Welcome to Part I of California Broker’s 2012 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 Organization (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.
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: has the following types of dental plans available nationwide: PPO, indemnity, voluntary, non-voluntary, groups from two lives and up, individual, consumer driven and cost containment plans.
Anthem Blue Cross: Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company offer a comprehensive line-up of dental plans and products that include: PPOs and DHMOs for individuals, small groups, large groups and national accounts. We offer voluntary dental plans for small and large groups.
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 are also available.
Blue Shield: Blue Shield provides a wide range of affordable and comprehensive dental PPO, in-network only (INO) and HMO plans to meet your clients’ needs, whether they’re large or small groups or individuals and families. We offer dental PPO plans and INO plans with MAC, UCR, and fee-for-service schedules. Our group dental plans are offered on a contributory or voluntary basis and can be sold with or without Blue Shield medical plans. Individual and family plans (IFP) dental PPO and HMO plans are available to our IFP medical members as well as on a stand-alone basis for dental PPO plans. We also offer two comprehensive dental PPO plans developed specifically for Medicare Supplement plan members.
Cigna: We offer the following dental plans:
• Cigna Traditional – dental indemnity
• DHMO Standard plans and split copays for general dentists and specialists
• DHMO Value Plans – including flexible plan options with alternative treatment provisions.
• DHMO Preventive Plans
• CignaFlex Advantage (monthly switch feature between a DHMO and DPPO or Dental indemnity plans)
• Cigna Dental WellnessPlus – Progressive Maximum, Progressive Coinsurance & Progressive/Regressive Coinsurance.
• Cigna Dental Waiver Saver
• Cigna Dental ProactivePlus – Two lower cost benefit design options – Class 1 coverage only and Class 1 & 2 coverage only.
• CignaPlus Savings, a dental discount card program (not an insurance product) which helps meet the needs of employers looking to offer an extra benefit to part-time employees, seasonal employees, or retirees. This is an affordable alternative to offering traditional dental insurance that provides access to dental care services at discounted rates
• Dental Shared Administration — provides qualified funds and clients the administrative flexibility to pay their own dental claims and still take advantage of Cigna Dental DPPO negotiated discounts and utilization management tools.
All plans are available on a stand-alone basis. All plans except the discount card are also available alongside medical and/or vision plans. Cigna also has three WellnessPlus features, which can be paired with DPPO, DEPO, or dental indemnity products. Individuals who get any preventive care in one plan year qualify for increased benefits in the following plan year. All plans are available on a contributory or voluntary basis. In addition to WellnessPlus, Cigna offers Cigna Dental Waiver Saver, where customers Class 1 (preventive) services can be waived for maximums and deductibles, providing an incentive for customers to seek preventive care.
Delta Dental: Managed fee-for-service, PPO and DHMO group dental plans; individual DHMO dental plans and group HMO vision plans.
Dental Health Services: 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 in conjunction 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.
Humana: PPO, prepaid/DHMO, traditional preferred, and preventive plus plans 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 both employer paid and voluntary plans, including PPO, EPO and POS. We also offer a choice between our plans and dental HMO plans through marketing alliances.
Securian Dental: Group Dental PPO and Indemnity
United Concordia: United Concordia offers flexible fully insured PPO and DHMO 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 upon 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 non-group 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 new Dental Prime and Dental Complete plans, both small and large group 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 are available if vision and/or life coverage is sold with a BEST Life dental plan.
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 depending 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: Dental plan designs and rates for small groups are similar to those of large groups. There are a series of standard DHMO plan designs and DPPO/indemnity plan designs. Cigna offers an individual plan in the state of California, available as a buy-up option to our medical plan offering. That plan is a DPPO offering, very similar to our group plans aimed at businesses trying to control costs while offering a broad network. Larger groups generally want more robust and flexible plans, while smaller groups gravitate toward standard offerings. We can custom-fit DPPO plans to offer a variety of cost-savings options for employers that want to keep claims costs low, such as missing tooth limitations, class shifting, low maximums, varying coinsurance, deductibles, waiting periods, etc. Our DHMO plans start with basic coverage, specialty discount, split copays, and other cost savings mechanisms and go up to very rich, low-copay plans at the higher end of the cost spectrum. Through recent acquisitions, Cigna can also deliver solutions for the smaller employer segment through the Cigna Voluntary limited benefit dental plan as well as leveraging the small segment capabilities of the former Great West distribution channel. We provide the full spectrum of products, each with varying price points based on product, funding type, and voluntary vs. contributory.
Delta Dental: While benefits offered to smaller groups are comparable to those offered to larger groups, larger groups have more options in terms of plan designs. Rates can be slightly higher for smaller clients and individuals, but Delta Dental strives to be competitive while balancing our financial risk. With individual DHMO plan benefits, we offer 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.
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.
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-50 employees) have two comprehensive Health Net Plus DHMO and 13 DPPO plans from which to choose. Mid-market groups (51-250 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).
Humana: We offer flexible plan designs with a range of deductibles, co-payments, and out-of-pocket expense limits to meet the needs of small to large groups. We also offer large groups the additional flexibility to customize plan options. Customers who see dentists participating in the HumanaDental PPO Network receive deep discounts. In Calif., our negotiated discounts average 34% off billed charges. All our dental plans provide employees with incentives for preventive dental care, which promotes their overall health. A free vision discount program is included.
MetLife: MetLife offers individual plans in Calif. Fla. and Texas though SafeGuard, a MetLife company. Dental HMO plans offered to individuals provide a mid-range level of benefits at a monthly fee that is slightly higher than rates quoted for groups. Small groups 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: The only significant rating difference pertains to experience rating, which is used on groups with 150+ employees.
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 both employers and employees.
Ameritas: Ameritas is known for our flexibility and expertise in dental. We talk to employers all over the country for input on their needs. Our plans are updated constantly to meet those needs. We have released several industry firsts including a rollover maximum product; fully insured Lasik eye benefits; dollar reimbursement plans; combined dental/vision deductible, frequency and maximum plans; shared family maximum plans; $5000 maximum plans, and stand-alone hearing care benefits. Our newest individual plan release is very popular across the nation.
Anthem Blue Cross: Yes, our plans are significantly better than previous incarnations. Our new 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. 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. An oral cancer screening coverage is not only a value-added benefit, but comes at no out-of-pocket cost to the member. We offer enhanced dental services for pregnant women for all dental PPO plans. Pregnant women receive one additional routine adult prophylaxis, and/or one course (up to 4 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 both in and out of network.
Cigna: Yes, our DHMO 08 Series provides an array of plan/benefit options to respond to clients’ dental plan needs. These plans feature easy access to four cleanings per year, two at $0 copay and another two available at a minimal copay, when recommended by the network dentist; expanded fluoride treatment options; coverage for prosthesis over implant procedures and a robust variety of schedules and copay structures. We’ve also added Identity Theft resolution services and access to a Dental Information Line free of charge exclusively with this Series.
Cigna added the affordable D Series with preventive and diagnostic coverage only, which provides preventive dental services. The E Series provides coverage for the majority of restorative services in addition to preventive and diagnostic coverage. Cigna’s dental plans include several enhancements we’ve made in recent years, such as coverage for oral cancer screening procedures including brush biopsy and VizilitePlus to aid in early detection of oral cancer. In addition, we removed the age limit on sealants for DHMO plans. And on most schedules, individuals don’t need a referral for their dependent children under age seven to seek dental care from a pediatric dentist. Individuals can also visit network orthodontists without a referral.
With the Core and Radius Networks, employers have the flexibility to select the network that best meets their benefit plan goals.
Our large network of private practice dentists encourages employees to choose Cigna Dental PPO over more costly options. DPPO/DEPO Discounts — those enrolled in either the Cigna Dental PPO (DPPO) or Dental EPO (DEPO) plan — can enjoy discounts on non-covered services (in states where allowed by law). The discounts also apply to covered services when they exceed their annual maximum or other plan limitations, such as frequency, age or missing tooth. This enhancement allows individuals to enjoy lower out-of-pocket expenses because most of our DPPO network dentists have agreed to offer enrollees their negotiated contracted fees for most non-covered services (in states where allowed by law). The Dental Network Savings Program (DNSP) is a standard cost-containment feature for DPPO (except MAC and Scheduled benefit plans) and Indemnity clients. Finally, we have added both identity theft and will preparation enhancements to the CignaPlus Savings discount card (not an insurance product).
Delta Dental: Most mid- to large-range plans offered by Delta Dental are customizable within basic parameters, and we incorporate changes in treatment standards and technology as they evolve.
Dental Health Services: We offer a number of cosmetic procedures as standard benefits in our plans. In addition, monthly premium rates and co-payments for services are evaluated frequently to ensure that they are appropriate and competitive.
Guardian: The key is flexibility, especially in today’s market as employers and employees are under more pressure than ever 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, our newest plan, 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).
For new groups purchasing a dental PPO plan with coverage for orthodontia, the orthodontic lifetime maximum starts over, even for members who have previously started treatment. We do not require the prior carrier’s PPO orthodontic paid claims and there is no reduction of the member’s lifetime orthodontia maximum for treatment already in progress.
The Health Net Dental Plus DHMO plans offer more than 340 covered benefits, including oral cancer screenings, additional teeth cleanings, teeth whitening and veneers. In addition, members have access to one of the largest DHMO networks in the state.
Humana: 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.
• 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: Full mouth debridement will be covered as a major service and will be a standard on all new DMO, dental PPO and indemnity plans with effective dates of October 1, 2010 and later. This procedure is part of our Dental/Medical Integration program enhanced benefits.
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 dental, dental/eye care and a $5000 maximum option for dental.
BEST Life: Last year we expanded our in-network access by contracting with an additional national PPO network. All our dental PPO plans now offer a regional and national PPO network. Our California network is one of the largest, with 17,920 provider locations throughout the State. Our national PPO network offers 122,00 provider locations in the country. By expanding our PPO network access, BEST Life members can access their in-network benefits anywhere in the country and receive excellent in-network savings.
Anthem Blue Cross: We recently introduced 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 5 enrolled employees.
BEN-E-LECT: BEN-E-LECT has evaluated its Freedom PPO benefits portfolio and narrowed it down to four plans that have proved 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.
Blue Shield: In response to market demand, Blue Shield developed two stand-alone dental plans for the IFP market – one comprehensive Smile PPO dental plan and one affordable Value Smile PPO dental plan. Now brokers can sell Blue Shield dental coverage to individuals and families with or without Blue Shield medical coverage.
We also added a portfolio of in-network only (INO) dental plans for the small and mid-large markets. Dental INO plans have a plan structure like a dental PPO but without out-of-network coverage.
For our Medicare Supplement plan members, a third teeth cleaning per year is covered at 100% when using a network provider for dental PPO plans. Additionally, we’ve expanded our dental PPO/INO network of providers to more than 172,000 nationwide.
Cigna: In addition to our response to question number three above: We developed the Cigna Dental Oral Health Integration Program (OHIP) in 2006 to encourage members to seek appropriate treatment for gum disease as part of their overall treatment plan. This made us the first carrier in the dental insurance industry to offer enhanced coverage for members who have cardiovascular disease, diabetes or who are pregnant. This coverage includes 100% reimbursement of coinsurance or copays for certain dental procedures associated with treating gum disease. In January of 2011, we enhanced the program to include coverage for stroke, head and neck cancer radiation, chronic kidney disease, and organ transplants. We also included additional caries (tooth decay) protection procedures for conditions that may cause dry mouth.
Program participants are also eligible for the following additional coverage:
• Discounts of up to 50 % off retail prices for chlorhexidine, fluoride toothpaste, and other dental prescription plan coverage’s targeted at patients with a high risk for oral health problems through Cigna Home Delivery Pharmacy
• Discounts on non-prescription plan coverage’s targeted at this group are also available through other companies.
• Behavioral guidance on subjects such as fear of going to the dentist, tobacco cessation, and stress and its impact on oral health. Additionally, employees may access discounts of 25% to 50% off Xylitol gum through the Cigna Healthy Rewards program.
Cigna provides coverage for the oral cancer screening procedure known as a brush biopsy for members enrolled in the Cigna Dental plans.
Members will have access to our consumer-driven tool, the dental Treatment Cost Estimator (TCE). Members can also access our dental Cavity Risk Assessment tool.
Our Periodontal Risk Assessment tool allows members to assess their risk for periodontal (gum) disease in minutes by answering 20 simple questions. Cigna’s Dental Oral Cancer Awareness Quiz is a fast and easy tool that’s designed to help members test their knowledge about the basics of oral cancer and understand what they can do to help reduce their risk. To take a tour of myCigna.com, go to https://my.cigna.com. The user ID is “userdemo123” and the password is “review1” (case sensitive). Please look for the various dental presentations throughout the site, and take a look at the myCigna.com tour offered on the main page. Both assessment tools are available in English and Spanish.
Cigna also developed an Oral Cancer Awareness quiz and an online toolkit to help parents care for their children’s teeth.
Delta Dental: 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 an expanded online presence that promotes 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 and encourages users to review their habits and take our free cavity and periodontal risk quizzes that 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: Our plans provide coverage for composites on posterior teeth, re-treatment on root canals, fixed fees for precious metals and porcelain on molars, titanium crowns, teeth whitening, and other cosmetic procedures.
Guardian: Guardian constantly develops new, innovative ideas in order to meet our customers’ needs by keeping their teeth healthy and saving them money. Guardian Freedom, allows members to choose among networks.
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.
Humana: 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. 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.
• Managed Dental Products Launch in NJ & NY — MetLife recently expanded its Dental HMO/Managed Care plans into New York and New Jersey, increasing choices for lower cost and higher coverage plan designs for employers. These managed dental products offer a cost-effective solution for providing employees a valued benefit that can aid in addressing loyalty and retention goals while also addressing the oral health needs of employees and their families.
• High Annual Maximum Plans are designed to offer more benefits ($5,000 annual plan maximum) while maintaining or even lowering the plan’s premium. With MetLife’s approach to recommending appropriate, researched based plan design changes, employers can offer a high annual maximum with little to no impact to their premium
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 to determine whether dental cleanings 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 – including 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.
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.
Ameritas: Insureds can use any provider, but they may incur additional out-of-pocket expenses.
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 both 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, both PPO and IndemnityPlus plans allow members to visit any dentist of their choice and receive coverage for services.
Blue Shield: Yes, dental PPO plan members can choose to go to any dentist, although their benefits will be covered at a higher percentage when choosing a network dentist, with less out-of-pocket expense.
CIGNA: Insureds can use their own dentist in the DPPO and dental indemnity plans. However, there are no out-of-network benefits with DHMO, CignaPlus Savings dental discount plans (not insurance) or with DEPO. Individuals can nominate their dentist to join our plan and if the dentist wants to participate and meets our criteria, he/she will be credentialed and added to the network. Additionally, DPPO and DEPO plans may include savings on most non-covered services (in states where allowed by law). Most of our DPPO network dentists offer their negotiated contracted fees to customers and their covered dependents for most non-covered services (in states where allowed by law). And the savings also apply to covered services when an individual exceeds his or her annual maximum or other plan limitations, such as frequency, age or missing tooth.
Delta Dental: Delta Dental Premier enrollees can visit any licensed dentist for care, although there are advantages to visiting one of more than 43,000 access points 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 27,400 access points for Delta Dental PPO dentists in California. PPO enrollees have access to both 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 nearly 5,000 dentist facilities for DeltaCare USA in California.
Dental Health Services: Our PPO and reimbursement plans allow members to get treatment from any dentist. Members of Dental Health Services’ prepaid and EPO plans choose their dentist from our extensive network of participating dentists.
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.
Humana: PPO members can visit the dentists of their choice. Out-of-pocket savings are great when members visit participating network dentists
MetLife: For Dental PPO plans, plan participants can visit any dentist and 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 either 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 will be 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 most 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 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. 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. On a BEST Life PPO plan, members can access their in-network benefits anywhere in the country and will not be balanced billed. Those who choose to visit a non-participating dentist may be balanced billed. Our 90th percentile UCR choice is a great cost-effective option for groups that have limited network access.
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: 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 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.
For coverage we do not cover, dentists may charge their usual fees. For certain orthodontic procedures, network dentists may charge incremental costs associated with optional/elective materials, including but not limited to ceramic, clear, lingual brackets, or other cosmetic appliances.
DPPO – Balance billing beyond the contract fee is not permitted for any service provided to the member.
In the case of Cigna owned networks, balance billing for covered procedures is strictly prohibited. We will counsel network dentists who do not comply, and continued balance billing may cause the network dentist’s file to be referred to our credentialing committee for review of future participation in the network.
Cigna’s network dentists’ contracts include language to assure that members are only charged in accordance with the contracted fee schedule amounts. They are prohibited from balance billing patients. Network fee schedules apply for covered services even after members have reached their annual maximums or exceeded frequency limitations, or if missing tooth limitations or other similar limitations are imposed by the applicable dental plan. For non-covered services, members are responsible for payment of the dentist’s usual fee or contracted fee for that procedure.
For leased networks, Cigna would address any balance billing with the dentist or our affiliated network partner(s). In the case of dentist contracted with an affiliated network, the affiliated network contract would apply.
Out-of-network dentists may balance bill the difference between the DPPO plan’s payment and their usual charges.
Since out-of-network services are not covered with the DEPO plan, members are responsible for the non-network dentist’s usual fees for any treatment received out-of-network.
Indemnity — We do not prohibit balance billing for our Traditional indemnity plan coverage; dentists may balance bill the difference between the plan’s payment and their usual charges. Members pay dentists at the time services are rendered and then submit claim forms to us, or dentists submit the claim forms directly to us for payment.
Delta Dental: Contracted dentists agree not to balance bill patients for services covered under the program for which he or she 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 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, members utilizing in-network benefits on our prepaid and PPO plans are protected from paying unexpected, additional fees from their dentist.
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.
Humana: Humana pays out-of-network dentists generally at the 90th percentile of UCR.
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 dentistís 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 both member and provider. If necessary, the provider relations area helps to 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 automatically applied at the time 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: Our contract with our in-network providers stipulates that they cannot bill members for fees that exceed the negotiated rate. Any complaints from members regarding balance billing by providers are forwarded to our Provider Relations Department for review and resolution. who do not comply. Continued balance billing may be referred to our Credentialing Committee for review of future participation in the network. Cigna monitors allegations of overcharging through enrollee feedback, surveys, and the dental network management staff.
For DHMO plans, the collection of copays is between the patient and the dentist. We encourage dentists to collect copays at the time treatment is rendered. For DPPO/Indemnity plans, it is illegal in some states for dentists to routinely waive deductibles. Since our group contracts indicate that Cigna is not responsible for any charge the patient is not required to pay, we may reduce our claim payment by the copay amount waived by the dentist. Our Investigations Unit may also contact the dentist and the patient for further information and has the ability to review claims on an ongoing basis.
Delta Dental: Delta Dental Premier and PPO dentists contract with us to establish acceptable fees as well as formally agree to certain protections for Delta Dental enrollees. Protections include: no balance billing – contracted dentists cannot charge enrollees for the difference between their contracted Delta Dental fee and their submitted charge for a service; 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 get 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 both 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.
Humana: Humana’s dental PPO network is in the top 3 nationally with more than 175,000 dentist locations, and growing daily. Our dental PPO network is one of the largest in California, with more than 27,000 dentist locations. Nearly 99% of the dentists who join our network stay in our network.
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.
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 6/1/12: DMO – 11,504 dentist locations nationally and 2,841 in California, PPO: 51,022 dentist locations nationally and 9,938 in California.
Aflac: Aflac Dental does not have network requirements. Policyholders may visit any provider they choose.
Ameritas/FDH Network: 40,354 California provider access points, (25,980 Ameritas; 14,374 FDH); 16,942 California locations, (11,042 Ameritas; 5,900 FDH)
Anthem Blue Cross: Our Dental Complete network, powered by the national Dental GRID for Blue plans, includes more than 14,700 unique dentists in California alone. It is one of the largest dentist networks in the state and nationwide. Dental Complete has more than 29, 410 access points in California. Our Dental Net DHMO network includes more than 7,300 provider locations in California to choose from.
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 network. Our California network has over 22,000 access points and an additional 28,680 provider locations throughout the state of California. Our national network has 141,546 provider locations, which offers our members network access when they are outside of California.
Blue Shield: Members have network access to more than 12,000 dental HMO and almost 27,000 dental PPO providers in California, and more than 172,000 providers nationwide. These are two of the largest statewide provider networks in the industry.
Cigna: Nationally we have more than 62,742 DHMO contracted access points and more than 253,285 DPPO Radius Network contracted access points and 198,425 Core Network contracted access points. In California we have more than 16,981 DHMO contracted access points and more than 45,540 DPPO Radius Network contracted access points and 34,643 Core Network contract access points nationwide. CignaPlus Savings (dental discount card, not insurance) includes more than 121,500 of our DPPO contracted access points.
Dental Health Services: Our network of participating dentists consists of 861 general practice offices with 3,274 participating dentists, and an additional 1,826 specialists. Our PPO network carries more than 16,000 dentists.
Delta Dental: In California, Delta Dental Premier, 43,383 access points; Delta Dental PPO, 27,415 access points; and DeltaCare USA (DHMO), 4,957 facilities. We also give our enrollees access to the national Delta Dental networks.
Guardian: There are over 171,000 PPO dentist-locations across the country and more than 27,400 in California. We are one of the largest PPO networks in the state based on unique dentists. The DentalGuard Alliance PPO network has over 2,982 dentist-locations in Southern California. For the DHMO, there are 13,055 locations across the country and 6,408 in California.
Health Net Dental: As of May 2012, our California PPO network includes 31,354 access points in 375 locations. Our California DHMO network includes 9,789 locations.
Humana: Humana’s dental PPO network is in the top 3 nationally with more than 175,000 dentist locations, and growing daily. Our dental PPO network is one of the largest in California, with more than 27,000 dentist locations. Nearly 99% of the dentists who join our network stay in our network.
MetLife: As of May 2012, our Dental PPO network includes over 180,000 participating dentist access points nationwide (22% growth from 2011), including over 28,000 in California. The Dental HMO/Managed Care network includes more than 19,763 participating dentist access points in California, Florida, New Jersey, New York and Texas (34% growth from 2011), including over 8,952 in California.
Principal Financial Group: We have approximately 36,800 PPO provider locations and 17,900 EPO provider locations.
Securian Dental: 143,000 dentist access points.
United Concordia: We have 76,830 dentists at 164,011 access points nationwide in our Advantage Plus PPO network. In Calif. alone, we have 13,739 dentists at 28,433 access points. Our DHMO network includes more than 2,600 primary dental offices and 1,720 specialists nationwide, with over 1,635 primary dental offices and 799 specialists in Calif.
Western Dental: Our Provider network is unique among DMO carries because it has over 240 Western Dental Centers (staff model) in addition to more than 2, 500 provider locations.
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 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/INO plan members may change providers at any time without notice; dental PPO plan members have the flexibility to see in-network or non-network providers and dental INO members can only see network providers. Dental HMO plan members may change their primary care dentist as needed; changes will be effective the first of the following month.
Cigna: Yes. 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. Members can call our customer service department to speak with a representative, or the transfer can be processed 24 hours a day through our automated transfer option. All transfers are effective the first of the following month. We suggest that members complete any dental treatment-in-progress before transferring to another dental office.
DEPO — Cigna Dental EPO 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 Dental PPO members have the freedom to visit either 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 deltadentalins.com. Requests submitted prior to the 21st of each month are effective the first of the following month.
Dental Health Services: Members can change their dentist at any time by contacting their Member Service Specialist by calling 800-637-6453 or online at www.dentalhealthservices.com.
Guardian: Members covered under Guardian’s PPO plans can change dentists at will, regardless of whether the dentists are participating or non-participating. Members covered under our DHMO plan may change dentists by using our online 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 online Web portal. The change is effective the first of the month, provided that the request is made by the 20th of the previous month.
Humana: 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 -1-800-99-AFLAC.
Ameritas: Providers can access individual plan information using the toll-free voice response system, the fax-back system, or our online benefit Website. We hope this educates both the provider and insured 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 that 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. We also have a fax back line dentists can use to obtain benefit information.
Blue Shield: Each provider receives a provider manual upon acceptance into the plan, which outlines requirements of participation and details on plan administration. Providers may receive in-person training with their staff, if requested
Cigna: A large staff of dental network managers, based in specific field locations and in operational offices, meets continuously with dental care professionals on our administrative and quality policies. Our network teams counsel any offices found to not be in compliance and remediation plans are put into place to ensure compliance. DHMO – The Cigna Dental Care Reference Guide and Patient Charge Schedules at a Glance, and Specialty Referral Guidelines are provided to each network dental office on the plan. DEPO/DPPO – The Cigna Dental Office Reference Guide and fee schedules are provided to each network dental office on the plan. DHMO – When a dentist submits an encounter form, the information is entered and stored in our database. A statistical report is generated monthly for each network dental office. DPPO/DEPO – Cigna Dental uses its provider profiling application as part of its utilization review program. It uses claims data to generate a report showing the practice profile for a given provider that can be compared with the average practice profile of their peers.
Delta Dental: Detailed program information for all enrollees is available through a secure area of our Website and through a toll-free telephone number including maximums, deductible and benefit levels. 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. Delta Dental also issues a quarterly quality-related newsletter to participating dentists that provides useful information to help improve the quality and efficiency of the care they provide. Delta Dental also 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 using our online Web tool, GuardianAnytime.com or by phone. All PPO dentists receive information about Guardian’s plans through local network recruiters as well as mailings of pertinent information. Our claim system tracks and monitors each dentist’s practice patterns for bundling, over-utilization, etc. 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 their plan. All offices that join our DHMO network receive an orientation that fully explains the plan. Additionally, our DHMO Regional Network Managers visit the offices periodically to review the plan. Dental Offices submit encounter data of services provided to DHMO members, which is reviewed quarterly by our Quality Assurance Committee.
Health Net Dental: We educate our providers about our administrative policies, including guidelines on appropriate care. Providers are encouraged to submit pre-treatment plans for review in order to learn what procedures would be covered under the member’s benefit plan and the level of reimbursement. In the process of reviewing pre-treatment estimates and in completed claims, we track and monitor each provider’s practice patterns. Providers with aberrant patterns get a focused review, including statistical analysis and record audits, which may result in appropriate corrective action plans. Our Professional Network Relations reps meet with providers to counsel them and to answer any questions about planning care for members. Our Internet portals provide real-time information to providers and members on their benefits.
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 online, 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 Website.
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 our quarterly newsletter, 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 12 months? If asked, will you provide the names and phone numbers of at least three of these offices?
Aetna: In 2010, we lost 2.5% or providers in our DMO network and 1% in our PPO network. This is the voluntary termination rate. We are not at liberty to provide specific dentist information, such as names and phone
Aflac: Aflac Dental has no provider networks. Policyholders have the freedom to choose any dentist without restriction.
Ameritas PPO: 2,591 provider access points were lost (Ameritas = 1,578, FDH =1,013). 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% 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: Less than 3% of providers have left our PPO networks over the past 12 months. Reasons for leaving include retirement, relocation of practice, changes within group practices, and voluntary terminations. For the sake of privacy, our network does not share such information for the purpose of a general interview. Our networks also focus on growth. Our national network has added 1,594 dentists in California for the month of May.
Blue Shield: Dental PPO: For 2011, the voluntary turnover rate (excluding deaths, retirements and practice relocations) was less than 1%. Dental HMO: For 2011, the voluntary turnover rate (excluding deaths, retirements and practive relocations) was 2%.
Cigna: Cigna’s dental network turnover rates have been lower than published industry average data. Dentist and dental office information can be shared with clients and brokers if required.
Delta Dental: Our Delta Dental Premier network increased by 16%; our Delta Dental PPO network increased by 16%; and our DHMO network increased by 7.3%. Turnover rates in 2011 were: Delta Dental Premier – 5.83%; Delta Dental PPO – 5.22%; and DeltaCare USA – 1.2%. 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 both our DHMO and PPO nationwide networks has been approximately 3%, 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 2011, our DHMO turnover rate for voluntary terms is 1% and our PPO turnover rate is 1%. We do not release specific information on our contracted dentists.
Humana: 87 California dentists were termed during the past 12 months, including seven that were termed by HumanaDental due to not meeting our credentialing standards. We will not identify terminated providers.
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 2,270 provider locations. For our EPO network, we’ve lost 720 provider locations.
Securian Dental: Very few providers choose to leave the DenteMax network. Less than 3% of our network dentists discontinue participation with DenteMax every year. The majority of these terminations are due to a provider’s retirement or death or the moving or closing of a practice. We would be willing to provide names and phone numbers of terminated offices upon request.
United Concordia: In California, we grew our PPO network from 13,485 to 13,739 dentists and our DHMO network from 1,612 to 1,635 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 so 0% is closed.
Aflac: Aflac Dental has no provider networks. Policyholders may visit any dentist they choose.
Ameritas PPO: Only 34 Ameritas Offices and 6 FDH Offices are closed to new enrollment. This represents approximately 0.1%.
Anthem Blue Cross: Our Dental Prime and Dental Complete network model is open-access. 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 2011, less than 2% of dental HMO plan network providers maintained closed practices; this represents approximately 30 offices.
Cigna: DPPO network offices don’t close to new enrollment. For DHMO in California, the total number of general dentist network locations is 1,475. Of those, 1,327 are open to new enrollment.
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; 5.3% 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 .029% of our PPO network and 5.1% 1.826% of our DHMO network is closed to new patients.
Health Net Dental: As of June 2012, for DHMO, 6% (116 out of 2,025) of our unique locations are closed to new enrollment. For PPO, 3% (1,049 out of 31,582) of our dentists’ offices are closed to new enrollment.
Humana: 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 almost 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.
BEN-E-LECT: All benefit levels are accepted and to date no offices have limited or requested to limit the programs they will accept.
BEST Life: All contracted offices accept every benefit level. Furthermore, by contract, all providers will honor the PPO discounts on all procedures, including non-covered services. They must also honor a discount for members who are within a waiting period or who have exceeded their annual maximum.
Blue Shield: Offices are not allowed to pick and choose which plan designs they accept.
Cigna: All contracted DPPO offices accept all of the insured benefit DPPO plan designs that we offer. All contracted DHMO offices accept all of the DHMO plan designs that we offer. For our discount dental programs, not all DPPO contracted dentists are required to participate. They may opt out of participation in these discount dental programs if they desire.
Delta Dental: Delta Dental holds contracts with individual dentists for participation with each network (Premier, PPO and DeltaCare USA [DHMO]). Dentists can choose to participate only in those programs with copayments they wish to accept.
Dental Health Services: All new dentists are contracted for all plans offered by Dental Health Services.
Guardian: All contracted PPO and CA DHMO offices accept all of the plan designs that we offer.
Health Net Dental: All participating PPO dentists accept all of our plan designs. Contracted DHMO providers accept all Health Net Dental DHMO plans.
Humana: The PPO contract is for all network-based programs, excluding DHMO, which requires a separate agreement.
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: A semi-annual written survey is collected from all Calif. DMO general dentists
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 with 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: The dental network management team monitors wait times in our DHMO general dentist facilities via monthly telephone calls. Additionally, we are able to identify lengthy wait times through our patient satisfaction surveys.
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 get feedback on office wait times from members calling our toll-free Health Net Dental Member Services number.
Humana: We rely on member calls to keep us apprised of scheduling issues. Sometimes, the member is limiting their options (i.e., after 5:00 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 online 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 are open on Saturdays.
Cigna: DHMO: There are 2,804 network offices (24.8% of the total DHMO network) offering Saturday office hours, and 3,778 network offices (33.5% of the total DHMO network) with evening hours (6:00 p.m. or later). DPPO: Since members are able to visit any licensed dentist for care, we do not measure evening or weekend hours for network dentists. Additionally, our dentist contracts require dentists to provide or arrange for emergency care 24 hours a day, 7 days a week and to provide emergency appointments within 24 hours.
Delta Dental: Our online dentist directory contains information on hours and access, including maps, directions and languages spoken. In addition to posting hours and access, DHMO network dentists are required to provide 24-hour emergency service to enrollees seven days a week.
Guardian: Many PPO and DHMO provider locations have extended or weekend hours.
Health Net Dental: The office hours of each dentist location is listed in our online provider directory. This information is also available to all members through Health Net Dental Member Services. As part of our dentist agreement, all locations are required to have an emergency contact available for members whenever the dental office is closed.
Humana: 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.
United Concordia: Yes.
Principal Financial Group: Members can see any provider of their choice, which can include those who have extended hours.
Securian Dental: Yes.
United Concordia Dental: 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.
Anthem Blue Cross: Decline to respond
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: Network general dentists’ payment consists of the following four components: fixed monthly payments (capitation), patient charges (copays), office visit payments, and supplemental payments for certain covered procedures. Network specialists are paid based on a fixed fee schedule.
Delta Dental: Capitation rates are developed based on the plan design, annual utilization data, enrollee/dependent mix and employer contribution. Compensation is designed to reimburse approximately 60% to 65% of usual fees.
Dental Health Services: Our 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.
Humana: 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
Securian Dental: We do not offer capitation plans. We offer PPO and Indemnity plans.
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: 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, as we feel that these types of programs do not increase the quality of care.
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: Appropriate care provided by dentists in our networks is measured continuously through numerous oversight mechanisms. While routine treatment plans are carried out by dentists without prospective review, more complicated treatments are evaluated by our dental consultants. These professionals assess the proposed treatments 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. Necessary 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: Our Integrated Quality Management Program drives overall quality across our all of our dental networks. While we do not provide incentives as part of our Quality Management Program, the expectation is that the dentists in our networks meet professionally recognized standards of care. The Cigna DHMO Pay for Performance Rewards Program is a new patient-centered care model that rewards Cigna DHMO general dentists for promoting routine preventive care, patient satisfaction, and patient convenience. While some medical insurance carriers offer pay for performance-type programs to doctors, Cigna is the first to offer this type of incentive program to dentists. We piloted the program in southern California in 2011 and have seen a 5% reduction in specialty costs versus the same time in 2010.
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: Our supplemental payments and rigorous Quality Assurance Program are designed as incentives to provide appropriate and thorough care. Only caring, experienced, qualified doctors are accepted into our exclusive prepaid network. All of our dentists undergo a careful and highly selective screening process. To ensure ongoing quality, a panel of quality assurance professionals conducts regular monitoring, reviews, and audits while an extensive checklist helps to make sure that plan members get the best and safest care possible.
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.
Humana: 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.
Securian Dental: All DenteMax dentists undergo a rigorous credentialing process to ensure the highest quality dentists are treating our members.
United Concordia: Our expectation is that all services performed by participating dentists will meet the high standards of the dental industry. In addition, participating DHMO primary dentists get supplemental reimbursement on the most highly utilized procedures in addition to monthly capitation and member co-payments, which encourage dentists to provide the services necessary to ensure the oral health of members.
Western Dental: Western Dental Services Inc. may pay the dentist a bonus based on exceeding standards specified by Western Dental with regard to accessibility of services and quality of care.
18. Do you provide coverage for all types of specialist referrals?
Aflac: Aflac Dental does not require referrals.
Ameritas PPO and the FDH Networks: Yes, specialty coverage can be a part of any Ameritas plan designs. Our networks are comprised of a full-spectrum of specialists to cover the needs of our customers
Anthem Blue Cross: Yes, specialist care is available for both our Dental PPO and DHMO plans. No referrals are required on our Dental PPO plans, including Dental Prime and Dental Complete. On our DHMO plans, the member’s general dentist can refer them to a specialist when needed.
BEN-E-LECT: Specialist referrals are not necessary. Coverage is available for all types of specialty procedures including, but not limited to, endodontic, periodontic, cosmetic, orthodontics, oral surgery and pedodontics.
BEST Life: Yes, specialists are covered at full contract benefits as described in our Indemnity and PPO plan Certificates of Insurance. Our orthodontic plan is available for all of our PPO and Indemnity plans either at a deductible and lifetime maximum.
Blue Shield: Dental PPO/INO plan members may self-refer to any specialist, although INO members can only see network providers. For the dental HMO plan member there is no coverage for prosthodontic specialists.
Cigna: DHMO – Specialty referrals are not required for orthodontic treatment, if covered on their plan design or for pediatric care for children up to age seven as long as individuals visit network specialists. The network specialist may submit a request for pre-authorization to Cigna Dental for oral surgery and periodontal services. Individuals are responsible for the applicable patient charges listed on the Patient Charge Schedule for all covered procedures. After specialty treatment is complete, the individual should return to the network general dentist for care. If it is determined that a network specialist is not available, the general dentist will refer the patient to a non-network specialist and the patient will only be responsible for charges listed on the Patient Charge Schedule.
DPPO – Members may choose to seek service from any in- or out-of-network specialist or general dentist at any time. Of course, network dentists have agreed to our reduced fee schedules, which lower out-of-pocket expenses.
DEPO – Members can visit any network specialist or general dentist at any time to receive coverage.
Indemnity – 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: Our plans provide specialty coverage for endodontics, periodontics, oral surgery, pedodontics, and orthodontics.
Guardian: We provide coverage for all types of dental specialists.
Health Net Dental: 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.
Humana: 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, claims for services by licensed dental practitioners will be considered for reimbursement based on the participant’s plan design. For Dental HMO/Managed Care, the SGX and MET Series of Dental benefit plans have co-payments and/or covered percentages for endodontics, periodontics, oral surgery, pedodontics, and orthodontics services provided by a participating specialist.
Principal Financial Group: Generally yes.
Securian Dental: Our plans do not require referrals. We provide coverage based on plan benefits.
United Concordia: Our PPO plans do not require specialist referrals. Our DHMO plans require referrals for specialty coverage for endodontics, periodontics, pedodontics, oral surgery, and orthodontics. The services provided by specialists that are considered for benefit reimbursement are limited to the specifics of the dental contract for each covered member.
Western Dental: Specialty coverage is available in all of our group plans. Oral surgery, periodontics, endodontics, pedodontics, and orthodontics are covered specialties.
19. If covered, explain the process that allows the general dentist to refer to the specialist.
Aetna: For DMO plans, general practitioners can refer to a participating specialist directly based on published guidelines. DMO members have direct access to participating orthodontists and do not need a specialty referral. Indemnity and PPO plans have direct access for specialty services.
Aflac: Aflac Dental does not require referrals.
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.
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 for covered procedures. After specialty treatment is finished, the member should return to the network general dentist for care. If a network specialist is not available, the general dentist will refer the member to a non-network specialist, and the member will only be responsible for charges listed on the patient charge schedule. However, Cigna Dental Care (DHMO) network general dentists render the range of services that are required for graduation from dental school, including diagnostic treatment, preventive treatment, operative dentistry, crown and bridge, partial and complete dentures, root canal therapy, minor oral surgery, preliminary periodontal therapy, and pediatric dentistry.
DPPO: There is no need for a referral by a primary care dentist to obtain services from a specialist with the Cigna Dental PPO plan. Members may choose to seek service from any in- or out-of-network specialist or general dentist at any time. Of course, network dentists have agreed to our reduced fee schedules, which lower out-of-pocket expenses
DEPO: There is no need for a referral by a primary care dentist to obtain services from a specialist with the Cigna Dental EPO plan. Members can visit any network specialist or general dentist at any time to receive coverage.
Indemnity: Cigna Traditional indemnity members are always free to seek care from any licensed dentist at any time.
Delta Dental: Fee-for-service enrollees can self-refer; referral by the general dentist isn’t required. For DHMO enrollees, the primary care dentist is responsible for submitting the predetermination request and directing the enrollee to the appropriate specialist once authorization is received.
Dental Health Services: 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.
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?
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 included in our network. Before a specialist can join our network, we require a license to practice, DEA/CDS certificates, Education/Training including Board Certification, work history, malpractice insurance, malpractice claims history, hospital privileges, sanctions against their license, Medicare/Medicaid sanctions, and perform ongoing monitoring of sanctions or regulatory actions. All providers must go through the credentialing process every three years.
Cigna: Yes, all network dentists contracted to provide specialty care have successfully completed post-graduate dental specialty programs in their fields. Cigna’s dental networks include specialists in periodontics, orthodontics, endodontics, pediatric dentistry and oral surgery.
It is important to note that in dentistry, board certification is not the norm. As a result, we do not require this item for credentialing. We accept dentists who are recognized specialists, including those who are board certified or board eligible.
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: 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
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
Cigna: DHMO and DPPO specialists are compensated similarly through discounted fee-for-service, which is paid from a portion of the overall collected premiums.
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 co-payment paid by the enrollee.
Dental Health Services: Specialty care and treatment is 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 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: To fund specialty care, 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 200 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 to the proposed policy period. We then add required administrative expenses and margins to create the required premium.
If prior carrier experience is not available, we actuarially create rates using client-specific demographics, including plan design, geographic location, prior carrier history, expected participation, and industry.
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: The member can self-refer.
Aflac: Aflac Dental does not require referrals. Policyholders may self-refer.
BEN-E-LECT: Members may self-refer to any orthodontist they prefer. In-network versus out-of-network and plan selection will determine coverage provided.
BEST Life: No referral is necessary on our PPO or Indemnity plans.
Cigna: None of our plans require a referral for orthodontic care.
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: 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.
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.
BEN-E-LECT: Referral is not necessary. Members may call and schedule the appointment as desired.
BEST Life: No referrals are required on our Dental PPO/Indemnity plans.
Cigna: For the DHMO, typical turnaround time for specialty referrals is five days for pre-authorization and five days for payments.
Delta Dental: For fee-for-service patients, specialty care referrals are not required and payments to specialists are processed the same as for general dentists. In 2011, the average time for processing predeterminations was five days. For DHMO enrollees, preauthorizations for specialty care processed within five business days.
Dental Health Services: Emergency referrals are processed immediately. In a non-emergency situation, referrals are processed within one to two weeks. Claims are paid within two to three weeks.
Guardian: Referrals are not required under our PPO plans. For our DHMO plans, payment to the specialist is within 30 days of receipt of the claim.
Health Net Dental: The average turnaround time in processing a non-emergency referral is 48 hours and then seven to 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 seven to 10 business days for specialists to receive payment in the mail. If the 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 2008, 85% of claims and 97.4% of referrals 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 processed immediately 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.
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. BEST Life offers multiple choices of calendar year maximums for preventive, basic and major procedures
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.
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.
BEN-E-LECT: BEN-E-LECT’s Interactive Voice Response (IVR) system provides eligibility 24/7. 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 BEST Life’s 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.
Cigna: Dentists can view eligibility information in real time by visiting our secure website for health care professionals (24/7). In addition, we send eligibility information to our DHMO general dentists on a monthly basis. The general dentist can also call the plan for automated verification for an individual who is assigned to a particular office but is not on the eligibility list. This automated system will fax the dentist a written confirmation of eligibility. There is no eligibility listing given to DPPO dentists as people can seek treatment from any DPPO network dentist at any time. If a DPPO dentist wants to verify an individual’s participation in the plan, they can check the secure website or call our toll-free number.
Delta Dental: Dental offices can verify eligibility by contacting Delta Dental via our website, calling our automated information line or speaking with a customer services representative. Under the fee-for-service plans, a patient who is not shown as eligible may be asked to pay 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 get 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 8:00 a.m. to 5:00 p.m., Monday through Friday.
Health Net Dental: Our DHMO dentists receive a monthly updated eligibility list that includes member name, member status (active, dropped, suspended or transferred), member ID number, dependent names and eligibility status, fee schedule code, group number and capitation amount, if applicable. DPPO dentists do not receive an eligibility roster since 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 Website, which are accessible 24-hours a day, seven days a week. Because the IVR and Web site are available 24/7 eligibility can be verified anytime 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.
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 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 www.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) 332-0366.
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.
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.
Cigna: Coverage for a dental procedure that was started before disenrollment from the plan (crowns, root canal treatment, bridges, dentures, and partials if the teeth were fully prepared or the final impressions), will be extended for 90 days after disenrollment unless it was due to non-payment of premiums.
Coverage for orthodontic treatment which was started before disenrollment from the dental plan will be extended to the end of the quarter or for 60 days after disenrollment, unless it was due to 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.
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.
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.
Cigna: Typically, dentists include these costs into their overhead and we do not allow dentists to charge for this separately. For our DHMO plans, we pay an encounter fee to the dentist to help offset their added cost for OSHA-required infection control.
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.
BEN-E-LECT: Yes. All data is provided at plan renewal and may be provided throughout the year by request.
BEST Life: Yes, we provide utilization information for large groups
Cigna: Typically, dentists include these costs into their overhead and we do not allow dentists to charge for this separately. For our DHMO plans, we pay an encounter fee to the dentist to help offset their added cost for OSHA-required infection control.
Delta Dental: Delta Dental provides standard utilization reports to clients and brokers on an annual basis upon request.
Dental Health Services: We provide 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 infomraiton 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:
dental, vision and hearing
P.O. Box 7809, Visalia CA 93290.
5429 Avenida de los Robles, Suite A, Visalia CA 93291.
888-886-7973, fax 559-733-2325.
800-210-BEST; fax: 949-553-0883
Northern California Sales Offices
100 First Street
San Francisco CA 94105
11155 International Drive, M/S A2S
Rancho Cordova CA 95670
30 East River Park Place West, Suite 410
Fresno CA 93720
Southern California Sales Offices
17871 Park Plaza Drive, Suite 200, Cerritos CA 90703
1450 Frazee Road, Suite 200, San Diego CA 92108
The Guardian Life Insurance
Company of America
Joe Stefano, director,
All of Southern/Central California & Phoenix
800-662-646, direct line: 949-885-1720, fax 949-453-9919
Arthur Stern, regional manager,
Los Angeles District Office
800-225-3399, direct line: 310-765-2201,
fax : 310-312-3371
Gregg Holdgrafer, regional manager, San Diego District Office
Main Phone : 800-769-6759 | direct line: 619-881-3502
The Guardian (continued)
fax 1: 619-296-3912
James Hill, regional manager, San Francisco District Office
Main Phone: 800-832-9555 | direct line : 415-490-4413
fax 1: 415.788-4412
Chris Anderson, regional manager, Sacramento District Office
Main Phone : 800-438-5853
direct line : 916-403-2326
fax 1: 916-638-0288
David Heil, Regional director, Northern California
1255 Treat Blvd, Suite 450
Walnut Creek, CA 94597
Doug Gehr, Regional director, Southern California
5 Park Plaza , Suite 1900
Irvine, CA 92614
The Principal Financial Group
711 High Street, Des Moines, IA 50392
Theresa McConeghey, Assistant Vice President – Dental, Life, Vision Products
United Concordia: 1-888-884-8224
Gregg Holdgrafer, regional manager,
San Diego District Office
800-769-6759, direct line: 619-881-3502, fax: 619-296-3912
James Hill, regional manager, San Francisco District Office
800-832-9555, direct line: 415-490-4413, fax: 415-788-4412
Chris Anderson, regional manager,
Sacramento District Office, email@example.com
800-438-5853, direct line 916-403-2326, fax: 916-638-0288
David Heil, regional director, Northern California
1255 Treat Blvd, Suite 450, Walnut Creek, CA 94597
Regional director, Southern California
5 Park Plaza, Suite 1900
Irvine, CA 92614
The Principal Financial Group
711 High Street
Des Moines, IA 50392
Theresa McConeghey, assistant vice president – Dental, Life, Vision Products