Up, Up & Away With Dental Sales
Get Carried Away with Our Annual Dental Survey

Welcome to California Broker’s 2009 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:
• DMO/managed dental
• PPO and indemnity (available in multiple plan designs)
• PPO Max
• Freedom of Choice (offering members their choice of two dental plans)
• Aetna DMO Access
• Aetna Dental Care Reward
• Aetna DentalFund (our consumer-directed dental plan)
• Vital Savings by Aetna, a dental discount program.
Ameritas: 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. For large groups, we also offer EPO plans.
BEST Life: In California we offer PPO, MAC and Indemnity dental plans. We also offer employer-contributory PPO and indemnity dental plans to 2-4 groups. All our dental plans are available on a voluntary basis to groups enrolling 5+. Group term life and vision coverage is also available.
Blue Shield: Group dental HMO and PPO plans are offered on a contributory or voluntary basis. These plans can be sold as riders to health plans or on a stand-alone basis. Individual and family plans (IFP) DHMO and DPPO plans are available to our IFP medical members as riders to health plans.

CIGNA Dental: We offer the following plans:
• DPPO
• DEPO
• CIGNA traditional -- dental indemnity
• DHMO standard plans and split co-pays for general dentists and specialists
• DHMO value plans – including flexible plan options with alternative treatment provisions.
• CIGNAFlex Advantage (monthly switch feature between a DHMO and DPPO or dental indemnity plans)
• CIGNAPlus Savings, a dental discount card program (not an insurance product) that 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 modules, 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.

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 individuals and groups. We also offer PPO, EPO, and indemnity (reimbursement) products for groups and ASO for self-funded groups.

Golden West: Golden West Dental & Vision offers a comprehensive line-up of dental plans and products that include: PP0 (nationally), dual option, triple option, stand-alone and DHMO for individuals, small groups, and large groups. We offer voluntary dental plans for small and large groups.

GroupLink: Stand-alone group dental and vision plans. Indemnity PPO, voluntary, and employer paid. Self-funded administration services are also available. We also fully insured vision programs and one-life dental plans for individuals and families.

Guardian: Guardian offers active and passive PPO, network access, indemnity, and DHMO plans on a stand-alone basis or in dual choice arrangements with an option to elect Monthly Switch. In addition to the dental plans, we also offer vision products. Our plans are available to large and small groups to self-funded, employer-paid, contributory and voluntary groups, and on a stand-alone basis, subject to certain restrictions. Guardian’s flexibility allows us to customize plans based on the needs and prices points of the employer group.

Health Net Dental: Health Net Dental HMO (DHMO) plans and Dental PPO plans offer robust benefits covering most dental procedures. Dental plans may be purchased with a Health Net medical plan or on a stand-alone basis. In addition, the dental plans may be purchased as dual choice.

HumanaDental: PPO, Prepaid/DHMO, Traditional Preferred (passive PPO), and Preventive Plus plans available on a voluntary or employer-sponsored basis. Administrative Services Only plans also available.

MetLife: Dental PPO, co-pay, dental HMO 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. (Group dental insurance policies featuring the Preferred Dentist Program are underwritten by Metropolitan Life Insurance Company, New York, NY 10166. Dental HMO plans are available in Calif., Fla. and Texas only, through a domestic company in the applicable state named SafeGuard Health Plans, Inc. The SafeGuard companies are part of the MetLife family of companies. “Dental HMO” is used to refer to products that may differ by state of residence of enrollee, including but not limited to: “Specialized Health Care Service Plans” in California.)

Principal Financial Group:  We offer both employer paid and voluntary plans, including PPO, EPO and POS.  We also offer a choice between our plans and dental HMO plans through marketing alliances.

Securian Dental: Group dental PPO and Indemnity.

United Concordia: United Concordia offers flexible dental FFS, PPO, indemnity and DHMO plans, and a hybrid PPO/discount plan, Concordia Access. Fully insured and ASO funding arrangements are available based on group size. Most plans can be offered on an employer-sponsored or voluntary basis.
Western Dental offers a DHMO mixed-model provider panel comprised of contracted independent general dentists and specialists along with Western Dental’s employee dentists and specialist who work in the company-owned Western Dental Centers. Western currently operates over 220 general dentistry and orthodontic offices throughout California and Arizona.

2.) How do plans you offer for the individual and small group compare in rates and benefits to the large group plans?
Aetna: The key difference between Aetna small group plans and larger group plans is that small group plans are pre-packaged plan designs. While larger groups can select from an array of benefits, the packaged small group plans make it easy for our customers to choose from plans that are competitive in the market.

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.

BEST Life: One of our PPO/indemnity dental product lines offers customized plans and provides coverage for posterior composites to groups with 5+. Depending on the plan selected, implants are standard for groups with 10+. A dental supplemental accident benefit is standard on all our dental plans, regardless of size.

Blue Shield: Rates for our large group dental HMO and PPO plans are
typically lower than our small group and IFP plans. However, rates may vary depending on the actual plan design. We allow dental plans to be customized based on the clients’ needs for large groups of 300 or more employees.

Anthem Blue Cross: Anthem Blue Cross normally uses the same provider network for individual, small group, and large group. There are different underwriting considerations (waiting periods, for example) for the individual and voluntary group products. Our larger groups can customize benefits to meet their employees’ needs.

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 Dental does not offer plans to individuals. Larger groups generally want more robust and flexible plans while smaller groups gravitate toward standard offerings. We can custom-fit plans with DPPO to offer a variety of cost-saving options for employers that want to keep claims costs low. These options include missing tooth limitations, class shifting, low maximums, varying coinsurance, deductibles, waiting periods, etc. Our DHMO plans start with basic coverage, specialty discount, split co-pays, and other cost savings mechanisms and go up to very rich, low-co-pay plans at the higher end of the cost spectrum. Through recent acquisitions, CIGNA can also deliver solutions for the smaller employer segment through the Starbridge 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 two different programs — one for individuals and families and one customized for seniors. The individual and family plan offers a wide range of covered services. The senior plan is designed to offer services most utilized by this particular population, which enables us to keep the rates low. (Waiver of plan co-payments and deductibles is considered fraudulent and is handled by notifying the dentist of the violation and possible network termination.)

Dental Health Services: All plans and premiums are developed based on individual and group needs. Co-payments and treatment options vary by plan, from very low levels of coverage all the way up to plans that provide member care at zero out-of-pocket cost. Customized plan designs are always available.

Golden West: Our small and large group products are specific to location, size, industry and contributions. While larger groups have more flexibility in customizing benefit options than do smaller groups, Golden West still focuses on plan flexibility for all size groups. This enables employers to custom design their products for their personal needs.

GroupLink: We use a state of the art, online system for group proposals called “myGroupLink.” This is available for takeover groups from two to 99 lives. Groups of 100+ with takeover are done in house. Our rates generally are competitive with similarly designed plans from other carriers.
Guardian: We offer the same PPO provider panel to small groups as to large groups. We offer an array of cost-reducing options, such as waiting periods, deferral of services, tie-ins to Guardian vision or Guardian medical products. Rates are based on group size and participation requirements. For DHMO customers, we also offer the same DHMO provider panel to small groups as to large groups. Rates are based on group size and participation requirements. We do not offer dental coverage to individuals.

Health Net Dental: DHMO plans offered to individuals provide a comprehensive schedule of benefits at a monthly fee that is slightly higher than rates quoted for groups. Small groups have two comprehensive Health Net Plus DHMO plans from which to choose. Rates are based on location, benefit plan chosen, employer contributions and participation. Individual and small group rates are based on book rates. Risk evaluation is taken into consideration when underwriting larger groups (over 250 eligible employees).

HumanaDental: We offer flexible plan designs with a range of deductibles, co-payments, and out-of-pocket expense limits to meet the needs of small to large groups. We also offer large groups the additional flexibility to customize plan options. Customers who see dentists participating in the HumanaDental PPO Network get deep discounts. All our dental plans provide employees with incentives for preventive dental care, which promotes their overall health. A free vision discount program is included.

MetLife: MetLife offers individual plans in Calif., Fla. and Texas though SafeGuard, a MetLife company. 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 (2-50 eligible lives) have a broad range of options within the Dental PPO and Dental HMO 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.
Securian Dental: Small group rates are developed on a pooled basis. Large group rates are developed on a custom basis.

Principal Financial Group:  The only significant rating difference pertains to experience rating which is used on groups with 100+ employees.  There are also, however, a few benefit limitations on very small cases which applies to groups under 10 lives.

United Concordia: The primary factors that affect our group rates are location, experience, and credibility. While larger groups have more flexibility in customizing benefit options than smaller groups, United Concordia offers an array of standard group products and options that provide small businesses with cost effective, quality choices.

Western Dental: Western Dental Benefits Division recently launched the DHMO Series 7 dental plans. Our new plans increased the number of covered procedures and now include coverage for cosmetic procedures and implants

3.) Is your plan better than previous incarnations? If so, how?
Aetna: Preventive Care -- a low-cost dental option that covers preventive and diagnostic procedures from 70% to 100%. Members also get reduced fees from dentists who participate in Aetna’s PPO network for non-covered services like fillings, adult orthodontia, and cosmetic tooth whitening.
Aetna DMO Access -- DMO Access offers the advantages of a DMO plan, such as lower out-of-pocket expenses, compared to most traditional indemnity plans. There are no out-of-pocket deductibles for the member to pay and no claim forms to file. It also includes the Aetna Dental Access discount network, which provides access to more dentists and discounts for non-covered services like bleaching. Aetna Dental Care Reward -- By going to the dentist for preventive services in one plan year, Aetna will cover a greater percentage coinsurance and/or annual maximum the next plan year.

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; and stand-alone hearing care benefits.

Anthem Blue Cross: With the Dental Blue PPO plans from Anthem Blue Cross Life and Health Insurance Company; there is greater access to more dentists in more locations. This increases the likelihood that members will have access to their own current dentist, increasing their satisfaction with their dental plan. The three networks offer flexibility in plan options and Dental Blue specialists participate in all three networks. Additionally, members have access to our negotiated discounts on non-covered services (such as veneers, implants, TMJ, and orthodontia), negotiated discounts after the annual maximum has been reached and negotiated discounts during waiting periods (if applicable). We have eliminated waiting periods for small group dental plans. The Anthem Blue Cross large group DHMO plans – the Dental Net 2000 Series Plans – are more cost-effective and consumer-friendly, with increased flexibility and choice. The plans include enhanced benefits for services not previously offered and often not offered by other plans. Our Tonik and Enhanced Tonik individual plans, designed for younger members, offer choice and affordability with a dental plan that’s embedded within a medical product.

Blue Shield: We now offer the enhanced dental services for pregnant women to all PPO plans including our IFP PPO plan. Pregnant women get one additional routine adult prophylaxis, and/or one course (up to four quadrants) of periodontal scaling and root planning, and periodontal maintenance if warranted by a history of periodontal treatment. Treatment is payable at 100% of the allowable amount for in and up to the allowable amount out-of-network.

BEST Life: We have expanded our plan design options. A maximum allowable charge (MAC) product is available in the Calif. market. perio, endo, and oral surgery may be moved individually into basic. There are more calendar year maximums and coinsurance options – including preventive/basic only plans. Clients can now choose a lifetime deductible in place of a yearly deductible. Most of our dental plans can be built with a focus on cost-effectiveness or provide rich benefits for a company’s employees.

CIGNA Dental: Our new DHMO 07 Series feature easy access to four cleanings per year (two at $0 co-pay and another two available at a minimal co-pay when recommended by the network dentist), expanded fluoride treatment options, and a robust variety of schedules and co-pay structures. The cost effective 07 Plans are focused on affordability, preventive care, and wellness. Teeth whitening, via take-home trays with bleaching gel, is also now available on most of the 07 schedules. We’ve also added Identity theft resolution services free of charge exclusively with this Series. CIGNA Dental added the D Series with preventive and diagnostic coverage only, which provides preventive dental services and access to network discounts for services that aren’t covered under the plan. CIGNA 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. Individuals do not 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 referral. Our WellnessPlus plan feature rewards individuals for getting preventive care by increasing their benefits in the following plan year. CIGNA Dental enrollees also get access to discounts in our CIGNA Healthy Rewards program including xylitol products and health management programs.

The DPPO network gives employers more choice. With the Core and Radius Networks, members can select the network that best meets their benefit plan goals. The new, larger Dental Radius Network offers the greatest nationwide access to dental providers at all discount levels and is appropriate for employers where network size is the primary driver.

Our large network of private practice dentists encourages employees to choose CIGNA Dental PPO over more costly options. DPPO/DEPO Discounts. Those enrolled in the CIGNA Dental PPO (DPPO) or Dental EPO (DEPO) plan can enjoy discounts on non-covered services. The discounts also apply to covered services when they exceed their annual maximum or other plan limitations, such as frequency, age or missing tooth. Finally, we have added identity theft and will preparation enhancements to the CIGNAPlus Savings discount card (not an insurance product).

Dental Health Services: Our plan benefits evolve to keep pace with changes in dental technology and work to find ways to provide better dental health to our plan members. Plans include coverage for a wide range of treatment options that were not offered in the past, including many cosmetic procedures. In addition, monthly premium rates and co-payments for services are frequently evaluated to ensure that they are appropriate and competitive.

Delta Dental: Most mid-large group plans are customizable within basic parameters and we incorporate changes in treatment standards and technology as they evolve. Delta Dental’s small business plans added the D&P Maximum Waiver option to its plan selection as well as a Delta Dental PPO plus Premier plan offering lower out-of-pocket costs to enrollees visiting Delta Dental Premier dentists.

Golden West: Yes, most recently we launched our High/Low PPO and Triple Option dental plans, which allow employees to choose their own level of coverage. In addition, our low cost DHMO plans offer cosmetic and elective procedures as an option in addition to our free vision and ortho benefits for all DHMO and PPO (CA) members.

GroupLink: Our FLEXIDENT offering is the most up to date dental benefit plan on the market. We offer many benefit options and offer fully customized options for groups of 5+. We can tailor a plan to satisfy nearly any dental benefit need a broker and his customer could request.

Guardian: We constantly strive to provide more flexibility in benefit design. We can vary deductibles, annual, and lifetime maximums and service frequencies; include deferrals of services; move services or groups of service to different service categories; and many coverage options. We also offer Incentive Coinsurance, Incentive Maximum, Preventive-Only and Preventive-Plus plans, and coverage for dental implants. Plans can be tailored to meet almost any client’s requirements exactly, while providing the prompt case implementation and rapid claim processing that our systems have always provided.

Health Net Dental: The Health Net Dental Plus DHMO plans offer more than 340 covered benefits including oral cancer screening, additional teeth cleanings, teeth whitening and veneers. In addition, members have access to one of the largest DHMO networks in the state. 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.

HumanaDental: 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 product offerings and plan design flexibility in the small (<500 employee) market providing more choices to help customers meet cost objectives without sacrificing quality.

Principal Financial Group:  Our current plan offers significant flexibility in plan design, options coverage for cosmetic services, TMJ treatment, dental implant coverage, accident coverage, employee choice options and multiple price points.  Employers can design any combination of plan options to meet their needs.

Securian Dental: We have added greater flexibility.

United Concordia: We introduced more voluntary plan options and added optional coverage for posterior composite restorations and implants to groups with 10 or more enrollees. In 2009, our DHMO plan in Calif. added more than 70 procedures, now covering over 300 in total. We have also launched Preventive Incentive, which encourages members to seek preventive care by covering diagnostic and preventive services without counting them toward the member’s annual maximum. United Concordia has introduced benefit features that focus on the oral and overall health of our members in response to research that has linked dental disease to certain medical conditions such as heart disease, stroke, diabetes, pre-term births and respiratory disease. In 2008, United Concordia introduced the Smile for Health program, which includes a maternity dental benefit, providing an additional cleaning for women during pregnancy, and an enhanced dental benefit, providing coverage for certain diagnostic, preventive and periodontal services that help dentists to identify and treat chronic oral infections.

Western Dental: Our Series 7 benefit plans cover more procedures
and have a cosmetic rider.

4.) What have been the most recent changes in your plan?
Aetna: Last year, we implemented coverage for general anesthesia as standard coverage for our DMO Fixed Co-pay plans, dental PPO, and indemnity plans now cover Periapical X-rays as a Type A service. Many buy-ups are now available for these plans as well.

Ameritas: Ameritas’ rollover maximum product, Dental Rewards, continues to set sales records. SoundCare, a hearing product that can be sold stand-alone or tied to dental, is gaining popularity.

Anthem Blue Cross: We recently simplified and streamlined our small group dental plan portfolio as a result of focus group sessions and one-on-one telephone calls with brokers we conducted last year. The redesigned portfolio includes uncomplicated and straightforward plans that are easier for brokers to sell and clear-cut so clients understand. For instance, we reorganized and restructured our portfolio, which resulted in the elimination of several old plans. So now, we offer 12 plans to small groups in California. Our goal is to continue to create and offer plans that meet the needs brokers hear from their clients. We believe our new dental portfolio meets this goal.
Blue Shield: We recently reduced pricing on four of our small group dental plans. We rolled out our Suite Deal Dental package that increases the number of plans small group employers can offer from two to five.

BEST Life: We have created three new product lines, each offering dental PPO and a dental passive PPO plan that works like an indemnity plan. See #3 for more details. Additionally, we offer a secondary dental PPO network through DenteMax. This allows members who cannot access a First Dental Health provider the option to utilize in-network benefits through DenteMax.

CIGNA Dental: CIGNA Dental’s plans address emerging research on the connection between oral health and overall health. CIGNA pioneered the introduction of integrated benefits between medical and dental in 2006 with our Oral Health Integration Program, which offers enhanced dental benefits to address populations at risk, such as those with diabetes, heart disease, or those who are pregnant. In addition, CIGNA Dental plans cover oral cancer screening procedures such as brush biopsy and VizilitePlus to aid in early detection of oral cancer. In addition, we do not have an age limit on sealants for DHMO plans. Individuals do not need a referral for their dependent children under age seven to seek dental care from a pediatric dentist. They can also visit network orthodontists without referral. CIGNA offers a complete package of very competitive plan designs with one of the largest national provider networks. CIGNA Dental enhanced its dental treatment cost estimator and also introduced its Periodontal Risk Assessment Tool and Cavity Risk Assessment Tool, designed to help individuals identify factors that increase the risk of gum disease and cavities. Both assessment tools are available in English and Spanish. CIGNA also developed an online toolkit to help parents care for their children’s teeth.

Delta Dental: We have redesigned and added various self-service features to our Web site to make it a more powerful, user-friendly tool for our dentists, enrollees and group customers. A new suite of open enrollment materials were created for benefits managers to provide to their employees to make using and understanding our dental plans and enhanced Web services easier.

Dental Health Services: Our plans now feature coverage for composites on posterior teeth, re-treatment on root canals, fixed fees for precious metals and porcelain on molars, titanium crowns, teeth whitening, and other cosmetic procedures.

Golden West: Our DHMO network has increased to over 4,800 participating providers; our national PPO plan reaching over 79,000 participating providers. Our PPO plans offer industry discounts which qualifies employers up to as much as 15% discount off PPO pricing. For DHMO plans, self-referrals have been routine for our plan participants. Our Individual SmileChoice plan includes Cosmetic/Elective Benefits, Vision and Ortho coverage.

GroupLink: We are about to introduce our new dental wellness option that will allow for preventive and diagnostic services to not be counted toward the annual maximum. We also will be coming out with more competitive voluntary rating options in the next 30-60 days.

Guardian: Guardian constantly develops new, innovative ideas in order to meet our customers’ needs by keeping their teeth healthy and saving them money. We have introduced new features that encourage preventive care, allowing members get even more value from their annual maximums including Maximum Rollover and Preventive Advantage. Other PPO plan design enhancements include coverage of up to four periodontal treatments per year and covered as a preventative benefit, oral cancer screening exams, adult fluoride treatment coverage, cosmetic teeth whitening coverage and the ability for planholders to offer their employees three plan designs. Our new enhanced DHMO plans will waive copays after three years and include orthodontia in progress benefit and coverage for services such as oral cancer screenings and adult fluoride. We also introduced the Direct Referral program that gives DHMO members access to any in-network specialist without pre-authorization, providing faster, easier access to important treatment.

Health Net Dental: On January 1, 2009, Health Net selected OptumHealth Specialty Benefits to administer Health Net’s commercial DHMO and dental PPO plans. Health Net Dental DHMO plans are provided by Dental Benefit Providers of California, Inc. and Health Net Dental PPO and indemnity plans are underwritten by Unimerica Insurance Company.

HumanaDental: Plans in our new generation of products are available as voluntary plans and to groups with as few as two employees. Our new plans offer an extended maximum benefit, where members get 30% coinsurance on services rendered after they reached their annual maximum. 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.

MetLife:
• Dental HMO Offering: Customers have more choices to help balance the needs of employees with their own benefit objectives.
• Graduating Dental Benefits: Participants, including dependents, are rewarded for maintaining their dental coverage with an increasing annual maximum benefit each year upon the participant’s anniversary for up to three years. Participants must maintain enrollment (no gaps) in the plan.
• Full Service Dental for Retirees: Customers can enrich their retiree benefits programs with no benefit expense and minimal administration.
• Dental Procedure Fee Tool: The dental procedure fee tool, provided by go2dental.com, lists requested dental service or services along with their appropriate in-network (PDP fee) and out-of-network fee information. Search results are based on the requested zip code. The out-of-network fees are provided by go2dental.com Inc., an industry source independent of MetLife. (Group dental insurance policies featuring the Preferred Dentist Program are underwritten by Metropolitan Life Insurance Company, New York, NY 10166. Dental HMO plans are available in CA, FL and TX only, through a domestic company in the applicable state named SafeGuard Health Plans, Inc. The SafeGuard companies are part of the MetLife family of companies. “Dental HMO” is used to refer to “Specialized Health Care Service Plans” in California. At this time, each increment to the annual maximum can be $250 for in-network and out-of-network or $500 for in-network only. Exact timeframes are determined by the employer. The highest annual maximum level is capped at three years or $3,000.)

Principal Financial Group:  Our most recent dental plan change was to add additional benefits of fluoride for members going through cancer treatments.

Securian Dental: More flexible participation guidelines and escalating annual maximum and lifetime deductible options.

United Concordia: United Concordia is offering additional voluntary plan options and optional coverage for posterior composite restorations and implants to groups with 10 or more enrollees. Recent changes also include additional covered procedures in our CA DHMO plan, the Smile for Health program and our Preventive Incentive benefit feature.
Western Dental: We now offer seven standard plans to choose from,
with multiple network options available.

5.) Can an insured use their own dentist even if they are not on your participation list?
Aetna: DPPO -- 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. DMO – Members must seek care from a participating DMO provider.

Ameritas: Insureds can use any provider, but they may incur additional out-of-pocket expenses.

Anthem Blue Cross: 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.

BEST Life: PPO and IndemnityPlus plans allow members to visit any dentist of their choice and get coverage for services. Our members can also access the First Dental Health Network (FDH) for excellent in-network savings. If a FDH provider is not available, they can use a provider from the DenteMax network.

Blue Shield: Dental PPO plan members can.

CIGNA Dental: Insureds can use their own dentist in the DPPO and dental indemnity plans. However, there are no out-of-network benefits with DHMO, CIGNAPlus Savings dental discount plans (not insurance) or with DEPO. Individuals can nominate their dentist to join our plan; a dentist wants to participate and meets our criteria will be credentialed and join the network. Additionally, DPPO and DEPO plans include savings on most non-covered services. Our DPPO network dentists offer their negotiated contracted fees to customers and their covered dependents for most non-covered services. And the savings also apply to covered services when an individual exceeds his or her annual maximum or other plan limitations, such as frequency, age or missing tooth.

Delta Dental: Fee-for-service enrollees can visit any licensed dentist for care, although there are advantages to visiting one of nearly 22,000 Delta Dental 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. PPO patients also have freedom of choice in selecting a dentist and access to two Delta Dental dentist networks with different levels of savings. DHMO enrollees must use a participating general dentist or approved specialist, except for emergency care.
Dental Health Services: Our PPO and reimbursement plans 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.

Golden West: Members covered under our True Advantage PPO and indemnity plans can get services from a non-panel provider. Their greatest discounts will be received through accessing our panel providers under our True Advantage PPO plan.

GroupLink: All of our indemnity plans offer freedom of choice. However, our true PPO plans do have in-network versus out-of-network benefits for seeking care from a network dentist. Covered Insureds will get a higher benefit for doing so.

Guardian: Yes, members covered under our PPO plans can go to any dentist they want to use. Benefits may be paid at a lower coinsurance rate for non-participating dentists.

HumanaDental: 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 get benefits. Participants may have additional savings by getting services from a participating dentist. For Dental HMO, members must use a participating dentist to utilize their benefits.
Securian Dental: Yes.

Principal Financial Group:  Yes, insured can see any dentist even if the dentist is not on the “participation” list.

United Concordia: Our FFS and PPO plans allow insureds to visit any dentist. However, insureds’ out-of-pocket costs may be higher when visiting a non-participating dentist. 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: Network dentists are contractually prevented from balance billing above the negotiated rate. Dentists who are not in our networks may balance bill members.

Ameritas PPO and the 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. Most Ameritas PPO providers offer a discount on noncovered procedures and members are financially responsible for those charges.

Anthem Blue Cross: No, not when visiting an Anthem Blue Cross dental PPO provider. Anthem Blue Cross participating provider contracts include negotiated fee agreements that prohibit balance billing. A participating dentist may not balance-bill members for amounts that exceed the negotiated and contractually agreed on fee. Members are not responsible for amounts in excess of negotiated rates. 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.

BEST Life: When visiting an FDH provider, members will not be balanced billed for amounts that exceed their plan’s UCR. Those who choose to visit a non-participating dentist may be balanced billed. Our 90% UCR choice is a great cost-effective option for groups that have limited network access.

Blue Shield: Innetwork providers cannot bill members for fees that exceed the negotiated rate. However, out-of-network providers can bill for charges that exceed the plans’ allowed amount.

CIGNA Dental: In-network DPPO and DHMO dentists are not allowed to balance bill for covered services. The only time dentists are allowed to balance bill the patient is with the out-of-network DPPO and, of course, with the dental indemnity plans. We cannot prevent non-network dentists from balance billing.

Delta Dental: Participating dentists agree not to balance bill patients above the Delta Dental approved fee. DHMO covered procedures are co-payment based. Patients are responsible for paying for non-covered and optional services in their entirety up to the allowed amount.

Dental Health Services: Members of our prepaid and PPO plans are protected from paying unexpected, additional fees from their dentist.

Golden West: Network dentists are contractually prevented from balance billing above the negotiated rate. Non-panel dentists can balance bill a PPO or indemnity member the difference of the billed fee and the average fee charged for that particular geographic area.
GroupLink: Claims are paid on a percentage of UCR.

Health Net Dental: When getting 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.

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.
HumanaDental: A dentist participating in our PPO network cannot balance-bill patients.

MetLife: When getting 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 getting services from a participating Dental HMO dentist, members cannot be billed any charge in excess of the specified plan co-payments, listed in the Schedule of Benefits for their plan. For some SafeGuard Dental HMO plans, there is a 25% fee reduction off of a participating dentist’s customary fee for non-listed procedures. (Members are responsible for the participating dentist’s full fee for procedures specifically excluded from coverage.)

Principal Financial Group:  Dentists cannot bill over the UCR 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: Not if the dentist is part of our network. However, a dentist who is not part of our network can do so.

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 focus is to respond to the member’s concerns and follow up with the provider as necessary for resolution. If necessary, the provider-relations area helps to resolve any issues whether related to over billing, waiver of co-payments, or other issues.

Ameritas: The explanation of benefits calculates the insured’s portion of the bill automatically to prevent these kinds of problems.

Anthem Blue Cross: Anthem Blue Cross’ extensive contracts with participating Dental Blue providers address these issues to avoid over billing and co-payment waivers. The same is true for our traditional. Prudent Buyer PPO dental plans. Additionally, our quality assurance teams assess claims and providers regularly to ensure our members are getting the highest level of service and satisfaction.

BEST Life: We do this in several ways: 1) Provider network discounts are applied at the time a claim is processed; 2) Pre-determination services are available to inform members what their charges will be prior to getting service; 3) We provide easy to understand EOBs that clearly illustrate network savings when utilizing an FDH provider; 4) We have educational flyers that inform members on how their dental plan works and why they should go to a network provider.

Blue Shield: Our contract with our in-network providers stipulates that they cannot bill members for fees that exceed the negotiated rate. Any complaints from members about balance billing by providers are forwarded to our Provider Relations Department for review and resolution.

CIGNA Dental: Balance billing for covered procedures is strictly prohibited. We counsel network dentists who do not comply. Continued balance billing may be referred to our Credentialing Committee for review of future participation in the network. CIGNA Dental monitors allegations of overcharging through enrollee feedback, surveys, and the network management staff. For DHMO plans, the collection of co-payments is between the patient and the dentist. We encourage dentists to collect co-payments at the time treatment is rendered. For DPPO/Indemnity plans, it is illegal in many states for dentists to waive deductibles. Since our group contracts indicate that CIGNA Dental is not responsible for any charge the patient is not required to pay, we will reduce our claim payment by the co-payment amount waived by the dentist. Our Investigations Unit may also contact the dentist and the patient for further information. Our system also has the ability to “flag” a specific dentist’s file when there is a history of balance billing so we can investigate future claims before processing.
Delta Dental: Delta Dental dentists contract with us to establish acceptable fees and formally agree to certain protections for Delta Dental enrollees. Protections include: no balance billing; contracted dentists cannot charge enrollees for the difference between their filed (accepted) Delta Dental fee and their submitted charge for a service; they can only collect the patient portion (co-payment plus any deductible and/or amount over the annual maximum) at the time of service. They agree not to unbundle a procedure that is on file with Delta Dental as one procedure.

Dental Health Services: Participating dentists are audited on-site on an ongoing basis to ensure treatment is rendered in accordance with Dental Health Services’ policies.

Golden West: Explanation-of-benefits statements are sent to members identifying the discounts taken and the member’s responsibility. The compliance department and dental consultant monitor utilization. Additionally, a proprietary claims system identifies over-utilization trends and patterns.
Health Net Dental: Under our PPO and DHMO plans, participating dentists are contractually prohibited from balance billing a member more than the maximum allowable charge or the contracted co-payment 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 who follows the state mandates for a full investigation, including the request for patient records from the office, and a review by a dental professional. These investigations must be completed within 30 days and written communications are sent to the member and provider. If the provider still refuses to comply, our Legal Department would be contacted and steps may be taken to terminate our relationship with the provider. In these rare instances, it might become necessary for the plan to reimburse the member or provider depending on the circumstances and to ensure a positive member experience.

Guardian: Guardian’s PPO dentists are prohibited from billing members for any amount for covered charges other than the deductible or coinsurance that may apply to the discounted fee schedule amount. Explanation of benefits statements sent to members specifically identify the discounts taken and the member’s responsibility.

HumanaDental: The dentist and the patient get an explanation of benefits to ensure that the dentist does not overcharge or omit fees. The claims processing systems adjudicates the claim based on the contracted fee schedule. Waiving co-payments does not apply under a PPO.

MetLife: For Dental PPO, our first protection for the patient against over-billing is our explanation-of-benefits, which clearly identifies the charges for services that the patient has a responsibility to pay. In addition, our customer service area is responsive to patient inquiries about questionable billing items. This area gathers information from the patient and investigates the issue fully. A response with our findings is provided to the patient. Waiver of co-payments can also be identified from calls to our customer service center and our auditing unit, which looks for atypical billing patterns. For Dental HMO, 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: Members are provided with explanations of benefits that clearly describe the services received and which charges are the member’s responsibility. United Concordia’s responsive customer service representatives also assist members with questions regarding their benefits. Thousands of claims are reviewed each year to ensure the acceptability of treatment and quality of services. Advisors and consultants also review dentists’ fees and practice patterns.

Western Dental: Providers are bound by contract to accept the member’s schedule of benefits.

8.) How many provider locations do you have?
Aetna: Aetna has more than 6,382 available DMO dentist locations in California. There are more than 42,000 available DMO dentist locations and 114,000 available PPO dentist locations nationally (These numbers are as of 6/1/09). These numbers represent available practice locations.
Ameritas/FDH Network: 30,527 California provider access points. (18,344 Ameritas, 12,183 FDH); 14,237 California locations (9,070 Ameritas, 5,167 FDH)

Blue Shield: We have more than 75,000 nationwide (including 19,000 in California) dental PPO directory entries and more than 8,600 dental HMO provider directory entries in California. These are two of the largest statewide provider networks in the industry.

BEST Life: We contract with one of the largest networks in Calif. First Dental Health, which has over 12,000 participating dentists.

Anthem Blue Cross: As of 05/4/09
California Dental Blue PPO locations:
Dental Blue 100 about 17,990
Dental Blue 200 about 19,813
Dental Blue300 about 20,647
Prudent Buyer 18,497
DHMO locations: over 5,000 in California

CIGNA Dental: Nationally, we have more than 42,000 DHMO contracted access points and more than 131,000 DPPO contracted access points. In Calif., we have more than 9,200 DHMO contracted access points and more than 27,000 DPPO contracted access points. CIGNAPlus Savings (dental discount card, not insurance) has more than 78,000 contracted access points.
Delta Dental: In Calif., Delta Dental Premier dentist locations, 30,500; Delta Dental PPO dentist locations, 18,200; and DHMO facilities, 4,200.

Dental Health Services: Our network of participating dentists includes more than 2,900 prepaid dentists and more than 13,000 PPO dentists throughout California.

Golden West: Our National Wellpoint PPO Network contracts with over 79,000 providers. Our DHMO network has over 14,700 statewide participating providers.

Health Net Dental: As of April 2009, our California PPO network includes 24,045 access points in 8,574 locations. Our California DHMO network includes 2,976 locations.

GroupLink: This number is always changing as the networks continue to recruit providers and we add new states monthly. We have multiple provider network options depending on the strength and service ability within a certain area

Guardian: There are over 120,000 PPO dentist-locations across the country and more than 20,000 in California. For the DHMO, there are 8,876 locations across the country and 3,714 in California. We are the largest PPO network in the state based on unique dentists.

HumanaDental: We have more than 26,600 network dentist locations in California, and over 120,000 locations nationwide.

MetLife: As of May 2009, our Dental PPO network includes over 121,000 participating dentist locations nationwide, including over 21,000 in California. And, the Dental HMO network includes more than 11,000 participating dentist locations in California, Florida and Texas, including over 6,000 in California, over 3,700 in Florida and over 1,800 in Texas.

Principal Financial Group:  We have approximately 24,000 PPO provider locations and 12,400 EPO provider locations.

Securian Dental: 87,000 dentist access points.

United Concordia: We have more than 67,600 dentists at nearly 130,000 total locations nationwide in our Advantage Plus PPO network. In Calif. alone, we have more than 13,700 dentists at over 30,200 total locations. Our DHMO network includes more than 2,500 general dentists and 1,700 specialists nationwide, with over 1,500 general dentists and 760 specialists in California

Western Dental: We currently have over 1,000 IPA contracted offices with more than 2500 dentists. We also have over 200 Western Dental office locations that are unique to our panel, as they do not contract with any other DHMO.

9.) Can insureds change providers easily if they are unhappy?
Aetna: Members in our DPPO/indemnity plan can do so. 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.

Ameritas PPO and the FDH Networks: Insureds can choose any provider at any time for procedures.
BEST Life: Members can choose any dentist without calling BEST Life to switch providers even if they are using the First Dental Health or DenteMax networks.

Blue Shield: DHMO members can change in-network dentists on a monthly basis. Requests must be made by the 10th of the month in order to be effective the first of the following month. DPPO members can see in-network or out-of-network providers.

Anthem Blue Cross: Dental Blue PPO members can visit any licensed dentist and will normally have more cost-savings when services are completed by a Dental Blue provider. There is no gatekeeper for the dental Blue PPO dental plans. The same is true for our traditional Prudent Buyer dental PPO plans. The DHMO members can change providers once a month.

CIGNA Dental: The DPPO/DEPO/indemnity plans allow individuals to change dentists whenever they want. No call is necessary. DHMO enrollees can easily change their primary-care dentist online via myCIGNA.com – our secure Website. They can also use our automated Quick Transfer option or simply call customer service. The change is effective on the first day of the month following the date they make the change. The CIGNAFlex Advantage feature provides individuals the flexibility to switch monthly between DHMO and DPPO or indemnity plans, depending on the plan design chosen by the employer.

Delta Dental: Fee-for-service enrollees can change dentists any time without notifying us. DHMO enrollees can change their contract dentist by contacting customer service or online at www.deltadentalins.com. Requests submitted before the 20th of each month are effective the first of the following month.

Dental Health Services: Members can change their dentist any time by contacting their member service specialist by calling 800-63-SMILE or online at www.dentalhealthservices.com.

Golden West: DHMO members can change their providers once a month by calling our member services department and requesting the change. In addition, members are allowed up to three dental offices per family unit. For the PPO plan, members choose their dental office from a list of participating providers through our Website or their own (non-contract) provider.
GroupLink: They can change providers any time.

Guardian: Members covered under Guardian’s PPO plans can change dentists at will, regardless of whether the dentists are participating or non-participating. The PPO plans do not require members to select primary care dentists; they can see any dentist they wish at any time. Members covered under our DHMO plan can change dentists by simply 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 can change their primary care dentists once a month by calling Health Net Dental Member Services or via our on-line Web portal. The change is effective the first of the month, provided that the request is made by the 20th of the previous month.

HumanaDental: With the PPO plan design, the member can change dentists without notifying the dental plan.

MetLife: With our Dental PPO benefit plans, there is no need to select a primary dentist or get referrals for specialty care. For the Dental HMO, a member can easily change their selected dentist online or by calling customer service.
Securian Dental: Yes.

Principal Financial Group:  Yes.

United Concordia: Members can change PPO providers at any time without notice. The DHMO insured can change dentists by writing or calling customer service and requesting a new DHMO provider, as long as there is no existing balance due to the dentist or treatment in progress. If the request is received before the 10th of the month, the transfer to the new provider is effective on the first of the following month.

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 your plan? Do you have a way of knowing if the dentists are soliciting or recommending services that are not compensated by your plan?
Aetna: Participating dental offices get a dental office guide that includes information on plan designs, policies, and procedures. We offer a Website for dentists, which includes real-time eligibility and benefits information, a 24/7 speech recognition system called Aetna Voice Advantage, and a dentist solutions team in our dental service centers. Unusual treatment patterns may be discovered during our review of utilization reports. This usually results in an office audit that includes a review of patient files and general office practices. The results are discussed with the dentist and recommendations are made for improvement.

Ameritas: Providers can access individual plan information using the toll-free voice response system, the fax-back system, or our online benefit Website. Also, 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 Web site, through our interactive voice response system, directly from our provider relations and customer service representatives and through occasional mailings. Practice patterns of participating providers are routinely monitored and reported through monthly utilization reports and claims experience. A network representative and the dental director are contacted when suspected over- or under-utilization patterns are identified. In such cases the dentist is contacted and we discuss findings along with a plan of action to help bring the practice within the standard.

BEST Life: Dentists can 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 gets a Provider Manual upon acceptance into the plan, which outlines requirements of participation and details on plan administration. Providers can get in-person training with their staff, if requested.

CIGNA Dental: A large staff of 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.

Delta Dental: Each dentist gets a regularly updated dentist’s hand book, which explains policies, procedures and programs. Detailed program information for all enrollees is available through a secure area of the company Website and through a toll-free telephone number including deductibles, maximums and benefit levels. Delta Dental publishes a quarterly dentist newsletter and holds seminars to keep dentists up to date. 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. Each office gets a comprehensive manual, and we monitor all services and treatments got by our members through monthly utilization reports.

Golden West: Network-area managers keep panel offices appraised of plan-design enhancements. Provider guides, which are kept in the dental offices, reflect the various plan designs and co-payment schedules. The guides are updated and reviewed regularly with the dental office staff.

GroupLink: The 24-hour, seven-day a week automated-eligibility system is accessed via an 800 number. Benefit information is faxed back automatically. Quality Management reviews member concerns and conducts regular chart audits.

Guardian: All PPO dentists get 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. PPO dentists whose patterns are flagged are counseled, and if they show no improvement, they may be terminated from the network. We recommend that members obtain a voluntary pre-determination of benefits before proceeding with any treatment that will cost $300 or more, but we do not reduce or deny benefits if the member does not submit the treatment plan for predetermination. The member will be advised if the treatment plan includes services that are not covered under his or her plan. All offices that join the DHMO network get an orientation that fully explains the plan. Additionally, Regional Network Managers from our DHMO network periodically visit the offices to review the plan. Dental Offices submit encounter data of services provided to DHMO members. Our Quality Assurance Committee reviews this information quarterly.

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 focused review, including statistical analysis and record audits, which may result in appropriate corrective action plans. Our Professional Network Relations Reps meet with providers to counsel them and to answer any questions about planning care for members. Our Internet portals provide real-time information to providers and members on their benefits.

HumanaDental: We recommend to members and dentists that a pretreatment plan be submitted for approval, if services are expected to exceed $300. If a procedure were not covered under the member’s benefit plan, we would notify the dentist and member at that time. Also, the claims system would reimburse only for the covered services.

MetLife: For our Dental PPO, MetLife provides 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. Treatment patterns are monitored to help ensure maintenance of appropriate practice patterns, but not plan design as 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 has a complaint regarding charges for services, covered or not covered by a MetLife plan, customer service representatives review the issue with the participant and generate a response and follow-up investigation, if necessary. For the Dental HMO, each dental office gets a facility reference guide with a section on the plans. A provider relations representative conducts a thorough orientation with the dental office staff to help them fully understand the plans. Quality Management reviews member concerns and conducts regular chart audits.

Principal Financial Group:  We provide on-line and telephone service options for providers to verify benefits and eligibility.  We encourage pre-determination to be performed for inlays, onlays, single crowns, prosthetics, periodontics and oral surgery.

Securian Dental: Dentists can verify benefits by calling our toll-free customer service phone number or via our Web site.

United Concordia: Dental offices can confirm benefit coverage information via “My Patients’ Benefits” on our Website, our Interactive Voice Response phone system, or by speaking live 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 check benefit information on our “Dentist Reference Guide,” available on our Website. Professional relations representatives are available to provide assistance when necessary. We identify abnormal practice patterns through a comprehensive quality assurance process. United Concordia reviews of thousands of claims are reviewed each year to ensure the acceptability of treatment and quality of services. Advisors and consultants also review dentists’ fees and practice patterns.

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: 2008 annual provider turnover was 2.9%. DMO was 5%
and PPO was 2.3%.

Ameritas PPO: 1,110 provider access points were lost (FDH = 944).
Yes, we would provide names, if requested.

Blue Shield: CA DPPO: In 2008, there were 179 dentists who volun- 

tarily terminated from our network. The voluntary turnover rate (excluding deaths, retirements and practice relocations) was 1%. CA DHMO: In 2008, there were 77 dentists who voluntarily terminated from our network. The voluntary turnover rate (excluding deaths, retirements and practice relocations) was 3%.
CIGNA Dental: While NADP has not yet released their 2008 average turnover rates, our national turnover rates are lower than the most recent NADP data. Provider information can be given to customers and brokers.

Delta Dental: All of our networks increased in size in 2008: Delta Dental Premier, by 2.55%; Delta Dental PPO by 2.2%, and DeltaCare USA, our DHMO network, by more than 3.49%. Delta Dental does not release specific information on its contracted dentists. National turnover: Premier, 0.86%; PPO, 2.57%; and DeltaCare USA, 3.31%.

GroupLink: N/A. We are not a network administrator. We do offer PPO options with our plans. Information could be got from them on request.

Dental Health Services: Although roughly 5% of participating dentists have been lost over the past 12 months, our overall network size has made up for this loss, and has increased in size by an additional 5% over the previous year. The names and phone numbers of all offices are available on request.

Golden West: The DHMO panel-retention rate average is 93%, including dental offices that have closed their practices. Golden West does not make it a practice to provide names and phone numbers of dental offices that have left the network.

Guardian: Over the past 12 months, turnover in both our DHMO and PPO nationwide network has been approximately 6%, terminating for voluntary (retirement, moving from area, closing the practice) and involuntary (terminated by network) reasons. We provide names and phone numbers of terminated offices, subject to permission from the offices. Over the past 12 months, turnover for the DHMO has been approximately 6%.

Health Net Dental: In 2008, our DHMO turnover rate for voluntary terms was 3% and our PPO turnover rate was 1% . We do not release specific information on our contracted dentists.
HumanaDental: 87 California dentists were termed during the past 12 months, including 7 that were termed by HumanaDental due to not meeting our credentialing standards. No, we will not identify terminated providers.

MetLife: For Dental PPO, our turnover rate was 1% for 2008. In California, the 2008 network turnover rate was 1%. For Dental HMO, less than 2% of contracted general dentists in California left the network in 2008.

MWG Dental Plans: The network saw a reduction in specific providers of less than .5%. This is mainly due to retiring dentists, passing away or no longer participating with managed care providers.

Principal Financial Group:  For our PPO network, we’ve lost 830 providers.  For our EPO network, we’ve lost 700 providers.

Principal Financial Group: For our PPO network, we’ve lost 830 providers. For our EPO network, we’ve lost 700 providers.

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 retained 98% of the dentists in our PPO network and more than 93% of the dentists in our DHMO network in the last 12 months.

12. What percentage of your network is closed to new enrollment? How many offices does this represent?

Aetna: For California, it is around 4%. Participating PPO dentists contractually cannot close their offices to new patients.

Ameritas PPO: Only 14 Offices (<1% of the network) are closed to new enrollment.

Anthem Blue Cross: All of our dental PPO providers are currently ac-
cepting new patients.

Blue Shield: In 2007, 2% of our DPPO network providers maintain closed practices.
CIGNA Dental: DPPO network offices do not close to new enrollment. For DHMO in California, the total number of general dentist network locations is 1,504. Of those, 1,342 are open to new enrollment.

Delta Dental: Our fee-for-service dentists do not close to new enrollment. Seven percent of DHMO dental offices are closed to new enrollment.

GroupLink: N/A, see response to Question 11.
Dental Health Services: About 5% of network dentists are closed to new enrollment.
Golden West: All of our PPO providers are accepting new patients. The DHMO providers listed on our website indicate their availability for a selected plan. The system is updated on an ongoing basis to ensure accuracy.

Guardian: In California, 10 of our 27,000+ locations of participating dentist offices are closed to new PPO patients, which represents 0.04% of our network. Nationally, 409 locations are closed to new PPO patients, representing 0.04% of our network. For the DHMO, 2% of our participating dentist offices are closed to new enrollment.
Health Net Dental: For DHMO, currently 2% (66 out of 2,976) of our offices are closed to new enrollment. For PPO, currently 1% (128 out of 8,574) of our dentists’ offices are closed to new enrollment.

HumanaDental: Under HumanaDental’s provider contract, participating dentists must schedule and treat members without discrimination, including benefit or payer differentials. Because this is a fee-for-service reimbursement program, closed practices are not common.
MetLife: Nationally, less than 1% of our participating Dental PPO dentists have requested that their names be removed from our provider listing for purposes of not accepting new MetLife-eligible patients. For Dental HMO, less than 5% of general dentist offices are closed to new enrollment in California.

MWG Dental Plans: Our network is an Open Access PPO, which is not closed to new enrollment.
Principal Financial Group: Less than 1% of the offices participating
in our network are “closed” to new enrollment.


Securian Dental: All of our network dentists are open to new enrollment.
United Concordia: In California, more than 99% of our PPO dentist network is open to new enrollment, as well as more than 98% 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 coinsurance and fixed copayment plan designs. In addition, all our PPO offices accept the negotiated charge from Aetna and the patient.

Ameritas: All providers accept patients from all plans sold through Ameritas Group Dental.
Anthem Blue Cross: Anthem Blue Cross recommends all Dental Blue providers accept all plans offered. The same is true for our traditional Prudent Buyer PPO and DHMO dental plans.

Blue Shield: Offices are not allowed to “pick and choose” which
plan designs they accept.

CIGNA Dental: 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 providers 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. Dentists can choose to participate only in programs with co-payments they want to accept.

Dental Health Services: All new dentists are contracted for all plans offered by Dental Health Services.

Golden West: Most of our DHMO panel offices accept all of our plans. However, they can choose specific plans in which to participate.

Golden West: Golden West encourages all providers to accept all plans offered. The DHMO providers listed on our website indicate the plan selected by each participating provider and is updated regularly.

GroupLink: Our leased networks would track this.
Guardian: All contracted PPO offices accept all of the plan designs that we offer. All contracted CA DHMO offices accept all of the plan designs that we offer.

Health Net Dental: All participating PPO dentists accept all of our plan designs. Contracted DHMO providers accept all Health Net Dental DHMO plans.
HumanaDental: The PPO contract is for all network-based programs, excluding DHMO, which requires a separate agreement.

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, when contracting with a dental-care provider, it is understood that the dentist will accept all Dental HMO plans. A few contracted dentists do not participate in some of the older custom plans.
MWG Dental Plans: Yes, all of our contracted offices accept every benefit level sold by our company.

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 CA DMO GP’s and specialists.

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, such issues as wait times are logged and monitored. Additionally, we monitor appointment wait times and emergency wait times through surveys conducted by our organization.

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 Dental: The 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 each quarter, which include questions about the enrollee’s waiting time to schedule dentist appointments and other customer satisfaction issues. The appointment availability at DHMO offices 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 and regular on-site dental office visits.

Golden West: Golden West monitors this as a metric in our member satisfaction surveys. Our complaint/grievance tracking process reviews issues such as wait times which are logged and monitored. We continue to monitor appointment wait times and emergency wait times through surveys conducted by our organization.

GroupLink: Our leased networks would track it.

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 access quarterly mailing access monitoring forms, member satisfaction surveys, transfers, and grievance data. Telephone calls are utilized on an “as needed” basis.

Health Net Dental: We monitor individual wait times in the dentist’s waiting room through our member satisfaction surveys and provider access surveys. Results of these surveys are a critical tool in assessing a member’s experience with network dentists and their specific offices. In addition, we receive feedback on office wait times from members calling our toll-free Health Net Dental Member Services number. Reports of dissatisfaction with office wait times are investigated by Quality Management. We also monitor feedback about specific dental offices received by customer service. We continually track lengthy dentist wait times, allowing us to identify problems and correct them.

HumanaDental: We rely on member calls to keep us apprised of scheduling issues. Sometimes, the member is limiting his/her options (i.e., after 5 p.m.), which is discovered through discussion with our customer-relations representatives. If the issue becomes chronic, the information is forwarded to our National Dental Network department because additional providers may be needed in the area.

MetLife: For Dental PPO, we monitor patient impressions of “wait time” through monthly satisfaction surveys that specifically ask this question. For Dental HMO, SafeGuard, a MetLife company, monitors 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.

MWG Dental Plans: Yes in 3 ways:
1. Random calls by Professional Relations Dept to Office Managers
2. Members calling into customer service with complaints
3. Annual Member Satisfaction Surveys.

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 on site reviews, surveys, and questionnaires. In addition, our staff model offices utilize Quality Assurance Management System a state-of-the-art, proprietary software tool that tracks measurable items, such as wait times. This 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 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.

Ameritas PPO: Yes, each office sets its own hours. Those hours are available to all our members on our on-line provider listings. Our goal is to balance care availability throughout the area to ensure needed care.

Anthem Blue Cross: Each dental office sets its own office hours. However, as part of the credentialing process, we document dentists’ office hours and use the information to ensure our networks include dentists who offer weekend and evening hours.

Blue Shield: This varies by provider, but some do stay open late and or are open on Saturdays.

CIGNA Dental: DHMO - there are 743 network offices offering Saturday office hours, 1081 network offices with evening hours (6:00 p.m. or later). For DPPO, there are 401 network offices offering Saturday hours and 984 network offices with evening hours (6:00 p.m. or later.)

Delta Dental: Our online dentist directory contains information on hours and access, including maps and languages spoken, or enrollees can call a toll-free number to request a list of dentists in their area with extended and Saturday hours. In addition to posting hours and access, DHMO network dentists are required to provide 24-hour emergency services to DeltaCare USA enrollees at all times.

Golden West: Yes, many of our providers offer evening and Saturday appointments. Our Member Services Department can help members with details.

GroupLink: Our leased networks would need to advise on such schedules.

Guardian: Yes, 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 also is available to all members through Health Net Dental Member Services. As part of our dentist agreement, all locations are required to have an emergency contact available for members whenever the dental office is closed.
HumanaDental: Members can see the provider of their choice and 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, SafeGuard, a MetLife company, contracts with individual dental practitioners, many who have evening and Saturday hours.

Principal Financial Group: Members can see any provider of their choice which can include those who have extended hours.

MWG Dental Plans: Our provider locator on www.mwgdental.com provides members with the hours our providers are open.

Securian Dental: Yes.

United Concordia: Yes.

Western Dental: Yes, many of our IPA providers have evening and Saturday hours. The Western Dental Staff Model Offices are open from 9:00 AM to 8:00 PM, Monday through Friday and 8:00 AM to 4:00 PM on Saturdays.

16. With respect to your mid-range benefit level, what is the specific amount of capitation paid to the general dentist? Do you offer validation for these amounts?

Aetna: We establish varying compensation rates under each customer’s plan for subscribers, spouses and children. Monthly compensation rates are based on case-specific dental experience, community averages, employee statistical data, and plan design. For DMO/managed dental plan, participating providers get a monthly check based on per member, per month compensation basis, subject to a guaranteed chair-hour rate. Actual capitation amounts are proprietary.

Ameritas PPO and the FDH Networks: Neither of these networks is used for dental HMO purposes, so no capitation is paid.

GroupLink: We are not a DHMO, so this is not applicable.

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.

Guardian: Not applicable to the PPO dental products Guardian offers in California. Capitation amounts paid to the general dentist vary based on plan design, adult or child, and region.

Health Net Dental: We do not offer financial incentives to our dentists. Our expectation is that our dentists perform in accordance with high professional standards without incentives. Our extensive credentialing process ensures that our contracting dentists are of the highest caliber.
HumanaDental: Fee-for-service reimbursement encourages thorough treatment. Member complaints are reviewed by our Quality Assurance Department and through our standard grievance process.

HumanaDental: Managed dental care capitation varies by plan schedule and geographic location.

MetLife: For Dental HMO, 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.

MWG Dental Plans: None of our plans are capitated. All PPO general dentists are on contracted fee schedule by ADA code.

Securian Dental: We do not offer capitation plans. We offer PPO and Indemnity plans.

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.

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. When deemed necessary and appropriate, supplemental payments may be made to participating dentists. However, these payments are not part of any bonus or incentive program.

GroupLink: This is usually asked in context of a DHMO arrangement. Providers under our programs are paid based on a fee-for-service basis or a negotiated fee schedule.

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 treatment(s) for appropriateness and benefit determination. All dentists involved in our review process are fully licensed. Our clinicians are also actively involved in the annual review of dentist records. These quality-of-care audits involve the use of comprehensive guidelines established by the American Academy of Dental Group Practice, the California Dental Association and the American Dental Association (through the University of North Carolina School of Dentistry). A random sample of each dentist’s records is selected for scrutiny by our dental consultants. 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 Dental: Our Integrated Quality Management Program drives overall quality and better outcomes across our entire network. While we do not provide incentives, the expectation is that the dentists in our networks meet professionally recognized standards of care.

Dental Health Services: Our supplemental payments and rigorous quality assurance program are designed as incentives to provide appropriate and thorough care.
Golden West: Golden West does not provide monetary incentives to dentists. Our expectation is that the providers in our network meet professionally recognized standards of care, while they are expected to perform in accordance with the high standards of competence, care, and concern for the welfare and needs of participants.

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 plan schedule, capitation, office visit fees, supplementals, and chair hour guarantees are adequate to encourage appropriate care. Participating dentists treat DHMO members the same as any other patient, and we have a grievance process in place to follow up on all quality of care complaints from members.

Health Net Dental: We do not offer financial incentives to our dentists. Our expectation is that our dentists perform in accordance with high professional standards without incentives. Our extensive credentialing process ensures that our contracting dentists are of the highest caliber.

HumanaDental: Fee-for-service reimbursement encourages thorough treatment. Member complaints are reviewed by our Quality Assurance Department and through our standard grievance process.

MetLife: Providers are expected to perform in accordance with high standards of competence, care, and concern for the welfare and needs of participants.

MWG Dental Plans: No, we have very strict guidelines for providers and if they do not adhere we terminate their contract.

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. Participating DHMO primary dentists receive supplemental reimbursement on the most highly utilized procedures in addition to monthly capitation and member copayments, which encourages dentists to provide the services necessary to ensure the oral health of members. In addition, PPO participating dentists who consistently provide thorough service to members are given x-ray exempt status. This allows them to submit many claims without x-rays, saving them time and money.

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?

Aetna: Yes.

Ameritas PPO and the FDH Networks: Yes, specialty coverage can be a part of any Ameritas plan design. Our networks are comprised of a full-spectrum of specialists to cover the needs of our customers.

Anthem Blue Cross: Yes, specialist coverage is a benefit for the Dental Blue PPO plans, but referrals are not required. Dental Blue contracted dentists are credentialed providers. And our contracted specialists, such as oral surgeons, periodontists and endodontists participate in all three Dental Blue networks. The same is true for our traditional Prudent Buyer dental PPOs.

Blue Shield: For the DHMO member there is no coverage for prosthodontic specialists. DPPO members may self refer to any specialist.

Delta Dental: Fee-for-service enrollees can visit any licensed dentist; referrals are not required for specialty care. For DHMO patients, referrals to specialists are handled by their general dentist. Prosthodontic procedures performed by the general dentist are covered, but services from a prosthodontic specialist are not covered under the DHMO plan.

Dental Health Services: Our plans provide specialty coverage for endodontics, periodontics, oral surgery, pedodontics, and orthodontics.
Golden West: Yes, all our group plans include Periodontics, Endodontics, Oral Surgery, Pedodontics and Orthodontia specialists. Individual plans are offered discounts for specialty services.

GroupLink: N/A.

Guardian: Specialty care referrals are not required under Guardian’s PPO plan. The DHMO offers Direct Referral where the member may be referred directly to a Specialist by their Primary Care Dentist without preauthorization. We provide coverage for all types of specialist dentists.

Health Net Dental: Health Net Dental DHMO plans cover a wide range of specialty care including endodontics, periodontics, oral surgery, pedodontics and orthodontics. If the procedure is covered under the plan, the member must first see general dentist for a specialty care referral to a participating specialist. The member is responsible for paying the established co-payment for the covered procedure. Our dental PPO plans cover a wide range of specialty care including endodontics, periodontics, oral surgery, pedodontics and orthodontics. Members may self-refer to the specialist of their choice, either in or out of network.

HumanaDental: Members can be referred to in-network and out-of network specialists, depending on the accessibility of the appropriate specialist in his or her area.

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, the SafeGuard SGX series of Dental benefit plans, available in CA, have co-payments for endodontics, periodontics, oral surgery, pedodontics, and orthodontics services provided by a participating specialist.
Principal Financial Group: Generally yes.

MWG Dental Plans: None of our plans require referrals.

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 speciality coverage for endodontics, periodontics, pedodontics, oral surgery and orthodonthics.

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, GPs 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 to specialty services.
Ameritas PPO and the FDH Networks: Specialist referrals are allowed any time from our general dentists. There is no gatekeeper involved in this process.

Anthem Blue Cross: With PPO dental plans, there is no formal process for a general dentist to refer to a specialist, but Anthem Blue Cross PPO dental plans use pre-treatment and post-treatment professional review to monitor referral activity. In-house dental consultants (licensed dentists) perform all professional review. Under the Dental Blue PPO contract, pre-treatment review is recommended for procedures in over $350, but not required. Members can also self-refer to specialists with our PPO dental plans. For the Dental Net DHMO, referrals that do not include the high-risk procedures are reviewed post-treatment. Using the Direct Referral program, the participating general dentist can refer a patient to a specialist without prior authorization. Dentists’ practice patterns have been scrutinized to help ensure that they share in our commitment to providing access to effective healthcare. For the Dental Net DHMO products, the member’s assigned general dentist can call the customer service hotline in an emergency to get an immediate authorization for emergency services.

Blue Shield: The general dentist completes a specialty care referral form and provides a copy to the DHMO member who brings this to the participating specialist at the time of the appointment. DPPO members may self refer to a specialist.

CIGNA Dental: DPPO plans do not require referrals and general dentists are not required to act as gatekeepers. For DHMO plans, general dentists act as coordinators for all specialty services except pediatrics (up to age seven) and orthodontic network dentists. Referrals are not needed for orthodontia or for individuals under age seven to visit a network pediatric dentist. General dentists refer individuals to network specialty care providers as deemed necessary. CIGNA Dental works directly with the specialists for preauthorization and direct payment when appropriate.
Delta Dental: Fee-for-service enrollees can self-refer; referral by the general dentist isn’t required. For DHMO patients, the general dentist must submit documentation for review and approval. Approvals are returned to the dentist, who directs the enrollee to the appropriate specialist.

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.
Golden West: Using our direct referral process, the participating general dentist can refer a patient to a specialist without prior authorization. For PPO plans the member would self refer.
GroupLink: The general dentist can refer to any specialist.

Guardian: Under our dental PPO plans, we do not require referrals to specialists. For the DHMO plan, any complex treatment requiring the skills of a dental specialist may be referred to a Participating Specialist Dentist upon written approval. When the General Dentist identifies the need for a referral, a Specialty Referral Form is completed and submitted to us for review. After review, the General Dentist, Specialist, and Member are notified of the determination.
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. Our PPO dental plans allow self-referrals to participating or non-participating specialists as needed.

HumanaDental: General dentists are encouraged to refer members to participating specialists to provide the highest level of benefit to the member. The general dentist can refer out-of-network if there are no specialists within a reasonable distance.

MetLife: Our Dental PPO product does not require referrals for specialist care. For Dental HMO, the SafeGuard SGX series of Dental benefit plans, available in Calif., allow participating general dentists the flexibility to refer members to participating specialists without prior approval from SafeGuard, except for orthodontic and pedodontic specialty services in Calif. where the member’s selected general dentists will contact SafeGuard for pre-approval.

MWG Dental Plans: Our national PPO network has Endodontists, Orthodontists, Pediodontists, Prosthosdontists and Oral Surgeons.

Principal Financial Group: Patients can choose any provider in the network; referrals are not required.

Securian Dental: No referral is required.

United Concordia: Although DHMO plan members must coordinate all care through their primary dental office, including referrals to specialists, no preauthorization or referral review is required, allowing the referral process for all specialty services to be completed immediately.
Western Dental: Once the general dentist determines that the necessary procedure is out of their scope of practice, the office will submit a written referral request to our plan. Western Dental’s dental director then determines whether the referral is medically necessary and whether the procedure is covered under the benefit plan.

20. Are any of your specialists board eligible/certified?

Aetna: Yes.

Ameritas PPO: Yes, all are board eligible or certified and are monitored
during the PPO credentialing process.

Anthem Blue Cross: All contracted specialists with Anthem Blue Cross must be board certified/board eligible.

Blue Shield: Yes, this varies by specialist.

CIGNA Dental: Yes, all network dentists contracted to provide specialty care have completed post-graduate dental specialty programs in their fields. The CIGNA 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: Yes, under state law, all specialists must be board certified or eligible.
Dental Health Services: Almost all of our participating specialists
are board eligible/certified.

Golden West: Yes, all contracted specialists must be board-eligible/certified.
GroupLink: Yes, but leased.

Guardian: Yes, many of our PPO specialists are board certified or eligible and all of the DHMO specialists are board eligible.

Health Net Dental: Yes, our provider network includes board-certified dentists. While we do not require our contracting providers to be board certified, if a provider indicates that he or she is board certified, Health Net Dental verifies this information during the credentialing process.
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, specialists must submit and keep current any certifications and/or other factors necessary to maintain their specialty.
MWG Dental Plans: All specialists are required to be board certified, the same as our general dentists.

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: Specialists agree to accept an amount per procedure as payment in full. If the member’s co-payment is less than the guaranteed amount, the plan will reimburse the specialist the difference between the negotiated fee and the member co-payment.
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.

Ameritas PPO and the FDH Networks: Specialty care claims are paid out of the same claims reserve that is established for the group’s general dentist claims. If employers are fully insured, all are funded out of the premium charged to each group. If employers are self-funded, the specialist claims would be included in the claim-funding bill provided to the employer.

Anthem Blue Cross: The PPO and DHMO specialty care is paid through claims processed according to the provider’s fee schedule.

Blue Shield: Specialty care is paid on a fee-for-service basis for both DHMO and DPPO plan designs. Member and plan co-payments vary depending on the plan design.

CIGNA Dental: DHMO and PPO 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. Specialists are reimbursed by a combination of maximum plan allowances by procedure (pre-contracted fees between Delta Dental and dentists) and co-payments paid by the covered 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.
Golden West: A percentage of sold premium is allocated for specialty care.
Guardian: Our PPO specialists are paid on a fee-for-service basis. For our DHMO plans, specialty care is funded through a portion of premium.

Health Net Dental: For both our DHMO and PPO 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 HMO, specialists are reimbursed based on a pre-determined fixed fee schedule. The SafeGuard SGX series of dental plans, available in CA, have co-payments for specialty services — listed on the Schedule of Benefits for the plan. These plans also provide a 25% fee reduction off the participating dentist’s usual and customary fee for non-listed services, unless specifically excluded from coverage.

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.

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: No.
Ameritas PPO and the FDH Networks: No, every member can self-refer.

Anthem Blue Cross: Members enrolled in the Anthem Blue Cross Dental Blue PPO program can self-refer. Members can seek services from a network specialist to realize the full cost savings advantage of their benefits. There is no paperwork involved since the member goes directly to the specialist. Once the specialist has performed an evaluation, they can submit a pre-treatment estimate, or on consent of the member, can perform the needed procedures without submitting a pre-treatment estimate. The same is true for our traditional Prudent Buyer dental PPO plans. Members enrolled in the Anthem Blue Cross Dental Net DHMO program must be referred by their primary dentist to an orthodontist. Using our Direct Referral program, the participating general dentist can refer the patient directly to the specialist without prior authorization.

Blue Shield: For DHMO plans, the general dentist completes a specialty care referral form and provides a copy to the member who brings this to the participating specialist at the time of the appointment. PPO plan members may self refer.

CIGNA Dental: DPPO/DEPO and dental indemnity plans do not require referrals to visit a specialist. Our DHMO plans do not require a referral to see a network orthodontist.
Delta Dental: Enrollees can self-refer. For DHMO plans, the enrollee can self-refer only to a contracted DHMO orthodontist.

Dental Health Services: Members must get a referral from one of our network dentists before visiting a participating orthodontist.

Golden West: The member can self refer to the panel orthodontist office.
GroupLink: Members can self refer.

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 PPO product does not require referrals for specialty or orthodontic care, so participants can 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, the Primary Care dentist must submit a specialty referral form. 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 in Calif., orthodontic specialty services require pre-approval. The member’s general dentist will contact SafeGuard for pre-approval, and once approved will contact the member with the name of a participating orthodontist.
MWG Dental Plans: No referrals required. They can self-refer.
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?

Ameritas: Since this is a self-referring process, this question is not applicable.

Aetna: DMO GP’s usually provide a member with an immediate referral. Specialty payments are made on receipt and adjudication of the claim.

Anthem Blue Cross: With Anthem Blue Cross PPO plans, the member can self-refer, so there is no timeframe. Our PPO plans do not require referrals to specialists. Members can go directly to any PPO specialist without any referrals. With Anthem Blue Cross Dental Net DHMO plans, referrals are usually processed within 48 hours through the use of our Direct Referral program. Referrals for emergency reasons are usually processed within the same day.

Blue Shield: For DHMO plans, the general dentist completes a specialty care referral form and provides a copy to the member who brings this to the participating specialist at the time of the appointment. Our average turnaround time for claims payment to the specialist after receipt of the claim is approximately six days.

CIGNA Dental: Typical turnaround time for specialty referrals is five days for preauthorization and five days for payments on our DHMO.
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 2008, the average time for processing all claims was five days. For DHMO enrollees, 2008 specialty care referrals were processed within an average of seven business days and specialists were paid within an average six 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.

Golden West: The general dentist provides a real-time referral to
the specialist. Plan approval is not required.

Health Net Dental: The average turnaround time in processing a non-emergency referral is 48 hours and then 7 to 10 business days for the EOB to be received by the member. Once the specialist submits the claim, our average turnaround time in processing is 10 business days from receipt and then 7 to 10 business days for the specialist to receive payment in the mail. If claim was sent electronically, it will be sooner.

HumanaDental: Most HumanaDental plans do not require a referral from a general dentist to a specialist. The member gets a higher benefit when seeing a participating dentist and specialist. In 2008, 85% of claims and 97.4% referrals were processed within 14 calendar days.
MetLife: For Dental HMO, standard referrals are processed in an average of five business days for member notification and 14 business days for payment to the provider.
MWG Dental Plans: No referrals required.
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 through Speed eClaim are processed for payment immediately unless a review of an x-ray or other document is required.

Western Dental: Emergency referrals are handled within 24-hours. 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 total amount Aetna will pay for covered benefits.
Ameritas: The maximum is the total amount of dollars payable to a member under their policy during the specified plan year.

Anthem Blue Cross: With Anthem Blue Cross PPO plans, the maximum dollar amount allowed refers to the amount allowed by the plan. With Anthem Blue Cross Dental Net and Dental Select DHMO plans, there are no annual or lifetime maximums.

Blue Shield: DPPO annual plan maximums range from $1,000 to $2,000 and are based on the amount paid by the plan. DPPO orthodontic calendar maximums are $1,000. We do not have lifetime orthodontic maximums. DHMO has no annual maximum.

CIGNA Dental: 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: The maximum dollar amount refers to the amount paid by the plan. Our DHMO plans do not have annual or lifetime maximums, except for the accidental injury provision.
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.

Golden West: The maximum amount is the total amount paid by
the plan.

GroupLink: It is the maximum out-of-pocket benefit a patient would get.

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.
Participating PPO dentists may charge no more than the fee schedule amount for services on the fee schedule, even when members have been reimbursed up to the plan annual or lifetime maximum. 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. For PPO, orthodontic lifetime maximums typically range between $1,000 and $2,000 per member. For DHMO, there are no orthodontic lifetime maximums.

HumanaDental: 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 eimbursement 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, there are no calendar or lifetime maximums as part of the SafeGuard plans.

MWG Dental Plans: Annual maximum is the annual amount the plan will pay for the member. For example, a plan has $1000 annual maximum. Once the plan has paid out $1000 the member no longer has coverage under the plan for the rest of that year.

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 & 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: ID cards are issued to our DMO, PPO and Vital Savings by Aetna members. There is a monthly roster the first week of the month to our DMO providers.
Ameritas: They will want to verify eligibility through our real-time system. Our plans do not require preauthorization or mandated PPO network usage.

Anthem Blue Cross: Our customer service representatives are available Monday through Friday from 5:00 a.m. to 7:00 p.m. (PST) to help members with locating network providers, verifying provider status, member eligibility, answering claim questions, quoting plan benefits, and mediating member complaints for resolution. An interactive voice response (IVR) system is also available to answer calls 24 hours a day, seven days a week. Through the IVR, members and providers can get eligibility and benefit information (voiced or faxed), and claim status information, hours of operation, and web site addresses. Members can also request ID cards through the IVR.

Blue Shield: Eligibility lists for DHMO plans are distributed to the DHMO dental center during the first week of each month. Providers are responsible for contacting our Customer Service Department to verify eligibility, if a member is not on their list. Our Interactive Voice Response (IVR) is available 24 hours, seven days a week and has the capability to verify eligibility and assign members.

CIGNA Dental: Dentists can view eligibility information in real time by visiting our secure website for healthcare 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 providers; 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: Eligibility and benefit information is available through secure online services. Delta Dental also provides an automated toll-free telephone and facsimile services for dentists and enrollees, which provide information on benefit levels, co-payments, deductibles, and maximums. In rare instances, a patient who is not shown as eligible may be asked to pay the entire bill up front, and Delta Dental will reimburse the patient (less applicable co-payment).
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.

Golden West: Eligibility is provided on the first week of the month to the DHMO providers. Eligibility lists are available in electronic format if the dental office selects this method of notification. A customer service representative can also phone, email or fax in member eligibility. The plan maintains a 24/7 emergency phone number for after-hour emergencies.
GroupLink: Automated eligibility is available. A fax-back system is accessible 24 hours a day, seven days a week via an 800 number.

Guardian: We do not provide eligibility lists for the PPO plan. Dentists can 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. PPO 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. PPO and DHMO dentists can verify eligibility information via our interactive voice response system and Web site, which are both accessible 24-hours a day, seven days a week. Because the IVR and Web site are available 24/7 eligibility can be verified anytime of the day regardless of whether the need occurs during business hours.

HumanaDental: Participating offices are encouraged to check eligibility before providing treatment. They can verify members and benefits by calling our toll-free customer service line or through our automated information line to get 24 hour-a-day, seven-day-a week eligibility verification.

MetLife: For Dental PPO and Dental HMO, MetLife has developed a multi-channel technology platform for customer service inquiries including Web, fax, or phone. Through dedicated, real-time channels (except when the systems are undergoing scheduled or unscheduled maintenance or interruption), 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, eligibility data is forwarded once a month to each participating dentist.

MWG Dental Plans: Through the VRU system eligibility is real time. Our plans have a palliative emergency benefit feature, which will get them temporary relief until they can get an appointment with their dentist.

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 can access member eligibility and benefit information online, or toll-free using United Concordia’s IVR system. DHMO providers also receive printed eligibility rosters once per month.

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: Quarterly claim payments cease on the member termination.

Ameritas PPO: PPO provider discounts are determined using the treatment start date. Our PPO providers are contractually obligated to honor those discounts for any ongoing covered treatment under their plan.

Anthem Blue Cross: Anthem Blue Cross’ contract with Dental Blue PPO participating dentists includes a provision that requires the dentist to complete work-in-progress in the event of contract termination.

Blue Shield: Once the member’s coverage is terminated, the cost of treatment is the responsibility of the member.

CIGNA Dental: Individuals whose plans are ending are covered for services through the end of the month of their termination.

Delta Dental: The enrollee’s coverage ends when the contract terminates. Payments for fee-for-service orthodontic services will be pro-rated based on the remaining treatments. A DHMO enrollee is responsible for the balance due up to a maximum amount defined in the benefit level. The contract orthodontist will prorate the amount over the number of months remaining in the initial 24 months of treatment, and the enrollee will make payments based on an arrangement with the contract orthodontist.

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 be responsible for only the prorated amount for completing their treatment.

Golden West: Coverage terminates at the end of the month in which a member is no longer eligible unless the member chooses to continue or maintain coverage.

GroupLink: Benefits end on the day coverage is terminated.

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. What we pay is based on the remaining charges. We limit what we consider 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 their Guardian coverage terminates, we pro-rate the benefit to cover only the period during which coverage was in-force. We do not extend benefits.

Health Net Dental: Upon termination of coverage, we will pay for orthodontic cases in progress on a prorated basis up to the last effective date of coverage. Benefits are no longer payable after the member terminates and are the responsibility of the member and/or the new dental carrier.
HumanaDental: HumanaDental will prorate to provide the appropriate amount given during the time the member was in the plan.

MetLife: Benefit consideration for orthodontic treatment will cease within the month that coverage terminates unless the participant gets 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.

HumanaDental: HumanaDental will prorate to provide the appropriate amount given during the time the member was in the plan.

MetLife: 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.
MWG Dental Plans: We do not provide any additional claim payments
beyond the termination date.

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: We consider these costs to be of doing business.
Ameritas: All paid procedures are based on CDT codes. Infection control is a cost that is already anticipated in the provider’s procedure fees.

Anthem Blue Cross: Our relationship with network providers is an independent contractor relationship. We are not, directly or in any manner, involved with how participating dentists operates and runs their offices. On our Dental HMO plans, our contracted providers cannot charge members for the additional cost of OSHA requirements. It is the responsibility of the participating offices to absorb the additional cost of these requirements.

Blue Shield: Our DHMO plans include a $5 sterilization fee, which is paid by the member.
CIGNA Dental: Typically, dentists include these costs into their over head 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. Each time an enrollee visits the general dentist, the office submits an encounter form, telling us which patient they saw and which procedures were performed. For each encounter form received, we pay the dentist a fixed dollar amount, which they can apply towards OSHA-required infection control or any other overhead costs as they see fit.

Delta Dental: The cost is included in regular dental office overhead The dentist cannot charge back to the enrollee or to the plan for this.

Dental Health Services: The combination of member co-payments, supplemental co-payments, and capitation is designed to help cover costs associated with operating a dental office including necessary additional costs such as OSHA required infection control measures.
Golden West: OSHA costs are the responsibility of the provider.

GroupLink: N/A

Guardian: Most dentists have incorporated the cost of 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-require 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 and SafeGuard. MetLife and SafeGuard use these fees as the basis for reasonable and customary data and/or for determining Dental PPO or Dental HMO provider fee schedules, as appropriate.

MWG Dental Plans: These costs are all included in our negotiated contracted rates.

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 dentist 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.

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?

Aetna: Yes.
Ameritas: Depending on the type of plan funding and the level of information, utilization data is available in conjunction with HIPAA requirements.

Blue Shield: Yes. This is available upon request for employer groups of 300 or more employees at renewal.

Anthem Blue Cross: Yes, for groups of 51+ employees, Anthem Blue Cross provides a complete standard utilization, reporting package for dental plans. The packages are also adapted to accommodate the reporting of a client’s dental experience.

Delta Dental: Yes, Delta Dental provides utilization data to client groups and brokers in accordance with state laws; the plan does not disclose any personally identifiable information.

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.
CIGNA Dental: Yes, we can report group utilization data to our clients on an annual basis at no charge. For more frequent reporting, additional charges may apply.

Golden West: Yes, utilization data is available to groups and brokers upon request.

GroupLink: Yes, at renewal if requested. It is only provided in summary formats based on new HIPAA standards. Individual private health information would not be provided on a routine basis unless we got a specific release from the employee to do so.

Guardian: Yes, our standard reports are available monthly, quarterly or annually, and detail: (a) paid vs. submitted charges showing 13 components of savings; (b) PPO savings; (c) PPO usage In network vs. out-of-network; (d) monthly summary report; (e) dental charges and payments by category; and (f) dental claim turnaround time.

Health Net Dental: Yes, we will provide utilization upon request for large groups.
HumanaDental: Yes, on requests and within the boundaries permitted by HIPAA.

MetLife: 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.

MWG Dental Plans: Yes, most requests for itemization data that
have validity are for groups over 200 lives.
Principal Financial Group: Yes, based upon the request of the client
and/or broker.

Securian Dental: Yes, we can provide this information to individually
rated employer groups upon request.
United Concordia: Yes, utilization reporting is available to cients and
brokers.
Western Dental: Yes, utilization data can be provided on request to clients and brokers for large accounts.

29. Please provide contact information for your company:

Blue Shield of California Dental Plan
Producer Services 888-559-5905
Specialty Benefit Group Sales (888) 800-2742

Guardian Life Insurance Company
Joe Stefano, Director, All of Southern
Central California & Phoenix
jstefano@glic.com
Main Phone: 800-662-6464 •Direct Line: 949-885-1720
Fax: 949-453.9919
Arthur Stern, Regional Manager, Los Angeles District Office
astern@glic.com
Main Phone: 800-225-3399 •Direct Line: 310-765-2201
Fax: 310-312.3371
Gregg Holdgrafer, Regional Manager, San Diego District Office
gholdgra@glic.com
Main Phone: 800-769-6759 •Direct Line: 619-881-3502
Fax: 619-296-3912
James Hill, Regional Manager, San Francisco District Office
jhill@glic.com
Main Phone: 800-832-9555 • Direct Line: 415-490-4413
Fax: 415-788-4412
Chris Anderson, Regional Manager, Sacramento District Office
canderso@glic.com
Main Phone: 800-438-5853 • Direct Line: 916-403-2326
Fax: 916-638-0288

MetLife
David Heil
Regional Director, Northern California
1333 North California Blvd, Ste. 170
Walnut Creek, CA 94596
925-658-1102
dheil@metlife.com
Jason Ackermann
Regional Director, Southern California
1 Park Plaza, Suite 1100
Irvine, CA 92614
949-471-2312
jackermann@metlife.com

The Principal Financial Group
711 High Street
Des Moines, IA 50392
www.principal.com
Theresa McConeghey, Dental Product Director
mcconeghey.theresa@principal.com