Two Dental Providers Weigh In
Compiled by Thora Madden
California Broker’s annual dental survey is a little lighter than most years, probably due to insurer’s dealing with COVID-19-related issues. Nonetheless, we’ve soldiered on — and so has Blue Shield and Guardian Life.
- What types of plans do you offer?
Craig Ohlsen, Specialty Sales Manager, Employer Markets, Blue Shield of California:
Blue Shield provides a wide range of affordable and comprehensive dental products to meet our clients’ needs. Our dental PPO and HMO plans offer members a wide variety of plan designs and networks to fit their budget.
For individuals and families, we offer a unique dental PPO plan with member copayments instead of the usual coinsurance percentages. Our dental HMO plan offers comprehensive benefits with predetermined member copayments. Finally, our Duo plan offers members dental and vision coverage at a single price. Our plans can be sold with medical plans or on a stand-alone basis.
For senior members, we offer two comprehensive dental PPO plans for Medicare supplement plan members. There is also a dental plus vision plan package option for Medicare Supplement plan members.
For groups, some of our dental PPO and HMO plans are available on a contributory or voluntary basis. Most can be sold with or without Blue Shield medical plans, and they are either based on Usual, Customary, and Reasonable fees or reimbursements that are capped by the Maximum Allowable Charge.
Joe Stefano, Divisional Vice President, Western Division, The Guardian Life Insurance Company of America:
Guardian offers an array of plan types and options to meet the needs of employers and employees; and individuals and families. Employer plans can be customized according to needs and price points. Dental PPO, Managed Dental Care (Prepaid/DHMO), Indemnity, Dual and Triple Choice, Monthly Switch (between a DHMO and PPO), and Administrative Services Only Plans can be offered as voluntary, contributory, or on an employer-sponsored basis. Individuals/Families can buy a PPO plan direct from guardiandirect.com. Additionally, Guardian offers family and individual PPO and DHMO plans through its subsidiaries Premier Access and Access Dental on the Covered California exchange.
- How do plans you offer for the individual and/or small group compare in rates and benefits to the large-group plans?
Ohlsen, 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 PPO plans come in a wide range of deductibles and annual benefit maximums.
Our individual, family, and Medicare Supplement dental PPO plans may vary in waiting periods, deductibles, and annual benefit maximums based on the plan selection.
All dental plans include generous benefits, competitive premiums, and strong California and national provider networks that are available to all members. We do not differentiate our provider network for small groups or Individual and Family Plan (IFP) markets.
Stefano, Guardian:
Individuals and small group employers can choose from nearly similar plans as large groups with cost-reducing options. Individuals/Families can buy direct from guardiandirect.com or on the exchange through Covered California.
- What have been the most recent changes in your plans?
Ohlsen, Blue Shield:
We are always looking to enhance our plans and provide valuable benefits to our members.
For IFP in 2021, we are planning to offer two new, on-exchange, family dental plans, one Dental Preferred Provider Organization (DPPO) plan and one Dental Health Maintenance Organization (DHMO) plan. The plans are currently pending regulatory approval.
For members on our Blue Shield 65 Plus plan who elect to enroll in our Optional Supplemental Dental PPO plan, the waiting period for all dental procedures has now been removed from the plan.
In addition to new plan designs, all Blue Shield plans include oral cancer screening coverage as a value-added benefit, which comes at no out-of-pocket cost to the member. We also offer enhanced dental services for pregnant women with all our dental PPO plans. Pregnant women receive one additional routine adult prophylaxis, and/or one course (up to four quadrants) of periodontal scaling and root planing, and/or periodontal maintenance if warranted by a history of periodontal treatment. Treatment is payable at 100% of the allowable amount both in and out of network.
Stefano, Guardian:
Guardian constantly develops new, innovative ideas in order to meet our customers’ needs. We recently introduced in-network coverage of byte® at-home invisible aligner treatments to help members straighten their teeth without visiting a dental office.
Additionally, as the cost of college tuition continues to rise, Guardian helps our members and their families by offering the College Tuition Benefit®, a value-added benefit that helps them pay for college. Members enrolled in a Guardian plan, like dental, that includes the College Tuition Benefit® can earn 2,000 Tuition Reward® points annually, per product. Each tuition reward point equals $1 in tuition reduction; accumulated points can be used to pay up to one year’s tuition at one of more than 400 private colleges and universities across the nation.
Finally, Guardian’s Administrative Services Only (ASO) option offers the same product features, network and claims processing as fully insured. For those hesitant to move to ASO, we offer an innovative Level-Funded option that offers fixed monthly costs starting with a 105% aggregate stop loss and if claims are lower than expected, Guardian returns the entire surplus to the employer.
- Has COVID-19 changed any of your offerings or had a substantial impact on any of your plans?
Ohlsen, Blue Shield:
Teledentistry is an added option during the COVID-19 pandemic. Teledentistry codes are included in Blue Shield dental plans, and members are able to meet virtually with a dentist to discuss issues and determine whether emergency care is needed. Customer Care has been able to assist members in finding a provider who offers teledentistry if their current provider does not offer this service.
Blue Shield is allowing a $10-per-visit personal protective equipment benefit for all products, both in and out of network, to support our members as they return to the dentist.
Stefano, Guardian:
We recognize the significant impact that the pandemic has had on our customers and their employees’ ability to receive dental care. We introduced Guardian’s Pandemic Support program to help employers manage costs and continue to provide affordable, uninterrupted access to dental care. We are offering a one-month premium credit for fully insured dental plans or an extended rate guarantee. We also made plan changes including enhancing frequency limits on dental cleanings, exams, and fluoride treatments (if applicable) to a minimum of two per calendar year beginning July 1, 2020 through December 31, 2021. Enhancements to our Dental Maximum Rollover feature include removal of the paid claim requirement in order to roll over funds for 2020, and $100 will be added to each member’s Maximum Rollover Account beginning January 1, 2021.
In addition, we have provided our Employee Assistance Program (EAP), including a COVID-19 resource center, to all of our planholders and network providers to help them through the challenging time, extended our Teledentistry coverage and supported our network providers with financial support and self-service enhancements.
- Can an insured use their own dentist even if they are not on your participation list?
Ohlsen, 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 a lower out-of-pocket expense.
Stefano, 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. Managed Dental Care/DHMO members must choose a participating primary care dentist.
- How many provider locations do you have?
Ohlsen, Blue Shield:
Members have network access to over 21,415 dental HMO and 47,563 dental PPO providers in California, and more than 406,169 providers nationwide. These are two of the largest statewide provider networks in the industry.
Stefano, Guardian:
There are over 461,000 PPO access points across the country and more than 54,846 in California (Source: Network360). We are one of the largest PPO networks in the state based on dentists. The DentalGuard Alliance network tier, a smaller group of dentists offering greater discounts, has over 5,547 dentist access points in California (Source: Network360). For the DHMO, there are 15,794 general dentists and specialist access points in California (Source: Guardian Internal Reporting). Guardian’s PPO network also includes dental offices in Mexico. International Assist, a value-added service available, provides dental members with access to dental care if needed while traveling outside of the U.S.
- What percentage of your network is closed to new enrollment? How many offices does this represent?
Ohlsen, Blue Shield:
In 2019, approximately 8% of dental HMO plan network providers maintained closed practices; this represents approximately 213 offices out of 2,662 unique locations.
Stefano, Guardian:
In California, only 0.27% (997 Dentist Locations) of our PPO network and 6.11% (516 Offices) of our DHMO network are closed to new patients.
- What is the time frame for processing a referral in terms of member notification and payment to the specialist?
Ohlsen, Blue Shield:
For PPO members, specialist referrals are not required, and payments to specialists are processed in the same manner as for general dentists. For DHMO members, pre- authorizations for specialists are normally processed within five business days.
Stefano, 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.
- How do you handle early termination of coverage when a member is still in the middle of orthodontic treatment?
Ohlsen, Blue Shield: Orthodontic coverage/payments end when cancellation of coverage occurs.
Stefano, 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 prorate the benefit to cover only the 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.
- Does your plan have annual and lifetime maximums on dental coverage? If so, what are they?
Ohlsen, Blue Shield:
Our annual maximums vary from as little as $500 to as much as $5,000 or more, dependent upon individual or group coverage and group size. Employers have a choice in annual maximums, with more flexibility for large group customers to customize their annual maximum to meet their needs.
For large groups, we also offer our Rollover Rewards benefit feature, allowing qualified members to boost their annual maximum. The annual account reward will vary depending on the annual claims threshold, which is determined by the plan’s chosen annual maximum. The annual network reward for members who visit a network dentist, rather than a non-network dentist, is $100.
Stefano, Guardian:
For PPO, 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. Guardian has flexibility with maximums. Typically, Preventive, Basic and Major have a combined maximum. We offer both an annual single maximum option (range from $500 – $5,000) and an annual split maximum option (maximums differ for in-network and out-of-network services). With the Preventive Advantage option, only Basic and Major services count toward the annual maximum. Maximum Rollover allows a portion of unused annual maximums to carry over for future years. We also offer an option to cover cleaning after the maximum is reached. For orthodontia, the lifetime maximum options range from $500-$2,500. Our DHMO plans do not include an annual maximum.
- Does your plan have a deductible. If so, what is it?
Ohlsen, Blue Shield:
Deductibles can vary from as little as $0 to as much as $300 or more, dependent upon group size and individual or family coverage. Employers have a choice in deductibles, with more flexibility for large group customers to customize their annual deductible to meet their needs.
Stefano, Guardian:
Our PPO product offers many different deductible options ranging from $0-$300 and will vary by plan design with $50 historically being the most common. Deductibles are often waived for Preventive Services as Guardian’s plans are designed to encourage members to get preventive care, thereby avoiding the need for more extensive dental care in the future. All of our DHMO plan designs offered in California have no deductibles.
- What percentage of preventive costs does your plan cover?
Ohlsen, Blue Shield:
Preventive care is covered at 100% when using a network provider. Out-of-network coverage will vary based on the plan selected, but is typically not less than 80%. Members may also be balanced billed for amounts exceeding the allowable payment to non-network providers based on their plan. For large groups, there is additional flexibility to customize the percentage of costs covered.
Stefano, Guardian:
For PPO, we offer coinsurance percentages ranging from 0%-100% for preventive services. The preventive coinsurance percent for our most common PPO plan sold is 100%. Our DHMO plans offer a wide variety of covered services usually covered at 100%.
- What percentage of root canal costs does your plan cover?
Ohlsen, Blue Shield:
For large groups, root canals can be covered under basic or major services. Typically, basic services are covered at 80%, and major services are covered at 50%. Out-of- network coverage will vary based on the plan selected, but the most common percentage is 50%. For IFP, root canals are typically covered under major services at 50%. For small groups, root canals are typically covered under basic services at 80%.
Stefano, Guardian:
For PPO, we most often cover root canals as a basic service. We offer coinsurance percentages ranging from 0%-100% for basic services. The basic coinsurance percent for our most common PPO plan sold is 80%. Our DHMO plans cover many root canal procedures at various copayment levels based on plan type.
- What percentage of crown costs does your plan cover?
Ohlsen, Blue Shield:
Typically, for all lines of business, crowns are considered major services and are covered at 50%.
Stefano, Guardian:
For PPO, we most often cover crowns as a major service. We offer coinsurance percentages ranging from 0%-100% for major services. The major coinsurance percent for our most common PPO plan sold is 50%. Our DHMO plans offer a wide variety of different crown option procedures covered at various copayment levels based on plan type.
- Do you provide dentist cost and quality transparency tools?
Ohlsen, Blue Shield:
Yes. Once registered on our website, members may review their claims information and locate providers. They also have access to treatment cost information through our Treatment Cost Estimator. The Treatment Cost Estimator allows members to search for common procedures, including exams, cleanings, X-rays, fillings, and root canals. This tool is quick and easy to use, with members being able to receive an estimated cost for procedures promptly.
Stefano, Guardian:
We have a Dental Cost Estimator tool that provides an estimated range of allowable charges (fee schedule amounts) for the selected procedure codes in a selected region and provider contracted tier. Note that this is not the actual Guardian fee schedule amount for a provider nor the expected paid amount for a particular Guardian plan design. At this time, we do not offer provider quality ratings.