electronically until they are resolved. We also conduct an annual member satisfaction survey, which contains specific questions about wait times with our network offices. BRIGHTER: Yes. Additionally, Brighter maintains an unprecedented high level of member satisfaction through an exceptional member service team that follows up with each patient to ensure their experience at the Brighter dentist met their expectations. Brighter backs this up with a satisfaction guarantee. Cigna: The dental network management team monitors wait times in our DHMO general dentist facilities via monthly telephone calls. Additionally, we are able to identify lengthy wait times through our patient satisfaction surveys.We investigate inquiries about excessive wait time and take corrective action if we determine that timely and efficient dental care was available, but not provided. If we determine that excessive wait time was the result of insufficient patient capacity, we initiate actions to expand the dentist’s capacity or recruit additional dentists in that particular area. Delta Dental: Delta Dental conducts random enrollee surveys semi-annually for the fee-for-service enrollees and annually for DHMO enrollees. Surveys include questions about dentist access (for example, number of dentists from which to choose and appointment availability with their dentist) as well as other customer satisfaction issues. For the DHMO, the appointment availability is also monitored via regular office visits from a Delta Dental representative. Dental Health Services: Yes, we monitor our members’ experiences through frequent member surveys, regular on-site dental office visits and quarterly access surveys. Guardian: We send monthly member satisfaction surveys, which include questions concerning wait times, to randomly chosen PPO members who have been to a network dentist within the previous 90 days. The DHMO has established access standards and monitors this quarterly through access monitoring forms, member satisfaction surveys, and transfer and grievance data.  Telephone calls are utilized on an  as-needed  basis. Health Net Dental: We monitor individual wait times in the dentist’s waiting room through our member satisfaction surveys and provider access surveys. Results of these surveys are a critical tool in assessing a member’s experience with network dentists and their specific offices. In addition, we receive feedback on office wait times from members calling our toll-free Health Net Dental Member Services number. HumanaDental: We rely on member calls to keep us apprised of scheduling issues. Sometimes, the member is limiting their options (i.e., after 5 p.m.), which is discovered through discussion with our customer-relations representatives. If the issue becomes chronic, the information is forwarded to our National Dental Network department because additional providers may be needed in the area. Principal Financial Group: We do not monitor this. Securian Dental: We do not monitor this. United Concordia: Yes, it is monitored through member surveys, a customer service grievance process and periodic phone and written survey audits of the offices. Western Dental: Western Dental monitors patient’s length of time by onsite reviews, surveys, and questionnaires. In addition, our staff model offices use the Quality Assurance Management System. The state-of-the-art, proprietary software tool tracks measurable items, such as wait times, which ensures that our members have timely access to quality dental care. 15. Are there plenty of providers who stay open late and are open on Saturdays? Aetna: Office hours are set by each individual dental office. We document dentists’ office hours as part of the credentialing process. We use the information to balance networks by contracting with dentists who offer weekend and evening hours. Aflac: Aflac Dental does not have a network of providers. Policyholders may visit any dentist they choose, which includes those with extended hours. Ameritas PPO: Yes, each office sets its own hours. Those hours are available to all our members on our on-line provider listings. Our goal is to balance care availability throughout the area to ensure needed care. Anthem Blue Cross: Each dental office sets its own office hours. However, as part of the credentialing process, we document dentists’ office hours and use the information to ensure our networks include dentists who offer weekend and evening hours. BEN-E-LECT: Yes, many of BEN-E-LECT’s provider offices offer extended evening and early morning hours in addition to weekend hours for ease of access. BEST Life: Yes, many providers have extended and flexible hours. Blue Shield: This varies by provider, but many do stay open late and/or are open on Saturdays. BRIGHTER: Yes, Brighter’s provider network includes practices that are open late and/or on the weekend. Cigna: DHMO — There are 3,405 network offices (24 percent of the total DHMO network) offering Saturday office hours, and 5,353 network offices (38 percent of the total DHMO network) offering evening hours (6:00 p.m. or later). DEPO/DPPO — Members are able to visit any licensed dentist for care; therefore, we do not measure evening or weekend hours for DPPO network dentists. Additionally, our dentist contracts require dentists to provide or arrange for emergency care 24 hours a day, 7 days a week and to provide emergency appointments within 24 hours. Delta Dental: Our online dentist directory contains information on hours and access, including maps, directions and languages spoken. In addition to posting hours and access, DHMO network dentists are required to provide 24-hour emergency service to enrollees seven days a week. Guardian: Many PPO and DHMO provider locations have extended or weekend hours. Health Net Dental: The office hours of each dentist location is listed in our online provider directory. This information is also available to all members through Health Net Dental Member Services. As part of our dentist agreement, all locations are required to have an emergency contact available for members whenever the dental office is closed. HumanaDental: Members can see the provider of their choice and they are encouraged to contact their dentist for appointment availability. Based on today’s busy lifestyles, many providers are extending their hours to meet the needs of their patients. Principal Financial Group: Members can see any provider of their choice, which can include those who have extended hours. United Concordia: Yes. Western Dental: Yes, many of our IPA providers have evening and Saturday hours. The Western Dental Staff Model Offices are open from 9:00 AM to 8:00 PM, Monday through, Friday and 8:00 AM to 4:00 PM on Saturdays. 16. With respect to your mid-range benefit level, what is the specific amount of capitation paid to the general dentist? Do you offer validation for these amounts? Aetna: We establish varying compensation rates under each customer’s benefits plan for subscribers, spouses, and children. Monthly compensation rates are based on community averages and plan design. Actual capitation amounts are proprietary. Aflac: Aflac Dental does not offer capitation plans. Ameritas PPO and the FDH Networks: Neither of these networks is used for dental HMO purposes, so no capitation is paid. BEN-E-LECT: This is not applicable for BEN-E-LECT’s PPO plans. All dentist capitation has been added to the dentist premium amounts collected for the DHMO products. BEST Life: We do not compensate our providers through capitation. Our Indemnity and PPO plans allow patients to utilize providers of their choice. Blue Shield: This information is considered proprietary. BRIGHTER: N/A Cigna: Network general dentists’ payment consists of the following four components: fixed monthly payments (capitation), patient charges (copays), office visit payments, and supplemental payments for certain covered procedures. Network specialists are paid based on a fixed fee schedule. Delta Dental: Capitation rates are developed based on the plan design, annual utilization data, enrollee/dependent mix and employer contribution. Compensation is designed to reimburse approximately 60% to 65% of usual fees. Dental Health Services: Dental Health Services’ compensation system involves many more components than capitation and is designed to keep the participating dentists whole while providing incentives for appropriate treatment and care. Guardian: DHMO capitation amounts paid to the general dentist vary based on plan design, adult or child, and region. Health Net Dental: Capitation information is proprietary. HumanaDental: Managed dental care capitation varies by plan schedule and geographic location. Principal Financial Group: N/A Securian Dental: We do not offer capitation plans. We offer PPO and Indemnity plans. United Concordia: Specific capitation amounts are considered proprietary information. United Concordia also compensates participating DHMO providers with supplemental payments on over 80 procedures. The supplemental compensation not only provides incentives for participating dentists to appoint patients and render necessary care but also provides a mechanism for the dentists to report utilization and thus allowing United Concordia to report DHMO utilization to our customers. Western Dental: Series 7 plans reimburse providers with capitation and supplemental payments. Total compensation, as with fee-for-service designs, depends on how much treatment is provided. 17. Are there incentives for the provider to be thorough? Aetna: Quality management programs are designed to help protect members and providers. Aflac: It is expected that the dentists selected by the policyholders treat their patients with the utmost respect and provide the highest standards of quality care without requiring incentives to do so. If the policyholders are unhappy with the service received, they may change dentists at any time. Ameritas PPO: Provider thoroughness is an expectation; we do not offer an incentive for this. We do, however, monitor patient care through quarterly utilization review. If standards are not met, it could result in the provider’s termination from the network. Anthem Blue Cross: We do not offer incentive programs to dentists because we expect quality of care with or without incentives. BEN-E-LECT: Yes. BEN-E-LECT may offer bonuses to providers who exceed quality of services and accessibility standards. BEST Life: Our networks administer comprehensive utilizations reviews for dental necessity and appropriateness of care. Blue Shield: We expect all network dentists to provide our members with high-quality, thorough care; we continuously measure appropriateness of care through numerous oversight methods. While routine treatment plans are carried out by dentists without prospective review, more complicated treatments are evaluated by our dental consultants who assess the proposed treatment(s) for appropriateness and benefit determination. All dentists involved in our review process are fully licensed. Our clinicians are also actively involved in the annual review of dentist records. These quality-of-care audits involve the use of comprehensive guidelines established by the American Academy of Dental Group Practice, the California Dental Association, and the American Dental Association (through the University of North Carolina School of Dentistry). A random sample of each dentist’s records is selected for scrutiny by our dental consultants. Recommendations are made to any dentists who do not meet our quality standards, and follow-up audits are conducted to verify corrective action has been taken. BRIGHTER: All Brighter members have the ability to rate their experience with a Brighter dentist. Poor ratings will impact their visibility on Brighter’s online shopping platform and, ultimately, ability to attract new patients. Cigna: Our Integrated Quality Management Program drives overall quality across our all of our dental networks. While we do not provide incentives as part of our Quality Management Program, the expectation is that the dentists in our networks meet professionally recognized standards of care. DHMO — Incentives play an important role at increasing participation. Payment for network dental offices is made up of four elements: fixed monthly payments, office visit payments, supplemental payments from Cigna, and patient payments made directly from the member to the dentist. This model is designed to encourage preventive dentistry and to protect the dental office from over-utilization. When these standard forms of payment do not satisfy a quality dentist, Cigna will work with the dentist to achieve the best outcome. Cigna’s network general dentists are able to earn bonus payments when they meet performance goals set for preventive care, specialty procedures and patient satisfaction through the DHMO pay for performance rewards program. DEPO/DPPO — Network dentists are paid based on discounted fee schedules that vary by 3-digit zip code. Our discounted schedules encourage preventive dentistry by offering more aggressive payment on preventive services while holding deeper discounts on Class II and Class III procedures. For noncovered services, members are responsible for payment of the dentist’s usual fee for that procedure. Delta Dental: Delta Dental does not pay any special incentives. We expect all credentialed network dentists to provide high-quality care within professionally accepted standards and to maintain the dental health of enrollees, with the intention to reduce the need for more invasive care later. Dentists who provide quality care and service retain their assigned enrollees, and as a result, gain enrollment and greater overall compensation. Dental Health Services: As a prepaid dental plan, Dental Health Services provides plans designed to remove the incentive for dentists to over treat, by using a different reimbursement structure. Through a combination of guaranteed monthly capitation payments, selected supplemental payments and reasonable patient copayments, dentists are rewarded for bringing patients to a state of optimum oral health and then maintaining this state. Dentists are required to submit encounter (utilization) data to the plan so that the services performed can be monitored and compared to expected parameters, resulting in the same monitoring ability as claims-based dental programs, while leaving very few actual submitted claim forms. (Specialty claims and claims for out-of-network emergency care being the common exceptions.) Guardian: Our PPO fee schedules and plan provisions encourage proper care. Guardian requires participating dentists to treat PPO members the same as any other patients and we investigate all quality of care complaints from members. Our DHMO reimbursement schedules, capitation payments, office visit fees, supplemental payments, and chair-hour guarantees encourage appropriate care. Participating dentists treat DHMO members the same as any other patient, and we have a grievance process in place to follow up on all quality of care complaints from members. Health Net Dental: We do not offer financial incentives to our dentists. Our expectation is that our dentists perform in accordance with high professional standards without incentives. Our extensive credentialing process ensures that our contracting dentists are of the highest caliber. HumanaDental: Fee-for-service reimbursement encourages thorough treatment. Member complaints are reviewed by our Quality Assurance Department and through our standard grievance process. Principal Financial Group: Being thorough is an expectation and we do not provide incentives to meet expectations. All providers in our networks must meet strict credentialing requirements. This means they have all been independently reviewed and found to have proper professional credentials and a verified history of responsible billings. However, a member is free to choose any provider. Securian Dental: All DenteMax dentists undergo a rigorous credentialing process to ensure the highest quality dentists are treating our members. United Concordia: Our expectation is that all services performed by participating dentists will meet the high standards of the dental industry. In addition, participating DHMO primary dentists get supplemental reimbursement on the most highly utilized procedures in addition to monthly capitation and member co-payments, which encourage dentists to provide the services necessary to ensure the oral health of members. Participating providers are routinely evaluated through utilization analysis and onsite quality assurance assessments. Western Dental: Western Dental Services Inc. may pay the dentist a bonus based on exceeding standards specified by Western Dental with regard to accessibility of services and quality of care.   18. Do you provide coverage for all types of specialist referrals? Aflac: The Aflac Group Dental plan does not require referrals. Assurant Dental Network: Yes. Ameritas PPO and the FDH Networks: Yes, specialty coverage can be a part of any Ameritas plan design. Our networks comprise a full spectrum of specialists to cover the needs of our customers. Aetna: Yes Anthem Blue Cross: Yes, specialist care is available for both our Dental PPO and DHMO plans. No referrals are required on our Dental PPO plans, including Dental Prime and Dental Complete. On our DHMO plans, the member’s general dentist can refer them to a specialist when needed. BEN-E-LECT: Specialist referrals are not necessary. Coverage is available for all types of specialty procedures including, but not limited to, endodontic, periodontic, cosmetic, orthodontics, oral surgery and pedodontics. BEST Life: Yes, specialists are covered at full contract benefits as describe in our Indemnity and PPO plan certificates of insurance. Our orthodontic plan is available for all of our PPO and Indemnity plans either at a deductible or lifetime maximum. Blue Shield: Specialist care is available for all dental plans. Dental PPO/INO plan members may self-refer to any specialist, although INO members can only see network providers. For dental HMO plan members, the primary care dentist is responsible for referring the member to a participating specialist; however, there is no coverage for prosthodontic specialists. BRIGHTER: Yes and Brighter features a provider network with specialists in all areas of dental. Cigna: DHMO – Network general dentists initiate patient referrals for endodontic, oral surgery, and periodontal treatment. Referrals are valid for 90 days from the approval date. Specialty referrals are not required for orthodontic treatment, if covered on their plan design or for pediatric care for children up to age seven as long as individuals visit network specialists. The network dentist may submit a request for pre-authorization to Cigna Dental for oral surgery, endodontic and periodontal services. Individuals are responsible for the applicable patient charges listed on the Patient Charge Schedule for all covered procedures. After specialty treatment is complete, the individual should return to the network general dentist for care. If it is determined that a network specialist is not available, the general dentist will refer the patient to a non-network specialist and the patient will only be responsible for charges listed on the Patient Charge Schedule. DPPO –There is no need for a referral by a primary care dentist to obtain services from a specialist with the Cigna Dental PPO plan. Members may choose to seek service from any in- or out-of-network specialist or general dentist at any time. Of course, network dentists have agreed to our reduced fee schedules, which lower out-of-pocket expenses. DEPO –There is no need for a referral by a primary care dentist to obtain services from a specialist with the Cigna Dental EPO plan. Members can visit any network specialist or general dentist at any time to receive coverage. INDEMNITY – Cigna Traditional indemnity members are always free to seek care from any licensed dentist at any time. Delta Dental: Fee-for-service enrollees can self-refer; referral by the general dentist isn’t required. For DHMO enrollees, the primary care dentist is responsible for submitting the predetermination request and directing the enrollee to the appropriate specialist once authorization is received. Dental Health Services: Yes. Dental Health Services’ plans provide specialty coverage for endodontics, periodontics, oral surgery, pedodontics, and orthodontics. Guardian: We provide coverage for all types of dental specialists. Health Net Dental: Health Net Dental DHMO plans cover a wide range of specialty care, including endodontics, periodontics, oral surgery, pedodontics and orthodontics. If the procedure is covered under the plan, the member must first see general dentist for a specialty care referral to a general dentist HumanaDental: HumanaDental provides coverage for specialist referrals; members are encouraged to refer to their certificate of coverage to confirm the service being sought is a covered benefit under their plan. Humana- Dental encourages members to check if the specialist referred by their dental provider is in-network. Humana has a provider directory available on our website, www.Humana.com. Members can also call the customer service number on the back of their insurance card. Members should request a pre-treatment estimate from the provider. Principal Financial Group: Generally yes. Securian Dental: Our plans do not require referrals. We provide coverage based on plan benefits. United Concordia: Our PPO plans do not require specialist referrals. Our DHMO plans require referrals from the general dentist office for specialty coverage for endodontics, periodontics, pedodontics, oral surgery and orthodontics. However, the DHMO referral process is open, in that there is no requirement for United Concordia to pre-authorize the referrals. The services provided by specialists that are considered for benefit reimbursement are limited to the specifics of the dental contract for each covered member. Western Dental: Specialty coverage is available in all of our group plans. Oral surgery, periodontics, endodontics, pedodontics, and orthodontics are covered specialties. 19. If covered, explain the process that allows the general dentist to refer to the specialist. Aetna: For DMO plans, general practitioners can refer to a participating specialist directly based on published guidelines. DMO members have direct access to participating orthodontists and do not need a specialty referral. Indemnity and PPO plans have direct access for specialty services. Aflac: The Aflac Group Dental plan does not require referrals. Ameritas PPO and the FDH Networks: Specialist referrals are allowed at any time from our general dentists. There is no gate-keeper involved in this process. Anthem Blue Cross: With our Dental Prime and Dental Complete plans, we do not require referrals. For the Dental Net DHMO, referrals that do not include high-risk procedures are reviewed post-treatment. Using the direct referral program, the participating general dentist can refer a patient to a specialist without prior authorization. Dentists’ practice patterns are reviewed to help ensure that they share in our commitment to providing access to effective healthcare. For the Dental Net DHMO products, the member’s assigned general dentist can call the customer service hotline in an emergency to get an immediate authorization for emergency services. Assurant Dental Network: The member does need a referral from the dentist. They may self-refer to a specialist. BEN-E-LECT: Referral is not necessary for any of BEN-E-LECT’s plans. The member may select a specialist and schedule an appointment upon making a phone call or personal visit. BEST Life: No referral is necessary. Insureds can visit a specialist at any time. Blue Shield: For DHMO plan members, the general dentist completes a specialty care referral form and provides a copy to the member, who provides the form to the participating specialist at the time of the appointment. Dental PPO plan members may self-refer to a specialist. BRIGHTER: There is no formal referral process with Brighter. Members are free to choose their dentist or specialist using our online platform. Cigna: DHMO – Network general dentists initiate patient referrals for endodontic, oral surgery, and periodontal treatment. Referrals are confirmed for 90 days from the approval date. Specialty referrals are not required for orthodontic treatment or pediatric care for children up to seven years old, as long as members visit network specialists. The network dentist may submit a request for preauthorization to Cigna for oral surgery, endodontic and periodontal services. Members are responsible for the applicable patient charges listed on the patient charge schedule (PCS) for covered procedures. After specialty treatment is finished, the member should return to the network general dentist for care. If a network specialist is not available, the general dentist will refer the member to an out-of-network specialist, and the member will only be responsible for charges listed on the PCS; however, Cigna Dental Care (DHMO) network general dentists render the range of services that are required for graduation from dental school, including diagnostic treatment, preventive treatment, operative dentistry, crown and bridge, partial and complete dentures, root canal therapy, minor oral surgery, preliminary periodontal therapy, and pediatric dentistry. DPPO – There is no need for a referral by a primary care dentist to obtain services from a specialist with the Cigna DPPO plan. Members may choose to seek service from any in- or out-of-network specialist or general dentist at any time. Of course, network dentists have agreed to our reduced fee schedules, which lower out-of-pocket expenses. DEPO – There is no need for a referral by a primary care dentist to obtain services from a specialist with the Cigna DEPO plan. Members can visit any network specialist or general dentist at any time to receive coverage. INDEMNITY – Cigna Traditional indemnity members are always free to seek care from any licensed dentist at any time. Delta Dental: Fee-for-service enrollees can self-refer; referral by the general dentist isn’t required. For DHMO enrollees, the primary care dentist is responsible for submitting the predetermination request and directing the enrollee to the appropriate specialist once authorization is received. Dental Health Services: The participating general dental office sends Dental Health Services a specialist referral authorization. Upon approval, the authorization is sent back to the general dentist who informs the patient that they are now eligible to get appropriate care from a specialist. Guardian: For the DHMO plan, any complex treatment requiring the skills of a dental specialist may be referred to a participating specialist dentist. Our DHMO plans offer direct referral in which the member may be referred directly by their primary care dentist to a participating specialist without pre-authorization. Health Net Dental: For DHMO plans that require pre-authorization, the contracting primary care dentist completes a specialty referral form and submits to Health Net Dental. Approvals are returned to the primary care dentist, member and specialist. Upon receiving the approval, the member contacts the specialty office to schedule an appointment for completion of treatment. For plans that have direct referral, the primary care dentist may directly refer the member to a participating specialist by visiting our website or by contacting our customer service. Our PPO dental plans allow self-referrals to participating or non-participating specialists as needed. HumanaDental: General dentists are encouraged to refer members to participating specialists to provide the highest level of benefit to the member. The general dentist can refer out-of-network if there are no specialists within a reasonable distance. Principal Financial Group: Patients can choose any provider in the network; referrals are not required. Securian Dental: No referral is required. United Concordia: If a general dentist determines that a patient requires referral to a specialist, all care must be coordinated through the primary dental office. The primary dental office should refer the patient to a participating specialist located in our Concordia Plus Specialist Directory and also complete the specialty care referral Form. The patient should be given a copy of the referral form to give to the specialist at the time of their appointment. The specialist will then be responsible to submit the claim, corresponding documentation and referral form to United Concordia for reimbursement. There is no requirement for United Concordia to pre-authorize the referral, thus providing better access to care when it is needed. Western Dental: Once the general dentist determines that the necessary procedure is out of his or her scope of practice, the office will submit a written referral request to our plan. Western Dental’s dental director then determines whether the referral is medically necessary and whether the procedure is covered under the benefit plan. 20. Are any of your specialists board eligible/certified? Aetna: Yes Ameritas PPO: Yes, all are board-eligible or certified and are monitored during the PPO credentialing process. Anthem Blue Cross: All contracted specialists with Anthem Blue Cross must be board certified/board eligible. Aflac: Aflac Group Dental has no provider networks, however, for benefits to be payable, the specialist must be licensed by his or her state to perform the required treatment. Assurant Dental Network: Yes. BEN-E-LECT: Yes. BEN-E-LECT requires that all participating specialists be board certified. BEST Life: All of our specialists are certified and must meet a rigorous credentialing process to be admitted into the network. DenteMax credentials its specialists using the following elements: • License to Practice • DEA/CDS Certificates • Education/Board Certification • Work History • Malpractice Claims History • Malpractice Insurance • Application and Attestation Content • Sanctions Against Licensure • Medicare / Medicaid Sanctions • Medicare Opt Out Blue Shield: Yes, but certification varies by specialist. Dental specialists may be certified, but it is not an industry requirement. Therefore we do not track board certification. We ensure that members receive the best possible care by credentialing and re-credentialing dentists following NCQA guidelines. BRIGHTER: All Brighter dentists go through a rigorous certification process that includes validation of industry eligibility and certifications. Cigna: DHMO/DEPO/DPPO – Network dentists contracted to provide specialty care have successfully completed postgraduate dental specialty programs in their fields. Our networks include specialists in periodontics, orthodontics, endodontics, pediatric dentistry, and oral surgery. We accept dentists who are recognized specialists, including those that are board certified or board eligible. INDEMNITY – Network related issues are not applicable to the Cigna traditional indemnity plan. Members may choose any licensed dentist to provide care. Delta Dental: Delta Dental requires board certification where it is required by state law. Under the fee-for-service plans, Delta Dental credentials all of its participating specialists in the same manner, whether they are board eligible or board-certified. Under the DHMO plans, Delta Dental requires all DeltaCare USA network specialists to be board-qualified. Dental Health Services: Yes. Majority of Dental Health Services’ dental specialists are board certified. Guardian: Many of our PPO specialists are board certified or eligible and all of the DHMO specialists are board eligible. Health Net Dental: Yes. HumanaDental: All participating specialists must provide copies of their specialty licenses or residency certificates. Principal Financial Group: Yes. All specialists are required to be board eligible, board certified or be a designated specialist by the ADA. Securian Dental: 100% of the specialists in our network are board certified or board eligible. United Concordia: Yes, as part of our credentialing process, we verify each dentist’s education, license and certifications. Western Dental: All contracted specialists are board-eligible/certified. 21. How do you fund your specialty care? Aetna: Specialty services are paid on a fee-for-service basis. Aflac: Aflac Group Dental insurance pays a set amount per procedure based on a table of allowances. Additionally, insureds have the freedom to choose their own providers without precertification. Ameritas PPO and the FDH Networks: Specialty care claims are paid out of the same claims reserve that is established for the group’s general dentist claims. If employers are fully insured, all are funded out of the premiumcharged to each group. If employers are self-funded, the specialist claims would be included in the claim funding bill provided to the employer. Anthem Blue Cross: Claims for specialty care for both Dental PPO and DHMO plans are paid according to the provider’s fee schedule. Assurant Dental Network: Proprietary BEST Life: Specialty care is built into the premium. Specialty care received by a network provider is reimbursed at a discounted fixed fee schedule. Specialty care received by a non-network provider is reimbursed on what is usual and customary for that area, procedure and specialty. Blue Shield: Specialty care is paid on a discounted fee for service basis for dental HMO, INO and PPO plan designs. Member and plan copayments vary, depending on the plan design. BRIGHTER: The employer sets its own funding & specialty amounts. Cigna: DHMO –We contract with an extensive network of specialists to ensure that we provide our members with the needed services at negotiated fee levels. We pay specialists based on a reduced fee schedule. Patient charges listed on the patient charge schedule (PCS) apply at the specialist’s office once we have authorized payment. We review referrals to specialists for eligibility and coverage. DEPO – The DEPO plan uses our national DPPO network. Specialists are part of the Cigna DPPO network, and members can seek care from any network specialist without a referral. Like network general dentists, network specialists are contracted on a discounted fee-for-service (FFS) schedule based on average charges in a geographic area. DPPO – Specialists are part of the Cigna DPPO network; members can seek care from an in-network or out-of-network specialist without a referral. Like network general dentists, we contract with network specialists on a discounted fee-for-service schedule based on average charges in a geographic area. We pay out-of-network dentists according to maximum reimbursable charge levels or fixed schedules, depending on the plan design. INDEMNITY – The Cigna Traditional indemnity plan is not a network-based plan. Delta Dental: Specialty care is built into the premium. Under the fee-forservice plans, specialists are reimbursed by a combination of maximum plan allowances by procedure (contracted fees between Delta Dental and dentists) and coinsurance paid by the covered enrollee. Under the DHMO plan, network specialists are reimbursed for preauthorized services on a per-claim basis according to contracted fee schedule and copayment paid by the enrollee. Dental Health Services: Specialty care and treatment are paid for on a contracted basis and payment varies by procedure. These costs are built into each plan’s monthly premium rate. Guardian: Our PPO specialists are paid on a fee-for-service basis. For our DHMO plans, specialty care is funded through a portion of premium. Health Net Dental: For both our DHMO and DPPO plans, we underwrite and rate dental plans based on an assumed specialty care claims liability and build an allowance into our dental premiums. HumanaDental: Specialists are paid on a fee-for-service basis according to a contracted fee-schedule amount or by reimbursement limit. Principal Financial Group: Through normal plan provisions. Securian Dental: Network dentists (general and specialty dentists) are reimbursed on the basis of a discounted fixed fee schedule. Network dentists agree to accept the fee schedule amount as full consideration, less applicable deductibles, coinsurance and amounts exceeding the benefit maximums and will not balance bill the member. United Concordia: Both PPO and DHMO specialists are paid on a negotiated fee-for-service basis. Western Dental: We incorporate into our premiums what we expect specialty care claims to be. We then pay the claims based on dental necessity and plan guidelines. 22. Does the member have to be referred by the primary dentist to the orthodontist or can he or she self-refer? Aetna: Member can self-refer. Aflac: The Aflac Group Dental plan does not require referrals. Insureds may self-refer. Ameritas PPO and the FDH Networks: No, every member can self-refer. Anthem Blue Cross: We do not require referrals in our PPO plans, including Dental Prime and Dental Complete. Members enrolled in the Anthem Blue Cross Dental Net DHMO program must be referred by their primary dentist to an orthodontist. Using our direct referral program, the participating general dentist can refer the patient directly to the specialist without prior authorization. Assurant Dental Network: They can self-refer. BEN-E-LECT: Members may self-refer to any orthodontist they prefer. In-network versus out-of-network and plan selection will determine coverage provided. BEST Life: No referral is necessary. Blue Shield: For dental HMO plans, the general dentist completes a specialty care referral form and provides a copy to the member, who brings this to the participating specialist at the time of the appointment. Dental PPO/INO plan members may self-refer. Brighter: Self-refer Delta Dental: Under the fee-for-service plans, enrollees can self-refer. For DHMO plans, the assigned network dentist submits a referral request for orthodontic treatment to Delta Dental. The network dentist is notified upon approval and is responsible for advising the DeltaCare USA enrollee who then contacts the assigned network orthodontist for an appointment. Cigna: None of our plans require a referral for orthodontic care. Dental Health Services: Yes. Members must get a referral from a participating Dental Health Services dentist before visiting a participating orthodontist. Guardian: PPO members can self-refer to all types of specialty care, including orthodontia. General Dentists in our DHMO network will refer the member to a participating orthodontist. The referral does not require plan authorization. Health Net Dental: Our DPPO product does not require referrals for specialty or orthodontic care, so participants may self-refer. For DHMO, there are three types of specialty referral processes based on the member’s schedule of benefits. For plans that require pre-authorization, a specialty referral form must be submitted by the primary care dentist. For plans that have direct referral, the primary care dentist may directly refer the member to a participating orthodontist by visiting our website or by contacting our customer service. For plans that allow self-referral, the member may go directly to a contracted specialist by visiting our website or by contacting our customer service. HumanaDental: In our PPO, the member can self-refer to an orthodontist. HumanaDental encourages members to ensure any dental provider is in network. Humana has a provider directory available on our website, www. Humana.com. Members can also call the customer service number on the back of their insurance card. Principal Financial Group: A member can choose to seek services from any provider. Securian Dental: The member can self-refer. United Concordia: Our PPO plans allow members to self-refer. Under our DHMO plans, the primary dental office determines if a specialty referral is required, regardless of the specialty. Western Dental: The member has to be referred by the primary dentist to the orthodontist for our IPA Dental Plan. Our Western Centers-only plan allows the member to self-refer. 23. What is the time frame for processing a referral in terms of member notification and payment to the specialist? Aetna: DMO general practitioners usually provide a member with an immediate referral. Specialty payments are made on receipt and adjudication of the claim. Aflac: Aflac Group Dental doesn’t require referrals because insureds have the freedom to choose their own dentist without restriction. Ameritas: Since this is a self-referring process, this question is not applicable. Anthem Blue Cross: With our PPO plans, there is no need for a referral. With Anthem Blue Cross Dental Net DHMO plans, referrals are usually processed within 48 hours through the use of our Direct Referral program. Referrals for emergency reasons are usually processed within the same day. Assurant Dental Network: N/A BEN-E-LECT: Referral is not necessary. Members may call and schedule the appointment as desired. BEST Life: No referrals are required. Members may self-refer to any specialist they choose. Blue Shield: For dental HMO plans, the general dentist completes a specialty care referral form and provides a copy to the member, who brings this to the participating specialist at the time of the appointment. Our average turnaround time for claims payment to the specialist after receipt of the claim is approximately six days. Our dental PPO plans do not require referrals. Brighter: N/A Delta Dental: For PPO and Premier patients, specialty care referrals are not required, and payments to specialists are processed the same as for general dentists. For DHMO enrollees, preauthorizations for specialty care processed within five business days. Dental Health Services: Emergency referrals are processed immediately. In a non-emergency situation, referrals are processed within one to two weeks. Claims are paid within two to three weeks. Guardian: Referrals are not required under our PPO plans. For our DHMO plans, payment to the specialist is within 30 days of receipt of the claim. Health Net Dental: The average turnaround time in processing a nonemergency referral is 48 hours and then 7-10 business days for the EOB to be received by the member. Once the claim is submitted by the specialist, our average turnaround time in processing is 10 business days of receipt and then 7-10 business days for specialists to receive payment in the mail. If claim was sent electronically, it will be sooner. HumanaDental: Most HumanaDental plans do not require a referral from a general dentist to a specialist. The member gets a higher benefit when seeing a participating dentist and specialist. In 2013, 97% of claims were processed within 14 calendar days Securian Dental: No referral is required. United Concordia: All referrals are immediately effective. There is no requirement for specialty referrals to be pre-authorized by United Concordia. The member is instructed to provide the referral to the specialist at the time of service and the specialist files the referral with the claim. All claims, including specialist claims, mailed to United Concordia are usually processed within 14 days. Claims filed electronically are processed during the weekly cycle. Western Dental: Emergency referrals are handled within 24-hours. The turnaround for non-emergency referrals is three business days. Specialists can expect payment in 10 business days for clean claims. 24. If you limit services with an annual or lifetime maximum, what does the maximum dollar amount allowed refer to? Aetna: The maximum dollar amount refers to the total amount Aetna will pay for covered benefits. Aflac: The annual maximum refers to the maximum amount of benefits that may be received within a policy year per covered person. Annual maximums do not apply to wellness and X-ray benefits. Ameritas: The maximum is the total amount of dollars payable to a member under their policy during the specified plan year. Anthem Blue Cross: Our Dental PPO plans have an annual maximum, which refers to the maximum dollar amount that will be paid by the plan in a calendar year. With Anthem Blue Cross Dental Net and Dental Select DHMO plans, there are no annual or lifetime maximums. Assurant Dental Network: Our PPO plans have a variety of annual maximums. BEN-E-LECT: The maximum dollar and lifetime maximum refers to all services and procedures unless specified otherwise by benefit. BEST Life: Lifetime maximum applies to orthodontia benefits. We offer multiple choices of calendar year maximums for preventive, basic and major procedures. Blue Shield: The “maximum” is the maximum amount paid for covered benefits under the plan. The dental HMO plans have no annual maximum or lifetime maximum. Dental PPO annual plan maximums range from $1,000 to $2,000 and encompass all dental services received except orthodontics. Dental INO plans have a $2500 annual maximum. There are no lifetime maximums for dental PPO/INO plans. Orthodontia is offered to adults and children in many dental PPO plans as an additional benefit, which does not apply to the plan annual maximum. Group dental PPO/INO plans provide a generous calendar year orthodontic maximum of $1,000; there is no lifetime orthodontic maximum. Individual and family dental PPO plans offer low copayment and a two-year lifetime orthodonture benefit. Dental HMO plans have no annual maximum. BRIGHTER: Services & claims payments actually utilized. Cigna: DHMO – There is no annual or lifetime maximum. DPPO/DEPO/Dental indemnity – The maximum dollar amount refers to the maximum amount payable by Cigna for covered services rendered. Delta Dental: Under the fee-for-service plans, the maximum dollar amount refers to the maximum dollar amount paid by the plan. Our DHMO plans do not have annual or lifetime maximums. Dental Health Services: The majority of Dental Health Services’ prepaid (D-HMO) plan offerings have no annual dollar maximums, although this option isavailable by client request. PPO plan annual maximums range from $500 to $2000. Please call or email your broker advocate, and a client service manager will help you and your clients receive excellent, innovative and custom benefit programs that fit their needs. Guardian: The maximum refers to the total of benefit dollars actually paidfor covered services incurred within the annual period, or the member’s lifetime in the case of orthodontia. With Preventive Advantage, only Basic and Major services count toward the annual maximum. We also offer an option to cover cleaning after the maximum is reached. Health Net Dental: The maximum dollar amount is the total amount the plan will pay for covered benefits. Humana Dental: Annual maximum refers to the maximum amount paid annually for services, excluding orthodontia. Orthodontic treatment has a lifetime maximum. Principal Financial Group: The maximum dollar amount refers to benefits paid. Securian Dental: The annual and lifetime maximum refer to the maximum dollar amounts we will pay for covered services in a calendar year (annual maximum) or over the coverage lifetime (lifetime maximum). Our plans generally include an annual maximum for non-orthodontic covered services and a separate lifetime maximum for orthodontia. United Concordia: DHMO plans do not have annual or lifetime maximums. PPO plan annual and lifetime maximums vary by benefit plan and refer to the total amount paid in benefits by United Concordia annually or over the member’s lifetime. Western Dental: The Series 7 DMO plans do not have an annual or lifetime maximum. 25. How and when do you provide eligibility information to your dental offices? How can you ensure that your offices will provide services to a member if they are not on the eligibility listing and it is after regular plan hours? Aetna: Eligibility is available to our providers 24/7 by calling our automated telephone inquiry system or by accessing the online eligibility roster. DMO providers receive eligibility rosters the first week of each month. Aflac: Providers may verify eligibility online — aflac.com — or by calling Aflac’s customer service center at 1.800.99.AFLAC. Aflac Group does not require prequalification for treatment. Ameritas: They will want to verify eligibility through our real time system. Our plans do not require preauthorization or mandated PPO network usage. Anthem Blue Cross: Participating providers can confirm eligibility via our secure website 24/7. Also, our customer service representatives are available toll-free Monday through Friday from 5:00 a.m. to 5:00 p.m. (PST) to help members with locating network providers, verifying provider status, member eligibility, answering claim questions, quoting plan benefits, and receiving member complaints. An interactive voice response (IVR) system is also available to answer calls and provide information 24 hours a day, seven days a week. Assurant Dental Network: Prepaid/DHMO eligibility is provided on a monthly basis. A call center is available during regular business hours for eligibility issues. BEN-E-LECT: BEN-E-LECT provides electronic eligibility 24/7 through our Empowr web portal for providers and members. The Pre-Paid product will provide services upon collecting information from the member. This information will be transferred to BEN-E-LECT’s system electronically. BEST Life: Providers can use our fax back eligibility system to determine if a member is eligible, outside of normal business hours. Offices routinely check eligibility prior to appointments and have a process in place for dealing with emergency situations. Blue Shield: Eligibility lists for dental HMO plans are distributed to the dental HMO dental center during the 1st week of each month. Providers are responsible for contacting our customer service department to verify eligibility, if a member is not on their list. Our Interactive Voice Response (IVR) is available 24 hours, seven days a week and has the capability to verify eligibility and assign members. Brighter: For every appointment scheduled via our online platform we are able to provide real-time eligibility information to the dental office prior to treating the patient. Cigna: Our dental health care professionals’ website, CignaforHCP.com, allows dentists to: • verify members’ network participation and eligibility • check members’ benefit information and details on their YTD accumulation toward maximums and deductibles • view claim status • enroll in EFT and receive payments faster • access and download payment reports, office management reports and financial reports in a printable PDF format (DHMO) • print forms – American Dental Association (ADA) claim, referral, and more • download policy manuals including the general dentist dental office reference guide • access patient charge schedule at-a-glance booklet (DHMO only) • take continuing education courses at no charge (contracted health care professionals only) • access information about the Cigna Network Rewards Program® Delta Dental: Dental offices can verify eligibility by contacting Delta Dental via our website, calling our automated information line or speaking with a customer service representative. Under the fee-for-service plans, a patient who is not shown as eligible may be asked to pay the entire amount of the bill up front. The dental office would be responsible for refunding the patient their overpayment after receiving Delta Dental payment. Under the DHMO plans, in addition to verifying eligibility as listed above, network dentists also receive eligibility lists at the beginning of each month. If an enrollee is not contained in Delta Dental’s eligibility database and claims to be eligible for benefits, Delta Dental contacts the client or the client’s benefit administrator to verify eligibility. If the eligibility verification is for an enrollee who has urgent or emergency needs, our customer service representatives will extend an urgent care authorization. Dental Health Services: Participating dental offices receive eligibility rosters twice a month. If immediate eligibility is needed at any time, the dental office can call Dental Health Services’ 24-hour automated eligibility verification system or check eligibility online through the company’s website. Guardian: Dentists can use our online self-service website, GuardianAnytime.com or call our toll-free line and receive a faxed verification of benefits from 3:00 a.m. to 8:00 p.m., Monday through Friday and from 3:00 a.m. to 1:00 p.m. on Saturday, Pacific Time. Eligibility rosters for the DHMO plan are provided to the offices twice a month, at the first of the month and the 10th of the month. Dental Offices may also call our Member Services Department from 8:00 a.m. to 5:00 p.m. Monday through Friday. Health Net Dental: Our DHMO dentists receive a monthly updated eligibility list that includes member name, member status (active, dropped, suspended or transferred), member ID number, dependent names and eligibility status, fee schedule code, group number and capitation amount, if applicable. DPPO dentists do not receive an eligibility roster as members are not required to select a primary care general dentist. Members would simply choose any network dentist (or non-participating dentist, if they desire) and schedule an appointment. DPPO and DHMO dentists can verify eligibility information via our interactive voice response system and Web site, which are both accessible 24-hours a day, seven days a week. Because the IVR and Web site are available 24/7, eligibility can be verified anytime of the day regardless of whether the need occurs during business hours. HumanaDental: Participating offices are encouraged to check eligibility before providing treatment. They can verify members and benefits by calling our toll-free customer service line or through our automated information line to get 24 hour-a-day, seven-day-a week eligibility verification. There are no eligibility rosters for PPO business. Securian Dental: Dental offices can use a toll free number to call customer service to verify eligibility and benefits. Dental offices can also access www.securiandental.com to verify eligibility. United Concordia: PPO dentists can verify eligibility at any time via our Dental Customer Service toll free number, or by using our online system, My Patients’ Benefits. Primary dental offices can verify DHMO members’ eligibility and benefit information 24 hours a day, 7 days a week through My Patients’ Benefits available online at UnitedConcordia.com or by using United Concordia’s IVR system, which can be accessed by dialing our toll free Dental Customer Service phone number at (866) 357-3304. Western Dental: Western Dental provides eligibility listings to our staff model offices electronically and printed eligibility listings to our IPA Providers. This information is updated on the 1st and 15th of each month. For members who are not on the eligibility listing, we offer guaranteed capitation to our network of providers. 26. How do you handle early termination of coverage when a member is still in the middle of orthodontic treatment? Aetna: We stop issuing our quarterly payments when the member is no longer covered. Aflac: Benefits will cease upon termination of coverage. Ameritas PPO: PPO provider discounts are determined using the treatment start date. Our PPO providers are contractually obligated to honor those discounts for any ongoing covered treatment under their plan. Anthem Blue Cross: While details vary by plan, with our Dental Prime and Dental Complete programs, benefit payment is pro-rated based on the services completed. Assurant Dental Network: Benefits are calculated to pay out through the period in which they will be banded, as long as they are still active members. If coverage terms in the middle of treatment, no additional benefits will be paid. BEN-E-LECT: Payment for benefits will cease at the end of the month for which the termination became effective. BEST Life: Coverage terminates at the end of the month in which a member is no longer eligible. Blue Shield: Once the member’s coverage is terminated, the cost of treatment is the responsibility of the member. BRIGHTER: We empower the employer, and their broker, to set their own policy for such situations and we pay claims accordingly. Cigna: Coverage for a dental procedure that was started before disenrollment from the plan (crowns, root canal treatment, bridges, dentures, and partials if the teeth were fully prepared or the final impressions) will be extended for 90 days after disenrollment unless it was due to nonpayment of premiums. Coverage for orthodontic treatment which was started before disenrollment from the dental plan will be extended to the end of the quarter or for 60 days after disenrollment, unless it was due to nonpayment of premiums. Our standard DEPO/DPPO/Indemnity extension of coverage is 90 days; however, other arrangements can be made. Delta Dental: Delta Dental’s obligation to pay toward orthodontic treatment terminates following the date the enrollee loses eligibility or upon termination of the client’s contract. Dental Health Services: If a member’s coverage is terminated in the midst of orthodontic treatment, members are encouraged to participate in a COBRA individual plan that will allow them to retain orthodontic benefits. If the member chooses not to maintain his or her coverage, the dental office can prorate any additional treatment fees. The member would then only be responsible for the prorated amount of the full treatment cost. Guardian: When an orthodontic appliance is inserted prior to the PPO member’s effective date, we will cover a portion of treatment. Based on the original treatment plan, we determine the portion of charges incurred by the member prior to being covered by our plan and deduct them from the total charges. Our payment is based on the remaining charges. We limit what we consider of the proposed treatment plan to the shorter of the proposed length of treatment, or two years from the date the orthodontic treatment started. Also, we enforce the plan’s orthodontic benefit maximum by reducing the total benefit that Guardian would pay by the amount paid by the prior carrier, if applicable. If a member is undergoing orthodontic treatment and his or her Guardian coverage terminates, we pro-rate the benefit to cover only the time period during which coverage was in force. We do not extend benefits. Our DHMO agreement provides for the contracted orthodontist to complete treatment at the contracted patient charge on a number of our plans. As an additional contract rider we can allow for supplemental transfer coverage for Orthodontia under our DHMO. Health Net Dental: Upon termination of coverage, we will pay for orthodontic cases in progress on a prorated basis up to the last effective date of coverage. Benefits are no longer payable after the member terminates and are the responsibility of the member and/or the new dental carrier. HumanaDental: HumanaDental will prorate to provide the appropriate amount given during the time the member was in the plan. Principal Financial Group: On individual terminations, most of our plans allow for extended benefits that provide one month of additional coverage. Securian Dental: Benefits are paid based on the services received while the member was covered by Securian Dental. United Concordia: The extension of orthodontic coverage for PPO plans is 60 days if payments are being made monthly. However, if payments are being made on a quarterly basis, coverage will be extended to the end of the quarter in progress or 60 days, whichever is later. Western Dental: Western Dental has designed a termination clause to protect the member. The member does not incur any additional fees for the early termination of a provider. 27. How do you handle the additional cost of OSHA required infection control in your participating offices? Aetna: These costs are a part of doing business. Aflac: Since Aflac Group Dental doesn’t have network requirements, insureds can choose any dentist without restriction. It is the responsibility of ... Continue Reading →
Fail

Insurance Insider News
Brokers Are Failing Their Clients
by Leila Morris – 8/27/14

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