Dental Judgement Day – Get Help with the Tall Order of Deciding on Dental Plans with our Annual Survey!
Welcome to California Broker’s 2013 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. Read the responses and sell accordingly.
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, 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, as well as personal dental plans are also available.
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.
Cigna: DHMO, DPPO, DEPO (ASO/self-insured only), and indemnity.
Delta Dental: Managed fee-for-service, PPO, and DHMO group dental plans; individual DHMO dental plans and group HMO vision plans.
Dental Health Services: Dental Health Services provides prepaid dental benefit solutions for groups and individuals. We also offer PPO, EPO, and 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.
MetLife: Dental PPO, managed dental plans and indemnity plans, with flexible designs and funding arrangements available to accommodate employer plan requirements – single or multi options, fully insured or self-funded as well as a full range of contribution options.
Principal Financial Group: We offer 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: Aflac dental rates and benefits do not vary based on the size of the account. However, when replacing existing dental coverage in larger accounts, waiting periods may be significantly reduced.
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, 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 our dental plans, regardless of size. A children’s vision benefit is also standard on plans with orthodontic coverage. Other benefits vary by group size: Adult orthodontic benefits are available to employer-contributory plans with 25 or more enrolling. Groups with 100 or more enrolling can customize benefits. Discounts for bundling higher participation, and new voluntary cases for groups of 10 or more enrolling are also available.
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.
Cigna: 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.
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. We offer an array of cost-reducing options, such as waiting periods, deferral of services, and tie-ins to Guardian vision products. In preparation for Affordable Care Act requirements beginning January 1, 2014, we are developing new options for employers with under 50 lives to ensure they have quality benefits that are compliant with state requirements. We will also be offering 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 13 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.
MetLife: MetLife offers individual plans in Calif., Fla., and Texas though SafeGuard, a MetLife company. Dental HMO plans offered to individuals provide a mid-range level of benefits at a monthly fee that is slightly higher than rates quoted for groups. Small groups have a broad range of options within the Dental PPO and Dental HMO/Managed Care benefit plans. Rates are based on location, plan chosen and participation. Risk evaluation is taken into consideration when underwriting larger groups; individual plans are quoted using shelf rates.
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 control the risk associated with individual insurance, we utilize waiting periods for selected types of procedures. 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 employers and employees.
Ameritas: We are known for our flexibility and expertise in dental. We talk to employers all over the country for input on their needs. Our plans are updated constantly to meet those needs. We have released several industry firsts including a rollover maximum product; fully insured LASIK eye benefits; dollar reimbursement plans; combined dental/vision deductible,frequency and maximum plans; 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’ve also recently added a MAC reimbursement option. 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.
Cigna: With the additional value added features and expanded offering of covered clinical procedures, our new DHMO plans provide employers with more options than were previously available. Employers now have 100 types of plan coverage to choose from, with a spectrum of preventive coverage only plans to richer plans with surgical implant coverage, providing many choices to meet their needs.
Dental Health Services: Yes. Dental Health Services frequently evaluates its monthly premium rates and copayments for services to ensure that they 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, things like Guardian Freedom, 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 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.
MetLife: We are continually improving our program contracts, plan-design flexibility, claims-processing guidelines, customer service, and quality programs based upon clinical research, consumer-value approaches, and dental industry trends. MetLife continues to expand our product offerings and plan design flexibility in the small (<1,000 employees) market by providing customers with more choices to help them meet cost objectives without sacrificing quality.
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 rolled out a new Preventive Passport feature. This allows for preventive charges to not count/reduce 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. Aetna also added a new plan option to exclude preventive services from the calendar year maximum.
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: Individual vision, dental, dental/vision and a $5000 maximum option for dental.
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.
BEST Life: Our current dental plans offer a lot more options compared to the dental plans we’ve offered in the past. We’ve also recently added a MAC reimbursement option. All of our dental plans can be tailored to offer rich or lean benefits, depending on an employer’s needs. We continually evaluate our dental plans to ensure the competitiveness of the benefits and our underwriting guidelines.
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.
We are also introducing eight new plans for the 51 to 99 segment patterned after the eight supplemental group dental PPO plans designed by Covered California, California’s state Exchange.
Cigna: The DHMO has had several enhancements including value added features for customers, additional coverage options for employers and new types of patient charge schedules. To complement the Cigna Healthy Rewards Program, customer value added offerings include identity theft protection services and a 24/7 dental information line, staffed by health professionals to assist customers with questions relating to clinical care. In addition, the number of covered procedures available has increased and schedules can now include coverage for TMJ, prosthesis over implant procedures, teeth whitening, and athletic mouthguards. The new schedules also give employers the option to offer employees coverage for additional applications of topical fluoride and topical fluoride varnish at minimal copays, and for same-day, in-office crowns, inlays, onlays and veneers.
The DHMO Patient Charge Schedule choice has also expanded to now include over 100 different plans to choose from. New plan types include plans with lab charges listed separately from base copays, plans with customer copayments expressed as coinsurance (as compared to fixed copays), and plans with coverage for surgical implant and related procedures such as bone grafting, sinus augmentation and cone beam CT X-Rays for diagnostic procedures.
Some of the updates made to our DPPO suite of products and features include enhancing our Cigna Dental WellnessPlus features that provides incentives for our members to get regular preventive care treatment, improving our dental classification shifting process to ensure our clients have access to our unique and cost effective features to offer their employees.
Delta Dental: Delta Dental’s mobile web functionality makes it easy for enrollees to access dental information from a smartphone. The online tools used most often have been streamlined so enrollees can get the information they need faster and easier. Enrollees can log on to:
• Check benefits, eligibility, deductibles and maximums
• Search for benefits by keyword or procedure code
• Check claims status and claims history
• View ID card (pull it up at dentist’s office)
• Go paperless by opting to “Receive Statements Online” under “My Account”
• Eligibility and plan information for enrollees in DeltaCare USA can still be accessed from a smartphone, in a full site view. Our enhanced online dentist directory makes it even easier for enrollees to find a conveniently located dentist.
The Find a Dentist feature at www.deltadentalins.com now offers:
• Easier navigation and a cleaner display.
• The ability to conduct a search using key words, such as the name of a practice (as well as by the dentist’s name).
• Faster narrowing of search results by specialty, language and gender.
• Improved toggling between Delta Dental PPO, Delta Dental Premier and DeltaCare USA network results.
We continue to promote our dental wellness program for our enrollees, the SmileWay Wellness Program. SmileWay provides an array of wellness resources, including plan designs that emphasize preventive care, enhanced oral health communications and promotion of oral health through social media channels such as Facebook and Twitter. Our SmileWay Wellness Program is self-managed, enabling enrollees to determine their level of participation.It encourages users to review their habits and take our free cavity and periodontal risk quizzes, which will indicate their risk level based on oral health habits and lifestyle choices. In the risk assessment results, we encourage users to stay connected with us by signing up for customized communications based on their results. Our extensive dental health article and video library contains more than 100 articles and videos.
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. Members are still free to see out-of-network dentists. Members can easily find a dentist near them at www.GuardianAnytime.com or on their smart phones with GuardianAnytime 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 newest feature to our dental plans is the option of Preventive Passport. This feature excludes preventive services/charges from counting towards the annual maximum.
Securian Dental: Enhanced benefit plans. Escalating Annual Maximum and Lifetime Deductible options where available.
United Concordia: Along with our parent company and the University of Pennsylvania, United Concordia recently completed a study that showed treating gum disease can help reduce the cost of medical care in patients who have certain diseases or conditions.
As a result, we now offer our UCWellness Oral Health Rider, delivering enhanced coverage for members with diabetes and other diseases. By providing greater benefits for the full coverage of services, such as surgery, that eligible members may need to treat and control their gum disease, UCWellness clears away any concerns members may have on the cost of getting treatment.
UCWellness makes it easy for employees to start saving employers money. An integrated communication and registration process is easily implemented. UCWellness – My Oral Health delivers:
• Oral health education and program details for all employees
• Targeted messaging to motivate those eligible for UCWellness 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. Indemnity – Members can visit any licensed dentist.
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, both 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.
Cigna: DHMO — For DHMO, customers generally must use a dentist that participates in the plan’s network to receive coverage, except in emergencies. Once an employee is enrolled in a Cigna DHMO plan, he or she needs to select a participating general dentist. We are continuously adding more dentists to the network, so a network dentist may be available. If a network dentist is not available in a member’s area, a customer service representative will suggest the member select a participating general network dentist near his or her work. If no office is available, the customer service representative will inform the member to contact his or her plan administrator to select another dental plan option.
DPPO — There are no restrictions within the Cigna DPPO plan about the use of non-contracted dentists. Cigna DPPO members always have the choice to receive care from a network dentist at in-network levels and discounts, or from a non-network dentist at out-of-network levels.
DEPO — With the Cigna DEPO plan, members must seek care from network general dentists and specialists. Services provided by non-network dentists are not covered.
Indemnity — The Cigna Traditional indemnity plan is not a network-based plan; members may visit any licensed dentist for care at any time.
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 and EPO plans choose their dentist from our select, Quality-Assured network. Our 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.
MetLife: For Dental PPO plans, plan participants can visit any dentist and receive benefits. Participants may realize additional expense savings by receiving services from a participating dentist. For Dental HMO/Managed Care plans, members must use a participating dentist to utilize their benefits.
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 our PPO or POS design. If a member is enrolled in our EPO design, however, network dentists must be seen for services in order to receive coverage.
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 UCR, 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.
Cigna: When an out-of-network dentist’s charge substantially exceeds our maximum reimbursable charge (MRC) determination, the claim is paid/processed based upon U&C charges, following appropriate guidelines. The claim would be denied if it does not meet required criteria for the procedure; the claim processors review and deny, or provide an alternative covered service, or the procedure is not covered under the plan. If an appeal is filed, we contact the dentist during the appeal process to determine whether unusual circumstances might support the additional amount. Disputes will occur because the work was more extensive than it appears on the submitted claim. In that case, we request a written description detailing the extent of the procedure and reasons why the work involved superseded average charges. Typically, a dispute is resolved within 10 working days. The member is responsible for any charges in excess of MRC for out-of-network DPPO and indemnity claims.
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 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. A member is sent an Explanation of Benefits booklet (EOB) that provides details about charges, contracted rates, and the portion of charges that are the patient’s responsibility. If a plan member is authorized to go to a non-contracted specialist, the company pays the entire billed fee for the specialty service less the member copayment. This ensures that the plan member is only charged for what the plan has specified as their portion. Patients are also encouraged, via member communications materials, to contact Dental Health Services if they suspect any billing irregularities.
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 responsible for any charges that exceed the maximum amount that Humana will reimburse for a specific service. Members are encouraged to visit in-network providers to experience lower out-of-pocket costs.
MetLife: When receiving services from a participating Dental PPO dentist, eligible employees and dependents cannot be billed any charge in excess of our maximum allowable fee (minus any plan benefits). If the patient goes to a non-network dentist, the dentist can bill the patient for the difference between the plan benefit and the dentist’s submitted charge.
When receiving services from a participating Dental HMO/Managed Care dentist, members cannot be billed any charge in excess of the specified plan co-payments listed in the Schedule of Benefits for their plan.*
* Members are responsible for the participating dentistÌs full fee for procedures specifically excluded from coverage.
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. 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.
Cigna: Network dentists sign an agreement to provide covered services at agreed upon fees. If a misunderstanding should occur, the member is encouraged to call our toll-free number for assistance from a customer service representative. We will initiate an investigation and resolve the issue as quickly as possible.
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. A network dentist will be counseled if they balance bill a member. Failure to comply with corrective action may result in the network dentist’s file being referred to our credentialing committee for review of future participation in the network.
DEPO/DPPO — Balance billing by network dentists beyond the contract fee is not permitted for any service provided to the member.
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: 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: Participating dentists’ charts are audited on-site on an ongoing basis to ensure treatment is rendered in accordance with Dental Health Services’ 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 identify 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 adjudicates the claim based on the contracted fee schedule. Waiving co-payments does not apply under a PPO.
MetLife: For Dental PPO, our first protection for the patient against over-billing is our explanation-of-benefits, which clearly identifies the charges for services that the patient has a responsibility to pay. In addition, our customer service area is responsive to patient inquiries about questionable billing items. This area gathers information from the patient and investigates the issue fully. A response with our findings is provided to the patient. Waiver of co-payments can also be identified from calls to our customer service center and our auditing unit, which looks for atypical billing patterns.
For Dental HMO/Managed Care, the dentist’s agreement prohibits billing a member above the specified co-payment. The plan conducts a thorough orientation with each dental office. The Quality Management department reviews member complaints that relate to charges. The Office Quality Assessment reviewer notes any apparent overcharges during the patient-record audit and works with the dentist’s office to correct the issues.
Principal Financial Group: Provider utilization patterns are studied and issues are addressed as uncovered.
Securian Dental: We systematically check every submitted claim.
United Concordia: 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 6/1/13: DMO over 74,000 dentist locations nationally and 98,000 in California, PPO: over 203,000 dentist locations nationally and 26,000 in California.
Aflac: Aflac Dental does not have network requirements. Policyholders may visit any provider they choose.
Our Dental Complete network includes 16,230 unique dentists and 35,570 access points in California alone. Our Dental Prime and Dental Complete members also have seamless access to the national Dental GRID, administered by GRID Dental Corporation. One of the nation’s leading dentist networks, the Dental GRID has providers in all 50 states – with 87,000 unique dentists and 185,355 access points
Additionally, Dental Prime and Dental Complete 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.
Our Dental Net DHMO network includes more than 7,300 provider locations in California to choose from.
Ameritas: Ameritas/FDH Network: 69,675 California provider access points, (49,551 Ameritas; 20,124 FDH); 19,172 California locations, (12,391 Ameritas; 6,781 FDH)
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 58,402 access points and an additional 9,277 provider locations throughout the state of California. Our national network has over 163,000 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.
Cigna: Not Available.
Dental Health Services: As a prepaid dental plan, Dental Health Services currently has 927 general practice offices with 4,354 participating dentists and an additional 1,924 specialists.
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.
Guardian: There are over 215,846 PPO dentist-locations across the country and more than 31,959 in California. We are one of the largest PPO networks in the state based on unique dentists. The DentalGuard Alliance PPO network has over 8,094 dentist-locations in Southern California. For the DHMO, there are 13,992 locations across the country and 6,914 in California. Guardian’s PPO network now includes more than 30 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 April 2013, our California PPO network includes 36,483 access points in 10,962 locations. Our California DHMO network includes 2,020 locations.
HUMANA Dental: Nationally, Humana has more than 200,000 provider locations. In California, we have approximately 29,000 provider locations.
Principal Financial Group: We have approximately 41,400 PPO provider locations and 24,000 EPO provider locations.
Securian Dental: 163,000 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. Freedom Pre-Paid Dental is the only plan in which a member must select a specific provider.
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.
Cigna: DHMO — Members may transfer to a new dental office once a month and for any reason, as long as accounts with the current office are paid in full.
DEPO — Cigna DEPO members may seek care from any network dentist; however, we do recommend that any treatment-in-progress be completed and outstanding balances paid in full before changing dentists.
DPPO — Cigna DPPO members have the freedom to visit a network dentist or any licensed dentist at any time. However, we do recommend that any treatment-in-progress be completed and outstanding balances paid 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. Members can change their dentist at any time by contacting their Member Service Specialist. Changes made before the end of the current month take effect the 1st of the following month. Members who have selected a Western Dental dentist can change providers on a monthly basis by phone or in writing.
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. Requests made by the 20th of the month are effective the first of the following month. We also offer a dual choice monthly switch plan which enables members to switch between the DHMO and PPO as often as desired on a monthly basis.
Health Net Dental: With our PPO plan design, there is no need to select a primary care dentist or to obtain referrals for specialty care. Under our DHMO plans, members 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.
MetLife: With our Dental PPO benefit plans, there is no need to select a primary care dentist or get referrals for specialty care. For the Dental HMO/Managed Care, a member can easily change their selected dentist online or by calling customer service.
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 24/7speech 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. A dentist who has any additional questions may call Aflac’s Customer Service Center toll-free at 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 of 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.
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.
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: We regularly provide on-site training, auditing, and service visits for our participating prepaid dentists. Additionally, each office gets a comprehensive manual and we monitor all services and treatments received by our 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. We recommend that members obtain a voluntary pre-determination of benefits before proceeding with any treatment that will cost $300 or more, but we do not reduce or deny benefits if the member does not submit the treatment plan for predetermination. The member will be advised if the treatment plan includes services that are not covered under his or her plan. All offices that join 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.
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.
MetLife: For our dental PPO, MetLife has developed a multi-channel technology platform for employers, participants, and dental offices, providing access to information via Internet, fax, or phone. At the time of service, dental offices can access eligibility, plan and other information through dedicated real-time channels. Once selected to participate in MetLife’s Dental PPO network, dentists’ treatment patterns are monitored to help ensure maintenance of appropriate practice patterns and not plan design since they may not address the unique needs of individuals. If a dentist’s treatment patterns become unacceptable, the dentist is educated and monitored via MetLife claim review processes, and, if warranted, removed from the network.
If a participant should have a complaint regarding charges for services, covered or not covered by a MetLife plan, our trained customer service representatives will review the issue with the participant and generate a response and follow-up investigation, if necessary.
For the Dental HMO/Managed Care, each dental office gets a facility reference guide with a section on the plans. A provider relations representative initially conducts a thorough on-site orientation with the dental office staff to help them fully understand the plans. The representative also conducts periodic on-site visits to reinforce understanding of the plans and policies. Quality Management reviews member concerns and conducts regular chart audits. The network specialist is also required to review all member concerns and address these concerns directly with the provider, this will allow the office to be counseled on these specific issues to help prevent any future member concerns and the potential risk of the office being closed to new member enrollment.
Principal Financial Group: We provide on-line, telephone and fax service options for providers to verify benefits and eligibility. We encourage pre-determination to be performed for inlays, onlays, single crowns, prosthetics, periodontics and oral surgery.
Securian Dental: Dentists can verify benefits by calling our toll-free customer service phone number or via our Web site.
United Concordia: Dental offices can confirm benefit coverage information 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 2012, we lost 2.7% or providers in our DMO network and 1.4% 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 ˆ we have no control of this number.) However, our provider locations have actually increased a total of 3,228 locations in the past12 months. Less than 3% 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 438 access points in California in May 2013.
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.
Cigna: Not Available.
Delta Dental: Our Delta Dental Premier network increased by 13.5%; our Delta Dental PPO network increased by 18.8%; and our DHMO network increased by 9.1%. In California, there were 40 Premier terminations and 115 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: Over the past 12 months, turnover in our DHMO and PPO nationwide networks has been approximately 6.9% for DHMO and 2.6% for PPO and includes dentists who voluntarily discontinue their participation (retirement, moving from area, closing the practice) and those whose participation is ended by Guardian. We can provide names and phone numbers of terminated offices, subject to permission from the offices.
Health Net Dental: In 2012, our DHMO turnover rate for voluntary terms was 0.2% and our PPO turnover rate was 0.5%. We do not release specific information on our contracted dentists.
HumanaDental: In the past 12 months, there were 105 provider offices termed in California, including 18 due to not meeting our credentialing requirements. We do not provide the names and phone numbers of termed offices.
MetLife: For Dental PPO, our turnover rate was 1.69 % for 2011. For Dental HMO/Managed Care, 2.22% of contracted dentists in California left the network in 2011
Principal Financial Group: For our PPO network, we’ve lost 1,500 provider locations. For our EPO network, we’ve lost 1,300 provider locations.
United Concordia: In California, we grew our PPO network from 13,739 individual dentists and 28,433 access points to 15,800 dentists and 37,833 access points. In addition, our DHMO network of primary dental offices increased from 1,635 to 1,657 dentists in the last 12 months. 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.
Cigna: DHMO — Our systems include data on dentist capacity and current and projected Cigna patient 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.
DPPO/DEPO — Network dentists do not cap or close their offices. Members are not required to select a primary network dental office.
Indemnity — There is no network of dentists associated with the Cigna Traditional indemnity plan.
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; 6.3% 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 1.6% 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 enrollmen
HumanaDental: Under HumanaDental’s provider contract, participating dentists must schedule and treat members without discrimination, including benefit or payer differentials. Because this is a fee-for-service reimbursement program, closed practices are not common.
MetLife: Nationally, less than 1% of our participating Dental PPO dentists have requested that their names be removed from our provider listing for purposes of not accepting new MetLife-eligible patients. For Dental HMO/Managed Care, 4.2% of general dentist providers are closed to new enrollment in California.
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: All DMO offices accept all of our DMO coinsurance and fixed co-payment plan designs. Our PPO offices accept all of our PPO plan designs.
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 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.
BEST Life: All contracted offices accept every benefit level sold by BEST Life. 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.
Cigna: Contracted dentists do accept all benefit levels within the products that they are contracted with Cigna.
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.
MetLife: For Dental PPO, all participating dentists accept all of our plan designs. They cannot pick and choose which MetLife plans to accept. For Dental HMO/Managed Care, when contracting with a dental-care provider, it is understood that the dentist will accept all managed dental plans that are actively marketed.
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.
Cigna: DHMO — Our dentist contracts require dental offices to be open during generally acceptable hours. They also require dentists to provide or arrange for emergency care 24 hours a day, every day of the week, and to provide emergency appointments within 24 hours. We maintain dental office profiles in our system and track wait times for network general dentists through routine phone contact. We also monitor appointment availability through on-site visits and patient surveys. If wait times are longer than four weeks, we collaborate with participating dentists whenever possible to reduce appointment wait times to acceptable levels.
Cigna: DPPO/DEPO — Approximately 94.6 % of DPPO members were able to receive an appointment within four weeks. We do not set the office-hour requirements for network dentists; however, our dental office reference guide outlines expectations about the scheduling of dental appointments.
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 do not monitor appointment scheduling or wait times for the PPO plan, although every month we send 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 by mailing access monitoring forms, member satisfaction surveys, transfers, 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.
MetLife: For Dental PPO, we monitor patient impressions of wait time through monthly satisfaction surveys that specifically ask this question. For Dental HMO/Managed Care, we monitor the length of time that patients wait in the reception area and the operatory through the quarterly accessibility survey and service visit reports by provider relations representatives. In addition, we track wait times through a monthly report and member satisfaction survey.
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 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.
Cigna: DHMO — Not Available.
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.
Indemnity — The Cigna Traditional indemnity plan is not a network-based plan.
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.
MetLife: For Dental PPO, as part of MetLife’s credentialing criteria, all participating dentists must provide acceptable hours of service and have established emergency care and/or off-hour protocols. For Dental HMO/Managed Care, we contract with individual dental practitioners, many who have evening and Saturday hours.
Principal Financial Group: Members can see any provider of their choice, which can include those who have extended hours.
Securian Dental: Yes.
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.
Cigna: We evaluate the adequacy of dentist payments in a number of different ways including a chair-hour measure. We review dentist payment annually and adjust payment to achieve targeted earnings. These targets are modified each year to help keep pace with inflation. Dentists receive payment from four different sources: fixed monthly payments, office visit payments, supplemental payments, and patient copays.
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.
MetLife: For Dental HMO/Managed Care, capitation is actuarially set by plan design and that information is proprietary. Capitation is augmented by supplemental payments for certain procedures. In addition, the plan pays fees for each member visit. Dental PPO plans do not pay capitation.
Principal Financial Group: N/A
United Concordia: Specific capitation amounts are considered proprietary information.
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.
Cigna: There are no financial incentives, monetary bonuses, or withholds built into our network payment agreements.
• DHMO — There are no financial incentives or penalties related to utilization, although we may make additional payments to dentists who have experienced significant utilization during a given period of time.
• DEPO/DPPO — There is no risk sharing or risk pool. Primary care dentists and specialists are contracted on a discounted fee-for-service (FFS) schedule based on average charges in a geographic area. There are no financial incentives or penalties related to utilization.
• Indemnity — We do not contract with any dentists for the Cigna Traditional indemnity plan. Dentists collect the full fee directly from the patient or they accept assignment of fees.
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 are adequate to encourage proper care. We do not offer incentives. 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 are adequate to 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.
MetLife: For Dental PPO and HMO/Managed Care, providers are expected to perform in accordance with high standards of competence, care, and concern for the welfare and needs of participants.
Principal Financial Group: Being thorough is an expectation and we do not provide incentives to meet expectations. All providers in our networks or those we might recommend 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.
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.
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.
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: Aflac Dental 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.
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.
California Dental Network: A general dentist will determine if a member is in need of a specialty procedure that is not within his/her scope of practice. The General Dentist then submits a referral request to the Plan. The Plan Dental Director then determines if the procedure is dentally necessary.
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 specialist may submit a request for preauthorization to Cigna for oral surgery 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.
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. 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 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.
MetLife: Our Dental PPO product does not require referrals for specialist care. For Dental HMO/Managed Care, the SGX and MET series of Dental benefit plans allow participating general dentists the flexibility to refer members to participating specialists without prior approval – except for orthodontic and pedodontic specialty services in CA where the member’s selected general dentist will contact us for pre-approval.
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.
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?
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: For benefits to be payable, the specialist must be licensed by his or her state to perform the required treatment.
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
Our network dentists will be credentialed upon requesting participation in the network, and will be recredentialed no less than every thirty-six months.
Blue Shield: Yes, while this 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.
California Dental Network: Yes.
Cigna: DHMO/DEPO/DPPO — Every network specialist must certify that they have successfully completed post-graduate dental specialty programs in their fields. Our networks include specialists in periodontics, orthodontics, endodontics, pediatric dentistry, and oral surgery. 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, the majority of our 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.
MetLife: In order to participate with the Dental PPO or HMO/Managed Care, specialists must submit and keep current any certifications and/or other factors necessary to maintain their specialty.
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 Dental insurance* pays a set amount per procedure based on a table of allowances. Additionally, policyholders have the freedom to choose their own provider without precertification. *Policies may not be available in all states. Benefits are determined by state and plan level selected. Refer to the policy for complete details, limitations, and exclusions. Coverage is underwritten by American Family Life Assurance Company of Columbus. In New York, coverage is underwritten by American Family Life Assurance Company of New York
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 premium charged 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.
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.
California Dental Network: For plans that have specialty care coverage, the costs are built into the plans monthly premium rate.
Cigna: DHMO– We contract with an extensive network of specialists to ensure that our members are provided with the needed services at negotiated fee levels. Specialists are paid 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. 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. DPPO — Specialists are part of the Cigna DPPO network; members can seek care from a network or non-network specialist without a referral. Indemnity — the Cigna Traditional indemnity plan is not a network-based plan.
Delta Dental: Specialty care is built into the premium. Under the fee-for-service 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.
MetLife: For Dental PPO and HMO/Managed Care, specialists are reimbursed based on a predetermined fixed fee schedule. The SGX and MET Series of dental plans have co-payments and/or covered percentages for specialty services listed on the Schedule of Benefits for the plan.
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: For groups up to 149 employees, United Concordia actuarially create rates using client-specific demographics, including plan design, geographic location, prior carrier history, expected participation, and industry.
For groups with 150 or more employees, we use standard transfer business techniques to create group rates for new business and client-specific experience for existing business. As such, United Concordia requires claims experience when determining rates for clients with at least 150 enrolled contracts. United Concordia adjusts the prior carrier’s client-specific experience for assumed changes in-network utilization and payment levels, changes in benefits and utilization review, and projects it forward to the proposed policy period. We then add required administrative expenses and margins to create the required premium.
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-referred.
Aflac: Aflac Dental does not require referrals. Policyholders 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.
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.
Cigna: DHMO — 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 specialist may submit a request for preauthorization to Cigna for oral surgery, endodontic, and periodontal services. 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. 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.
California Dental Network: For tracking and quality review purposes the Plan prefers that the primary dentist refer through the Plan. However, members may 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.
Dental Health Services: Yes, members must get a referral from one of our network dentists 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.
MetLife: Our Dental PPO product does not require referrals for specialty or orthodontic care, so participants can self-refer. For Dental HMO/Managed Care in CA, orthodontic specialty services require pre-approval. The member’s general dentist will contact us for pre-approval, and once approved will contact the member with the name of a participating orthodontist.
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 dentist 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 Dental does not require referrals because policyholders 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.
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.
California Dental Network: Referral authorizations must be processes within 5 working days of receipt from the provider. Emergency referrals are processed immediately. Payment to the specialist is made within 30 days of receipt of a complete claim, often significantly faster.
Cigna: Not Available.
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 are 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 non-emergency 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 2012, 96% of claims were processed within 14 calendar days
MetLife: For Dental HMO/Managed Care, standard referrals are processed in an average of five business days for member notification and 14 business days for payment to the provider. Our Dental PPO product does not require referrals for specialty or orthodontic care.
Principal Financial Group: N/A
Securian Dental: No referral is required.
United Concordia: All referrals are immediately effective. 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 prioritized and processed accordingly with payment rendered during the weekly check writer 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.
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.
California Dental Network: For the DHMO, there is no annual or life time maximum for general dentistry care. Specialty care maximums vary by plan design and are separately explained in each plan’s benefit schedule. The maximum does not limit access to negotiated fees for covered services after the maximum is reached.
Cigna: For DHMO: There is no annual or lifetime maximum. For DPPO/DEPO/Dental indemnity: The maximum dollar amount refers to the maximum amount payable by Cigna for covered services rendered. Each plan design can be set-up with varying maximum dollar amounts.
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 our prepaid plan offerings have no annual dollar maximums, although this option is available by client request. PPO plan annual maximums range from $500 to $2,000.
Guardian: The maximum refers to the total of benefit dollars actually paid for 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.
MetLife: For Dental PPO, maximums affect only the total annual reimbursement amount available under a plan to an individual or family. It does not limit access to our negotiated fees for services after the maximum is exceeded.
• For Dental HMO/Managed Care, there are no calendar or lifetime maximums.
• Negotiated fees for non-covered services may not apply in all states.
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 – 1.800.99.AFLAC. Aflac Dental 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.
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 first 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.
California Dental Network: Eligibility is available to CDN providers via Member Services 5 days a week. Providers also receive a monthly eligibility roster. The plan’s Website provides 24/7 eligibility.
Cigna: Members and dental offices can call 1-800-Cigna24 for access to our automated eligibility system, which is updated daily. In addition, an eligibility list is mailed to each network general dental office monthly for the Cigna DHMO plan. If no information is available for an individual who has identified him or herself as being covered, we will instruct the member to contact his benefits office for assistance.
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 our 24-hour automated eligibility verification system or check eligibility online through our website.
Guardian: We do not provide eligibility lists for the PPO plan. 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 8:00a.m. to 5:00p.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.
MetLife: For Dental PPO and Dental HMO/Managed Care, MetLife has developed a multi-channel technology platform for customer service inquiries including Web, fax, or phone. Through dedicated, real-time* channels, dentists have access to the same plan information provided to employees at the time of service. Dental offices do have access to dedicated online and automated phone system benefit information services to verify eligibility and plan details at any time. Additionally, Dental HMO/Managed Care eligibility data is forwarded once a month to each participating dentist. Transactions are processed in real-time except when the systems are undergoing scheduled or unscheduled maintenance or interruption.
Principal Financial Group: N/A
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: Dentists receive monthly capitation (eligibility) reports to verify DHMO members’ eligibility. They can also access member 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 (800) 307-8514.
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.
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.
California Dental Network: Members losing eligibility during treatment will be charged the treating Orthodontist’s usual and customary fees for any unfinished treatment.
Cigna: 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 non-payment of premiums. Our standard 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 middle of orthodontic treatment, we encourage the member to participate in a COBRA individual plan that will allow the member to retain orthodontic benefits. If the member chooses not to maintain their 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.
MetLife: For Dental PPO and HMO/Managed Care, benefit consideration for orthodontic treatment will cease within the month that coverage terminates unless the participant obtains continuation of coverage, in which case benefits would continue as long as coverage remains in effect.
Principal Financial Group: On individual terminations, some 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 DHMO and 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 Dental does not have network requirements, policyholders can choose any dentist without restriction. It is the responsibility of the each individual dentist to meet OSHA requirements.
Ameritas: All paid procedures are based on CDT codes. Infection control is a cost that is already anticipated in the provider’s procedure fees.
Anthem Blue Cross: Our relationship with network providers is an independent contractor relationship. We are not involved with how participating dentists run their offices. We do not allow a participating network dentist to bill members or receive plan payment for infection control as those changes are not allowed to be billed separately from a contacted dentist. On our Dental HMO plans, our contracted providers cannot charge members for the additional cost of OSHA requirements. It is the responsibility of the participating offices to absorb the additional cost of these requirements.
BEN-E-LECT: This cost is maintained by each participating office. BEN-E-LECT is not responsible for the cost.
BEST Life: OSHA costs are the responsibility of the provider.
Blue Shield: There is no sterilization charge paid by the member on our dental PPO plans; any additional OSHA costs are incremental and included in the fees of the provider.
Cigna: All Network Dentists should follow Centers for Disease Control and Prevention, American Dental Association, Occupational Safety and Health Administration, and any applicable state recommendations for sterilization and/ or infection control. Cigna considers sterilization, infection control, tray/setup and the handling/disposal of biohazardous waste to be included as part of the delivery of dental services and patient care. Therefore, neither the member nor Cigna may be charged separately for these services.
Delta Dental: The cost is included in regular dental office overhead. Network dentists are not contractually allowed to charge Delta Dental or its enrollees a sterilization/infection control fee
Guardian: Most dentists have incorporated the cost of Occupational Safety and Health Administration (OSHA) requirements into the fees for services and do not charge separately. If it is the office policy to charge separately for OSHA, we do not restrict or limit the fee as long as all patients, not just the PPO patients, are charged. Since there is no CDT/ADA code for OSHA, Guardian plans do not cover such charges. Also, we do not allow participating DHMO dental offices to charge additional fees for this.
Health Net Dental: OSHA-required infection control procedures are not eligible for payment. It is industry standard to implement OSHA compliant infection control standards for all equipment, facilities and staff without a standalone fee and/or reimbursement. For those dentists who do charge a separate fee, payment is the responsibility of the patient, although a Maximum Allowable Charge (MAC) is established.
HumanaDental: Most offices have incorporated the cost of OSHA required infection control in their overall service charges. These costs would be reflected in the data used to compile fee schedules. It’s not usually a separate billable expense.
MetLife: Most dentists include these charges as part of their general overhead expenses which, in turn, are part of the fees submitted to MetLife. We use these fees as the basis for reasonable and customary data and/or for determining Dental PPO or Dental HMO/Managed Care provider fee schedules, as appropriate.
Principal Financial Group: N/A
Securian Dental: The dentist must be in compliance with OSHA required standards including:
1. Meeting OSHA guidelines for hazardous material disposal including sharps.
2. Meeting all state and local requirements for safety and health. The participating office would absorb any costs associated with fulfilling this requirement.
United Concordia: Participating dental offices include sterilization costs in their service fees. In turn, United Concordia uses these fees to determine our maximum allowable charge (MAC) and fee schedules. Through a partnership with an outside vendor, we offer participating dental offices access to discounted sterilization monitoring services.
Western Dental: Western Dental handles the additional cost of infection control in its rates and does not charge a co-payment.
28. Do you provide utilization data to your clients and brokers?
Aflac: Since Aflac products are individually issued, this is not applicable.
Ameritas: Depending on the type of plan funding, size of case and the level of information, utilization data is available in conjunction with HIPAA requirements
Anthem Blue Cross: Yes, Anthem Blue Cross provides a complete standard utilization and reporting package.
BEN-E-LECT: Yes. All data is provided at plan renewal and may be provided throughout the year by request.
Blue Shield: Yes. This is available upon request for employer groups of 300 or more employees at renewal.
BEST Life: Yes, we provide utilization information for large groups.
California Dental Network: OSHA and infection control costs are the responsibility of the providers. The Plan will not permit providers to sub charge the members for either of these costs
Cigna: Yes. Cigna offers a wide range of dental plan coverages and features that meet the needs of existing and prospective clients. Dental utilization information was integrated into the consultative analytics platform in late 2011 to enable more flexible request parameters, a consistent look and feel to medical/pharmacy/other reporting and updated norm information. We generally provide a standard package of dental information reports quarterly or annually at no additional charge. There is a charge for standard reports produced more frequently and for optional reports. Cigna dental plans are offered by Cigna Health and Life Insurance Company, Cigna HealthCare of California, Inc. or their affiliates.
Delta Dental: Delta Dental provides standard utilization reports to clients and brokers on an annual basis upon request.
Dental Health Services: Yes, Dental Health Services provides a wide range of utilization reporting, including treatment access, specialty claims activity, and member service call activity on client or broker request.
Guardian: Our standard reports are available monthly, quarterly or annually, and include the following detail: (1) dental plan summary, (2) monthly claims review, (3) cost management, (4) top 25 CDT codes by paid amount, (5) top 25 CDT codes by frequency, (6) benefits category claims comparison, (7) network overview, (8) out-of-network submitted charge comparison, and (9) claims by membership type.
Health Net Dental: Yes, we will provide utilization data upon request for large groups.
HumanaDental: Yes, on request and within the boundaries permitted by HIPAA.
MetLife: For Dental PPO and HMO/Managed Care, brokers are provided utilization data, if requested, as part of a proposal situation. Clients have online access to their utilization data or can be provided upon request.
Principal Financial Group: Yes, based upon the request of the client and/or broker.
Securian Dental: Yes, we can provide this information to individually rated employer groups upon request.
United Concordia: Yes, utilization reporting is available to clients and brokers.
Western Dental: Yes, utilization data can be provided on request to clients and brokers for large accounts.
29. Company Contact Information:
We have people available to talk with producers in a variety of locations:
We also have a general switchboard: 860-273-0123.
P.O. Box 7809
Visalia CA 93290.
5429 Avenida de los Robles, Suite A,
Visalia CA 93291
Toll Free 888-886-7973 • Fax 559-733-2325.
Blue Shield of California
Producer Services 800-559-5905
Member Services 888-800-2742
California Dental Network
23291 Mill Creek Drive, suite 101
Laguna Hills CA 92653
Fax 949-830-1655 • Toll Free: 877-4DENTAL
Northern California Sales Offices
100 First Street
San Francisco, CA 94105
Phone: 415-972-8300 Fax: 415-972-8466
11155 International Drive, M/S A2S
Rancho Cordova, CA 95670
Phone: 916-861-2409 Fax: 916-858-0327
30 East River Park Place West, Suite 410
Fresno, CA 93720
Phone: 559-433-3010 Fax: 559-433-3009
Southern California Sales Offices
17871 Park Plaza Drive, Suite 200
Cerritos, CA 90703
Phone: 562-402-4040 Fax: 562-924-3172
1450 Frazee Road, Suite 200
San Diego, CA 92108
Phone: 619-683-2549 Fax: 619-542-0269
Dental Health Services Corporate Office
Contacts: Josh Nace
3833 Atlantic Ave.
Long Beach, CA 90807
562-595-6000 Fax: 562-276-1211
The Guardian Life Insurance Company of America
Joe Stefano, Director, All of Southern/Central California, Las Vegas & Arizona
Main Phone 800-662-6464
Direct Line 949-885.1720 Fax 949-453-9919
Rick Porterfield, director, San Francisco, Sacramento & North, including Oregon/Washington
415-490-4433 • Fax 415-828-1990
David Heil, Regional director, Northern California
1255 Treat Blvd, Suite 450
Walnut Creek, CA 94597
925-658-1102 • email: firstname.lastname@example.org
Doug Gehr, Regional director, Southern California
5 Park Plaza , Suite 1900
Irvine, CA 92614
949-471-2312 • email: email@example.com