We’ve been through some rough times— and we aren’t yet out of the woods. But Californians are still smiling, thanks in no small part to the folks in the dental health world. We checked in with some key dental health providers to hear about their plans, how COVID-19 impacted business and more.
1. What types of plans do you offer?
Mark Zeedik, senior manager, specialty sales, consumer, and small group, Blue Shield of CA:
Blue Shield has provided dental coverage for more than 25 years, and our dental program is an integral part of Blue Shield’s mission to provide Californians with access to high-quality health care at a reasonable price. We are committed to providing excellent dental care and member satisfaction through a spectrum of diverse dental plans. We develop and customize our plans to meet changing marketplace demands and the individual needs of our customers. Currently, more than 500,000 members are either enrolled in the Blue Shield dental program or use its networks for services.
Our dental PPO and HMO plans offer members a wide variety of plan designs and networks to fit their budget.
For individuals and families, we offer a unique dental PPO plan with member copayments instead of the usual coinsurance percentages. Our dental HMO plan offers comprehensive benefits with predetermined member copayments. Finally, our Duo plan offers members dental and vision coverage at a single price. Our plans can be sold with medical plans or on a stand-alone basis.
For senior members, we offer two comprehensive dental PPO plans for Medicare supplement plan members. For groups, some of our dental PPO and HMO plans are available on a contributory or voluntary basis. Most can be sold with or without Blue Shield medical plans, and they are either based on Usual, Customary, and Reasonable fees or reimbursements that are capped by the Maximum Allowable Charge.
Joe Stefano, divisional VP, Western U.S., The Guardian Life Insurance Company of America:
Guardian offers an array of plan types and options to meet the needs of employers/employees and individuals/families. Employer plans can be customized according to needs and price points. Dental PPO, Managed Dental Care (Prepaid/DHMO), Indemnity, Dual and Triple Choice, Monthly Switch
(between a DHMO and PPO), and Administrative Services Only Plans can be offered as voluntary, contributory, or on an employer-sponsored basis. Individuals/families can buy direct from www.guardiandirect.com. Additionally, Guardian offers family and individual plans through its subsidiaries Premier Access and Access Dental on the Covered California exchange.
Chrissy Cabra & Michele Childers, executive sales consultants, Premier Access:
We offer dental DHMO and PPO plans and vision plans.
Diana Steinhoff, SVP of Client Services at Aflac:
Aflac Dental Insurance is available in Maximum Allowable Charge (MAC) and Preferred Provider Organizations (PPO) plans, each with three levels of coverage and optional orthodontia benefits available. Coverage includes no waiting periods (excluding orthodontia services) and no copays required for most preventative procedures.
2. How do the offerings for individual and small group compare to large group plans?
Zeedik, Blue Shield of CA:
There are different underwriting considerations for each business segment. Our ability to customize offerings for groups with more than 101 employees typically results in lower rates and more choices to meet the employer’s needs.
Group PPO plans come in a wide range of deductibles and annual benefit maximums.
Our individual, family, and Medicare Supplement dental PPO plans may vary in waiting periods, deductibles, and annual benefit maximums based on the plan selection.
Stefano, Guardian:
Individuals and small group employers can choose from nearly similar plans as large groups with cost-reducing options. Individuals/Families can also buy direct from www.guardiandirect.com or on the exchange through Covered California.
Cabra & Childers, Premier Access:
We don’t offer individual plans at this time. Both small group and large group plans offer great flexibility in benefit options.
Aflac has the ability to match most plan designs offered by other carriers, allowing for limited disruption for employees.
— Diana Steinhoff, Aflac
Steinhoff, Aflac:
Aflac’s current individual dental plan is an indemnity plan that reimburses members different dollar amounts for specific procedures.
Our small-group plans, which are for two to 99 eligible employees, have three PPO plans and three MAC plans available with different coinsurance and annual max options. Orthodontia is available as an optional benefit, and all plans come standard with a deductible that decreases over time, carry-over credit and no waiting periods.
With our large-group plans, which are for 100+ eligible employees, we offer customized plan designs. Aflac has the ability to match most plan designs offered by other carriers, allowing for limited disruption for employees. Dual choice, high/low, and core/buy-up plan offerings are all available within our large-group space, in addition to the listed benefits within the small-group plan offering.
3. What changes in plans or benefits should brokers be aware of for open enrollment this year?
Zeedik, Blue Shield of CA:
We are always looking to enhance our plans and provide valuable benefits to our members. For members on our Blue Shield 65 Plus plan who elect to enroll in our Optional Supplemental Dental PPO plan, the waiting period for all dental procedures was removed on 1/1/2021.
All Blue Shield plans include oral cancer screening coverage as a value-added benefit, which comes at no out-of-pocket cost to the member. We offer enhanced dental services for pregnant women with dental PPO plans. Pregnant women receive one additional routine adult prophylaxis, and/or one course (up to four quadrants) of periodontal scaling and root planing, and/or periodontal maintenance if warranted by a history of periodontal treatment. Treatment is payable at 100% of the allowable amount both in and out of network.
Our ability to customize offerings for groups with more than 101 employees typically results in lower rates and more choices to meet the employer’s needs.
—Mark Zeedik, Blue Shield of CA
Stefano, Guardian:
Brokers should be aware of new features introduced to address the changing needs of members. This includes discounts on byte® at-home invisible aligner treatments to help members straighten their teeth without visiting a dental office. In addition, members now have access to Guardian Teledentistry if they are seeking easy access to urgent dental care without visiting the dentist.
One benefit that brokers should be aware of is Guardian’s College Tuition Benefit®, a value-addedbenefit that helps families pay for college. Members enrolled in a Guardian plan, like dental, that includes the College Tuition Benefit® can earn 2,000 Tuition Reward® points annually, per product. Each tuition reward point equals $1 in tuition reduction; accumulated points can be used to pay up to one year’s tuition at one of more than 400 private colleges and universities across the nation. The benefit can be included with up to four lines of Guardian coverage with rewards increasing each year and with each line of coverage.
In addition, Guardian’s Administrative Services Only (ASO) option offers the same product features, network and claims processing as fully-insured. For those hesitant to move to ASO, we offer an innovative Level-Funded option that offers fixed monthly costs starting with a 105% aggregate stop loss, and if claims are lower than expected, Guardian returns the entire surplus to the employer.
Cabra & Childers, Premier Access:
We have not made changes.
Steinhoff, Aflac:
Aflac has the ability to enroll several product lines within the same third-party enrollment platform. All of our traditional supplemental insurance products, life, disability, dental and vision insurance plans can all be enrolled by our team at the same time. We can also help HR staff streamline their open enrollment process by bundling several products together.
4. Has COVID-19 changed any of your offerings or had a substantial impact on any of your plans, like a change in claims or use of benefits due to postponing care during the pandemic?
Zeedik, Blue Shield of CA:
Teledentistry has been an added option during the COVID-19 pandemic. Teledentistry codes are included in Blue Shield dental plans, and members are able to meet virtually with a dentist to discuss issues and determine whether emergency care is needed. Customer Care has been able to assist members in finding a provider who offers teledentistry if their current provider does not offer this service.
Stefano, Guardian:
In 2020, we introduced Guardian’s Pandemic Support program to help employers manage costs and continue to provide affordable, uninterrupted access to dental care. Through the program we offered a one-month premium credit for fully insured dental plans or an extended rate guarantee. We also made plan changes including enhancing frequency limits on dental cleanings, exams, and fluoride treatments (if applicable) to a minimum of two per calendar year from July 1, 2020 through December 31, 2021. We also provided PPE financial relief to our network providers to help ensure the safety of their practices as well as our members.
To help address the changing needs of members, we offered in-network coverage and discounts on byte® at-home invisible aligner treatments to help members straighten their teeth without visiting a dental office, and we launched Guardian Teledentistry to provide easy access to urgent dental care without visiting the dentist.
Cabra & Childers, Premier Access:
We have not made COVID-19 related changes to plans/benefits.
Steinhoff, Aflac:
Across the industry, pandemic conditions led to a decrease in dental claims last year. This helped influence multi year rate guarantee extensions as well as more aggressive new business pricing. Persistency within the industry has been at an all-time high, and we have now seen an increase of people using their dental providers and insurance benefits as they become comfortable visiting their providers.
5. Do you reimburse for out-of-network dentists if an insured chooses to go outside of your network?
Zeedik, Blue Shield of CA:
Yes. PPO plan members can choose to go to any dentist, although their benefits will be covered at a higher percentage when choosing a network dentist, with a lower out-of-pocket expense.
For non-network claims, the reasonable and customary expense allowance is provided by FAIR Health. The FAIR Health data is updated every six months and has UCR allowances from 50% to 95% in 5% increments. The UCR percentage utilized to process claims depends on the plan’s out-of-network (OON) benefit design.
Stefano, Guardian:
Members covered under our PPO plans can visit any dentist; however, benefits may be paid at a lower coinsurance rate for non-participating dentists. Managed Dental Care/DHMO members must choose a participating primary care dentist.
Cabra & Childers, Premier Access:
Yes. Members can access care from any dentist. With our PPO plans, they can use our Premier Choice Network (PCN), which is a smaller, select group of dentists that offers extreme member discounts; our Preferred Provider Network, which includes all contracted dentists with significant discounts; or an out-of-network dentist of the member’s choice.
Steinhoff, Aflac:
Our Passive PPO plans and MAC plans provide coinsurance options as well as reimbursing and paying claims directly for out-of-network providers. Our PPO plans use the 90th usual, customary and reasonable (UCR) amount within our small-group segment. Our large-group segment has the ability to customize the UCR amounts and increase or decrease it depending on the customer’s needs.
6. How many provider locations do you have?
Zeedik, Blue Shield of CA:
Blue Shield’s Dental HMO network includes more than 22,000 access points in California. Our Dental PPO network includes more than 45,000 provider access points in California and over 400,000 nationwide. These are two of the largest statewide provider networks in the industry.
Stefano, Guardian:
There are over 482,063 PPO access points across the country and more than 50,728 in California (Source: Network360). We are one of the largest PPO networks in the state based on dentists. The DentalGuard Alliance network tier, a smaller group of dentists offering greater discounts, has over 4,721 dentist access points in California. For the DHMO, there are 8,558 general dentists and specialist access points in California. Guardian’s PPO network also includes dental offices in Mexico.
International Assist, a value-added service available, provides dental members with access to dental care if needed while traveling outside of the U.S.
Brokers should be aware of new features introduced to address the changing needs of members.
— Joe Stefano, Guardian
Cabra & Childers, Premier Access:
In California, we have 10,900 PPO locations and 1,298 DHMO locations. Steinhoff, Aflac: Aflac Dental Insurance offers over 303,000 access points and comprises over 75,000 unique providers in the Aflac Dental Network.
Steinhoff, Aflac: Aflac Dental Insurance offers over 303,000 access points and comprises over 75,000 unique providers in the Aflac Dental Network.
7. What percentage of your network is open to new enrollment? How many offices does this represent?
Zeedik, Blue Shield of CA:
In 2020, approximately 96% of dental HMO plan network providers maintain open practices. This represents 21,910 out of 22,834 access points. View our dental network map for an overview of county coverage.
Stefano, Guardian:
In California, only 0.003% of our PPO network and 4.5% of our DHMO network are closed to new patients.
Cabra & Childers, Premier Access:
We do not have this data at this time. Historically, the DHMO panel is at about 80 % and PPO is at about 90%.
Steinhoff, Aflac:
In the Aflac Dental Insurance network, 99.5% of our in-network offices are accepting new members to their offices.
8. What happens if a member is still in the middle of orthodontic treatment and they lose their coverage due to a job change or other circumstance?
Zeedik, Blue Shield of CA:
Providers are typically reimbursed for orthodontia over a 24-month period. In the event of an insured’s loss of coverage for any reason, if at the time of loss of coverage the insured is still receiving orthodontic treatment during the 24-month treatment period, the insured and not the dental plan administrator will be responsible for the remainder of the cost for that treatment, at the participating orthodontist’s billed charges, prorated for the number of months remaining.
Stefano, Guardian:
If a member is undergoing orthodontic treatment and his or her Guardian coverage terminates, we prorate the benefit to cover only the period during which coverage was in force. We do not extend benefits.
Our DHMO agreement provides for the Contracted Orthodontist to complete treatment at the contracted patient charge on a number of our plans. As an additional contract rider, we can allow for supplemental transfer coverage for Orthodontia under our DHMO.
Cabra & Childers, Premier Access:
If the member has a PPO plan: Orthodontia is based on a percentage paid to a provider over the course of treatment. Premier Access pays the provider a portion of the maximum ortho benefit at the start of treatment and pays in increments throughout the course of treatment. If a member were to leave Premier Access mid-treatment and move to a new carrier that also had ortho, the member would provide a copy of their EOB, and the new carrier would pay the remaining portion based on the benefit level they offer. If the member has a DHMO plan: Orthodontia is based on a copayment and an agreement between the member and provider. If the member were to leave Premier Access prior to the completion of treatment, the provider would determine whether they will still accept the copayment amount.
Steinhoff, Aflac:
If a member loses eligibility during orthodontic treatment, the reimbursement is typically prorated based on the number of months the member was eligible. However, services required beyond the eligibility period are typically not covered.
9. What are your annual and lifetime maximums if any?
Zeedik, Blue Shield of CA:
Our annual maximums vary from as little as $500 to as much as $5,000 or more, depending upon individual or group coverage and group size. Employers have a choice in annual maximums, with more flexibility for large-group customers to customize their annual maximum to meet their needs.
For large groups, we also offer our Rollover Rewards benefit feature, allowing qualified members to boost their annual maximum.
The annual account reward will vary depending on the annual claims threshold, which is determined by the plan’s chosen annual maximum. The annual network reward for members who visit a network dentist, rather than a non-network dentist, is $100.
Stefano, Guardian:
For PPO, the maximum refers to the total of benefit dollars actually paid for covered services incurred within the annual period, or the member’s lifetime in the case of orthodontia. Guardian has flexibility with maximums. Typically, Preventive, Basic and Major have a combined maximum. We offer both an annual single maximum option (range from $500 – $5,000) and an annual split maximum option (maximums differ for in-network and out-of-network services).
With the Preventive Advantage option, only Basic and Major services count toward the annual maximum. Maximum Rollover allows a portion of unused annual maximums to carry over for future years. We also offer an option to cover cleaning after the maximum is reached. For orthodontia, the lifetime maximum options range from $500-$2,500. Our DHMO plans do not include an annual maximum.
Cabra & Childers, Premier Access:
Benefit maximus are determined during the quoting process. Our maximums will only change if a request is completed during the renewal process. Annual maximums are per member and vary between $500 and $5,000.
Steinhoff, Aflac:
For our small-group segment, depending on the plan level, Aflac Dental Insurance annual maximums range from $1,000-$2,000. All plans allow insureds to carry over $250 each year toward their annual maximum, up to a total of $1,000, for use with any qualifying dental expense.
Optional orthodontia benefits provide an annual maximum of $750 and a lifetime maximum of $1,500.
Our large-group plans allow for customization for both annual and lifetime maximums. Our annual maximums start at $500 and are capped at $10,000. Our lifetime maximums within our orthodontia benefit start at $500 and are capped at $5,000.
10. What is the plan deductible?
Zeedik, Blue Shield of CA:
Deductibles can vary from as little as $0 to as much as $300 or more, dependent upon group size and indivi-dual or family coverage. Employers have a choice in deductibles, with more flexibility for large-group customers to customize their annual deductible to meet their needs.
Stefano, Guardian:
Our PPO product offers many different deductible options ranging from $0-$300 and will vary by plan design with $50 historically being the most common. Deductibles are often waived for Preventive Services as Guardian’s plans are designed to encourage members to get preventive care, thereby avoiding the need for more extensive dental care in the future. All our DHMO plan designs offered in California have no deductibles.
Cabra & Childers, Premier Access:
Deductibles vary between $0 and $100. The plan deductible is determined during the quoting process and will only change if a request is completed during renewal. Plan deductibles are typically for three members of family coverage; however, if the broker/group would like to see other options — such as a deductible for two or four members — they can request that during the quoting process. Deductibles are one-time occurrences during a calendar year. We can give a credit for the deductible for new business if proof the deductible was met is provided.
Steinhoff, Aflac:
In our small group segment, Aflac Dental Insurance plans provide a deductible that decreases over time. With this new-to-market benefit, insureds see a reduced deductible each year the plan is in force, with the first year at $50 per person, the second decreasing to $25 per person, and the third and subsequent years seeing no deductible. Aflac large-group dental insurance plans can use the same deductible that decreases over time and customize their deductibles to any annual or lifetime amount.
11. What percentage does your plan cover for: preventive costs, root canals, crowns?
Zeedik, Blue Shield of CA:
Preventive costs
Preventive care is covered at 100% when using a network provider. Out-of-network coverage will vary based on the plan selected, but is typically not less than 80%. Members may also be balance billed for amounts exceeding the allowable payment to non-network providers based on their plan. For large groups, there is additional flexibility to customize the percentage of costs covered.
Root canals
For large groups, root canals can be covered under basic or major services. Typically, basic services are covered at 80% and major services are covered at 50%. Out-of-network coverage will vary based on the plan selected, but the most common percentage is 50%. For IFP, root canals are typically covered under major services at 50%. For small groups, root canals are typically covered under basic services at 80%.
Crowns
Typically, for all lines of business, crowns are considered major services and are covered at 50%.
Stefano, Guardian:
Preventive
While we offer a variety of options, the most common for DHMO and PPO is 100%.
Root canals
For PPO, we most often cover root canals as a basic service. 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.
Crowns
For PPO, we most often cover crowns as a major service and 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.
Cabra & Childers, Premier Access:
Percentages are determined during the quoting process and vary among our PCN network, PPO network, and out-of-network dentists. Procedures can be moved among preventive, basic, and major services. The covered benefit percentage is at the discretion of the broker and the client, with the goal of providing the most comprehensive, cost-effective plan for the members.
Steinhoff, Aflac:
For our small-group segment, all Aflac Dental Insurance plans cover 100% of costs and waive the deductible for preventative and diagnostic services. Depending on the plan level, basic services, including crown repair, are covered at 80-90% and major services, including root canals and crowns, are covered at 10-50%. Aflac dental Insiurance plans in our large-group segment can have customized coinsurance percentages, allowing for several different coinsurance options. For preventative costs, 100% coverage is standard.
12. Do you provide dentist cost and quality transparency tools?
Zeedik, Blue Shield of CA:
Yes. Once registered on our website, members may review their claims information and locate providers. They also have access to treatment cost information through our Treatment Cost Estimator. The Treatment Cost Estimator allows members to search for common procedures, including exams, cleanings, X-rays, fillings, and root canals. This tool is quick and easy to use, enabling members to promptly receive estimated costs for procedures.
Members are encouraged to have a pre-determination completed for any services estimated at $300 or more. This will provide a detailed report with member’s total out-of-pocket expense based on the services suggested by a determined provider.
— Cabra & Childers, Premier Access
Stefano, Guardian:
We have a Dental Cost Estimator tool that provides an estimated range of allowable charges (fee schedule amounts) for the selected procedure codes in a selected region and provider contracted tier. Note that this is not the actual Guardian fee schedule amount for a provider nor the expected paid amount for a particular Guardian plan design. At this time, we do not offer provider quality ratings.
Cabra & Childers, Premier Access:
Members are encou-raged to have a pre-determination completed for any services estimated at $300 or more. This will provide a detailed report with member’s total out-of-pocket expense based on the services suggested by a determined provider. Members are encouraged to use our website to find an in-network—either PCN or PPO—provider to get the lowest possible out-of-pocket cost.
Steinhoff, Aflac:
Aflac launched all group dental plans nationally in January 2021, and we are still completing some of these detailed tools. We are able to provide network analysis reports, premium vs. claims, provider utilization reports and procedure utilization reports.
13. Who can readers contact for more information?
Zeedik, Blue Shield of CA:
Brokers who currently work with Blue Shield of CA should contact their Blue Shield representative.
Stefano, Guardian:
The Guardian Life Insurance Company of America. Joe Stefano, Divisional VP, Western U.S. at jstefano@glic.com
Cabra & Childers, Premier Access:
Readers can contact the Premier Access sales team at sales@premierlife.com.
Steinhoff, Aflac:
For more information, including plan highlights, provider search and member portal, get to know Aflac and our Dental Insurance at Aflac.com/NetworkDental.
For other inquiries, please email mediarelations@Aflac.com.