2018 Dental Survey
This is Part 2 of Cal Broker’s 2018 Dental Survey. Thank you to the dental carriers for your responses! Readers: Please reach out and let us know what you find valuable – or not- in the dental survey. Email Thora@calbrokermag.com
Question 8: How do you handle early termination of coverage when a member is still in the middle of orthodontic treatment?
Anthem Blue Cross: Orthodontic payments will cease if coverage is not active at the time the payment is due.
Beam: Beam will pick up orthodontic treatments in the middle of their period for new members. For an early termination, Beam will cease making payments on that coverage when it terminates.
Blue Shield: Orthodontic coverage/payments end at cancellation of coverage.
Delta: Delta Dental’s obligation to cover orthodontic treatment ceases after the date the enrollee loses eligibility or terminates coverage.
Guardian: When an orthodontic appliance is inserted prior to the PPO member’s effective date, we will cover a portion of treatment. Based on the original treatment plan, we determine the portion of charges incurred by the member prior to being covered by our plan and deduct them from the total charges. Our payment is based on the remaining charges. We limit what we consider of the proposed treatment plan to the shorter of the proposed length of treatment, or two years from the date the orthodontic
treatment started. Also, we enforce the plan’s orthodontic benefit maximum by reducing the total benefit that Guardian would pay by the amount paid by the prior carrier, if applicable.
If a member is undergoing orthodontic treatment and his or her Guardian coverage terminates, we pro-rate the benefit to cover only the period during which coverage was in force. We do not extend benefits.
Our DHMO agreement provides for the Contracted Orthodontist to complete treatment at the contracted patient charge on a number of our plans. As an additional contract rider we can allow for supplemental transfer coverage for Orthodontia under our DHMO.
Humana: For orthodontic claims, Humana will pay benefits monthly through the month that the member is termed. Orthodontia is prorated over the time of treatment depending on how long they are in treatment.
National General: Not applicable to our coverage, as our plan does not provide such benefits.
Premier Access: If a member is undergoing orthodontic treatment and Premier Access coverage terminates, we will prorate the benefit to cover only the time period during which coverage was in force. We do not extend the benefits beyond the policy termination. Our DHMO agreement provides for the contracted orthodontist to complete treatment at the contracted patient charge on a number of our plans.
Question 9: Does your plan have annual and lifetime maximums on dental coverage? If so, what are they?
Anthem: The annual maximums for our plans vary from as little as $500 to as much as $10,000 with the option of an unlimited annual maximum for large group customers of the Anthem Dental Essential and Consumer Choice PPO plans. We also offer our Carry-Over benefit feature allowing qualified members to enhance their annual maximum each benefit year by carrying over an unused portion of the prior year’s annual maximum when certain qualifications are met. Additionally, we have the flexibility to vary the annual maximum for members who visit an Anthem Prime or Complete PPO provider versus a non-participating provider. Currently, lifetime limits are only imposed on child or child and adult orthodontia benefits. Lifetime maximums can range from $500 to as much as $3,000 or more dependent upon individual or group coverage and group size. There are no annual and/or lifetime limits on Dental Net HMO policies.
Beam: All plans have customizable maximums. Beam’s new Ultra plans can support annual maximums of $5000 and orthodontic maxes of $3000. One of our strategic advantages is flexibility; we can underwrite a wide variety of maximums based on the needs of the employer!
Blue Shield: Our annual maximums vary from as little as $500 to as much as $5,000 or more dependent upon individual or group coverage and group size. Employers have a choice in annual maximum with more flexibility for large group customers to customize their annual maximum to meet their needs.
- For large groups, we also offer our Rollover Rewards benefit feature allowing qualified members to boost their annual maximum. The annual account reward will vary depending on the annual claims threshold which is determined by the plan’s annual maximum chosen. The annual network reward for members who visit an in-network vs. a non-network dentist is $100.
- For 2019, we will be adding lifetime limits on child orthodontia benefits on some PPO plans. Lifetime maximums can range from $1000 to as much as $2,000 dependent upon plan chosen.
Delta: Virtually none of our DeltaCare USA (DHMO) plans impose annual or lifetime maximums on dental coverage. For most PPO and Premier plans, annual and lifetime maximums vary, and are determined by the group purchaser. Maximums typically range from $1,000 to $2,000.
Guardian: For PPO, the maximum refers to the total of benefit dollars actually paid for covered services incurred within the annual period, or the member’s lifetime in the case of orthodontia. Guardian has significant flexibility with maximums. Typically, Preventive, Basic and Major have a combined maximum. We offer both an annual single maximum option (range from $500 – $5,000) and an annual split maximum option (maximums differ for in-network and out-of-network services). With the Preventive Advantage option, only Basic and Major services count toward the annual maximum. Maximum Rollover allows a portion of unused annual maximums to carry over for future years. We also offer an option to cover cleaning after the maximum is reached and an unlimited maximum plan. For orthodontia, the lifetime maximum options range from $500-$2,500. Our DHMO plans do not include an annual maximum.
Humana: We offer flexible plan designs with a range of annual maximums to meet the needs of small to large groups. We do not have lifetime maximums. We are the only specialty carrier in the market to offer an Unlimited Annual Maximum.
National General: Yes. The Basic Plan has a $500 maximum calendar year benefit; Intermediate is $1,000; and the Plus plan is $1,500. However, preventive benefits do not take away from this annual benefit (adding $150-200/annually in benefit, depending on plan level). Members can use their savings card on covered and non-covered services at any and all times of the coverage being in force.
Premier Access: Premier Access offers plan design flexibility to allow brokers and employers to custom design their dental benefits, including annual or lifetime benefits. The most common annual benefit maximums are $1,000, $1,500, and $2,000. We do offer custom benefit plans above those amounts if the employer and broker desire that.
Question 10: Does your plan have a deductible. If so, what is it?
Anthem Blue Cross: The deductible for our plans can vary from no deductible to as much as $250. The Anthem Consumer Choice product is a high deductible, consumer driven dental plan with a minimum deductible of $100 per individual. We can also vary the deductible for members who visit an Anthem Prime or Complete PPO provider versus a non-participating provider. Large group customers also have lifetime deductible option as an alternative to annual deductibles. A lifetime deductible can be a good fit for a customer who maintains coverage with Anthem for multiple years. There is no annual and/or lifetime deductibles on Dental Net HMO policies.
Beam: Beam plans include a standard $50 deductible ($150 family) but is fully customizable. Our Ultra plans can go as low as a $0 deductible!
Blue Shield: Deductibles can vary from as little as $0 to as much as $300 or more dependent upon group size and individual or family coverage.
- Employers have a choice in deductible with more flexibility for large group customers to customize their annual deductible to meet their needs.
Delta: Virtually none of our DeltaCare USA (DHMO) plans require enrollees to satisfy a deductible. For most PPO and Premier plans, deductibles vary, and are determined by the group purchaser. Deductibles of $50 per individual / $150 per family are not uncommon.
Guardian: Our PPO product offers many different deductible options ranging from $0-$300 and will vary by plan design with $50 historically being the most common. Deductibles are often waived for Preventive Services as Guardian’s plans are designed to encourage members to get preventive care, thereby avoiding the need for more extensive dental care in the future. All our DHMO plan designs offered in California have no deductibles.
Humana: We offer flexible plan designs with a range of deductibles to meet the needs of small to large groups. The deductible is always waived for preventive care. We want to ensure there are no barriers to members receiving the necessary preventive care.
National General: There are no deductibles.
Premier Access: Employers and brokers can custom design their dental benefits, including plans with no deductible. The most common designs requested are no deductible, $25, and $50.
Question 11: What percentage of preventive costs does your plan cover?
Anthem Blue Cross: When using an Anthem Blue Cross Dental Prime or Dental Complete PPO provider, preventive care is covered at 100 percent. Out-of-network coverage will vary based on plan selection, but is typically not less than 80 percent. Large group customers receive additional flexibility to customize the percent of costs covered. Most Dental Net HMO preventative care is covered with a $0 member office visit copay and $0 member service level copay.
Beam: Beam will cover preventive at 100% in all cases’ we strongly believe in preventive care’s role in the dental health equation for all members!
Blue Shield:
- Preventive care is standardly covered at 100% when using an in-network provider.
- Out-of-network coverage will vary based on plan selected but typically not less than 80 percent. Members may also be balanced billed for amounts exceeding the allowable payment to out- of- network providers based on their plan.
- For large groups, there is additional flexibility to customize the percentage of costs covered.
Delta: Delta Dental’s fee-for-service coinsurance percentages vary by plan. DHMO copays are set at a fixed schedule and vary by plan design.
Guardian: For PPO, we offer coinsurance percentages ranging from 0%-100% for preventive services. The preventive coinsurance percent for our most common PPO plan sold is 100%. Our DHMO plans offer a wide variety of covered services usually covered at 100%.
Humana: Preventive care is always covered at 100 percent, unless a large group designs a custom plan. We encourage all employers to cover preventive care at 100 percent. We want to ensure there are no barriers to members receiving the necessary preventive care.
National General: The member is reimbursed a select amount toward their preventive visit based on benefit level plan selected. For example, our ‘Plus’ plan offers $100 cash reimbursement toward preventive services.
Premier Access: Brokers and employers can customize this coverage from 0 percent to 100 percent; the most common is 100 percent coverage for preventive costs.
Question 12: What percentage of root canal costs does your plan cover?
Anthem Blue Cross: Anthem Blue Cross Dental Prime or Dental Complete PPO plans typically cover root canals at 50 or 80 percent. Out-of-network coverage will vary based on plan selected, but is typically covered at 50 or 80 percent. Large group customers receive additional flexibility to customize the percent of costs covered. Dental Net HMO members can expect a member service level copay between $30 and $225, dependent upon the type of root canal and plan chosen.
Beam: We will typically cover root canals at 50%, but it is customizable based on employer preference.
Blue Shield:
- For Large groups, root canals can be covered under Basic or Major services. Typically, Basic services are covered at 80% and Major Services are covered at 50%. Out-of-network coverage will vary based on plan selected but the most common percentage is 50 percent.
- For Individual/Family plans, root canals are typically covered under Major services at 50%
- For Small Group, root canals are typically covered under Basic services at 80%.
Delta: Delta Dental’s fee-for-service coinsurance percentages vary by plan. DHMO copays are set at a fixed schedule and vary by plan design.
Guardian: For PPO, we most often cover root canals as a basic service. We offer coinsurance percentages ranging from 0%-100% for basic services. The basic coinsurance percent for our most common PPO plan sold is 80%. Our DHMO plans cover many root canal procedures at various copayment levels based on plan type.
Humana: We offer flexible plan designs with a range of co-insurance percentages from 50 percent to 90 percent to meet the needs of small to large groups. A group can elect to have endodontic coverage in Basic or Major.
National General: According to our cost and transparency calendar, a molar root canal – for example – may cost $1,382. The plan cost is $707 with a network savings of $675 or a percentage savings of almost 50 percent.
Premier Access: Brokers and employers can customize this coverage from 0 percent to 100 percent; the most common designs cover 80 percent or 50 percent.
Question 14: What percentage of crown costs does your plan cover?
Anthem Blue Cross: Anthem Blue Cross Dental Prime or Dental Complete PPO plans typically cover crowns at 50 or 80 percent. Out-of-network coverage will vary based on plan selected, but is typically covered at 50 percent. Large group customers receive additional flexibility to customize the percent of costs covered. Dental Net HMO members can expect a member service level copay between $25 and $240 dependent upon the type of crown and plan chosen.
Beam: We will typically cover root canals at 50%, but it is customizable based on employer preference.
Blue Shield: Typically, for all lines of business, crowns are considered Major services and are covered at 50%.
Delta: Delta Dental’s fee-for-service coinsurance percentages vary by plan. DHMO copays are set at a fixed schedule and vary by plan design.
Guardian: For PPO, we most often cover crowns as a major service. We offer coinsurance percentages ranging from 0%-100% for major services. The major coinsurance percent for our most common PPO plan sold is 50%. Our DHMO plans offer a wide variety of different crown option procedures covered at various copayment levels based on plan type.
Humana: We offer flexible plan designs with a range of co-insurance percentages to meet the needs of small to large groups. Crowns are typically covered as part of Major services and the coinsurance ranges from 50 percent to 60 percent.
National General: The cash benefit for a Crown ranges from $45 to $450. However, if the Careington Network is used – for example – the cost for a Crown (porcelain fused to noble metal) may cost $1,424. The plan cost is $726 with a network savings of $698 or a percentage savings of almost 50 percent.
Premier Access: Brokers and employers can customize this coverage from 0 percent to 100 percent; the most common design covers 50 percent.
Question 15: Do you provide dentist cost and quality transparency tools?
Anthem Blue Cross: Yes, all Anthem Dental Essential and Consumer Choice PPO consumers have access to free online tools via the member services portal. These tools include Dental Health Assessment, which helps consumers better understand their oral health by answering questions about their mouth, teeth, and overall health to produce an individualized report they can share with their dentist for follow-up care. To help plan for needed care, Anthem also offers an additional online tool called a Dental Cost Estimator allowing members to search for common procedures including exams, cleanings, x-rays, fillings or root canals and get an estimated cost within seconds.
Beam: Our Lighthouse portal is for brokers and administrators and offers the ability to quickly and effectively edit account and member level details, manage everything from enrollments to COBRA, and gain unique insights into how a group is performing against plan, especially as it relates to their Beam Brush data and renewal rates.
Blue Shield: Yes. Once registered on our website, members may review their claims information and locate providers. They also have access to treatment cost information through the Treatment Cost Calculator. The Treatment Cost Calculator allows members to search for common procedures including exams, cleanings, x-rays, fillings or root canals. This tool is quick and easy to use with members being able to get an estimated cost for procedures quickly.
Delta: Yes. Enrollees can use our Cost Estimator to determine costs for procedures based on dentist participation and location. Additionally, our Find a Dentist tool provides links to Yelp reviews as well as other helpful information including languages spoken, wheelchair accessibility and public transit access.
Guardian: We have a Dental Cost Estimator tool that provides an estimated range of allowable charges (fee schedule amounts) for the selected procedure codes in a selected region and provider contracted tier. Note that this is not the actual Guardian fee schedule amount for a provider nor the expected paid amount for a particular Guardian plan design. At this time, we do not offer provider quality ratings.
Humana: Humana’s website does not currently provide cost information for our dental products.
National General: Yes. If a member decides to use our Careington Network for specific services, they can go to: http://www.careington.com/ngahdsavings/. These resources provide a simplified way to determine costs of treatment.
Premier Access: We are currently developing cost and quality tools for the website, which we believe we help consumers make better informed decisions. We also offer pre-determination of benefits to members who request them through our phone-based customer service representatives.
Question 16: Who can readers contact for more information?
Anthem Blue Cross
CJ Faust, Director, Specialty Sales, Northern California cj.faust@anthem.com
Randy Ebersberger, Director, Specialty Sales, Southern California randy.ebersberger@anthem.com
Beam
You can email Beam at info@beam.dental for more information, and one of Beam’s Broker Success Managers will be respond.
Blue Shield
Brokers who currently work with Blue Shield of CA contact their BSC representative.
For those who do not have a direct contact, they can locate more information by logging onto our website at our Broker Connection. The link is listed below.
https://www.blueshieldca.com/bsca/bsc/wcm/connect/broker/broker_content_en/broker/home
Delta
Readers can navigate to https://www.deltadentalins.com/about/contact/ to find the number specific to their location and area of interest.
The Guardian Life Insurance Company of America
Rick Porterfield, Regional Director
San Francisco, Sacramento & North, including Oregon/Washington, Hawaii and Alaska
(415) 490.4433 office, email: Richard_Porterfield@glic.com
Joe Stefano, Regional Director
SoCal Metro, San Diego, Las Vegas, & Central California Markets
(949) 885.1720 office, email: Joe_Stefano@glic.com
Humana
Brian Sullivan, California Vice President, Employer Group(818) 598-1104bsullivan6@humana.comwww.humana.com
National General
Kellie Bernell, Regional Sales Director
(805) 341-7843 / Kellie.Bernell@NGIC.com
Company Site: https://ngah-ngic.com/supplemental-insurance.php
Premier Life
www.premierlife.com
Robert Semrow, Sale Excutive
Phone: (888) 326-3210, email: robert@premierlife.com