While Delta Dental now offers a Pediatric Oral Essential Health Benefit (POEHB) plan on Wisconsin’s Federally Facilitated Marketplace (FFM) of Individual and SHOP exchanges available at healthcare.gov, we would like to point out that off-exchange, more comprehensive dental benefits are available.
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We talk in abstract terms about the importance of accurate network listings. Here’s a specific, real-life example of what we mean.
One of our sales executives received a message from an agent a couple of weeks ago. A competing dental-insurance carrier was challenging our network listings, claiming they overstated the strength of Delta Dental’s network and understated the competing carrier’s network.
As proof they supplied their own network listings for a large metropolitan-area chain of dental clinics.
The agent passed on the accusation to the sales executive, who passed it on to me.
When we get these sorts of things – and we get them more often than you’d think – we have a standard protocol for addressing them.
First, we have a scrupulously maintained database of dentists – all dentists statewide. We have not only their network affiliation with us, but their affiliations with all the major carriers. We know at a glance who the dentists are in a county or city, what networks they belong to, and whether they practice at more than one location. We update this information monthly – or more frequently, if circumstances warrant.
In this case, the competitor had produced a listing of 24 dentists, and claimed they were all practicing at the stated locations. We found that only 10 were practicing where the competitor claimed they were – but better than that, five of these “active” dentists had not been practicing at that location for two years. Four more “active” dentists had been inactive for more than a year.
But we didn’t stop there. We picked up the phone and called the offices in question. We asked them, “Could you please tell me what dentists are practicing in your office?” The answers we received from three of the four offices corresponded perfectly with Delta Dental’s network listings.
We didn’t receive an answer from the fourth office on the competitor’s listing. It was closed – because there was no provider to practice there.
In less than five minutes we were able to show that a competitor’s listing that was touted as being 100 percent correct was actually less than 42 percent correct. And Delta Dental’s listings were 100 percent correct.
This isn’t an accident. Other carriers have a couple of professional-relations representatives to cover the entire nation. Delta Dental’s has two professional-relations experts that cover the state, visiting offices and auditing locations for accuracy—plus we devote a lot of time and effort to analyzing everyone’s network listings. We put them on a common footing and see whose numbers truly are the largest.
Coincidentally, we just released a video that talks about our approach to building and counting networks. Visit http://www.deltadentalwi.com/Alert-Resources-Aug13 and you’ll see what we mean.
We appreciate challenges like this. Personally, it gets me fired up. It’s not only an opportunity to set the record straight, but it’s another opportunity to help our agents and employers stay informed and succeed.
Next time we’ll look at how “industry-standard” numbers might not be so standard, and what we do on our end to ensure our network numbers are as accurate as possible.
Life is full of uncertainties, and knowing your risk is one way of controlling your future. Oral health is no different. Understanding your oral-health risk helps you understand how likely a future dental problem might be.
Risk is controlled by “risk factors,” which can be related to personal habits, behaviors, or your environment. Take tooth decay; personal habits like brushing and flossing and environmental factors such as drinking from a fluoridated water supply can influence your risk of tooth decay.
Risk factors can also be positive or negative. Brushing with fluoridated toothpaste is a positive risk factor decreasing the risk for future tooth decay, while eating frequent sugary snacks is a negative risk factor – it increases risk.
When taken together, these risk factors provide an overall risk profile – a risk score that helps you understand and predict the likelihood of future problems. Your overall score can determine if your risk is low, moderate, high, or even very high for future oral-health problems.
By knowing your risk factors, you can also determine what behaviors or environmental factors you need to change to improve your overall score. Maintaining a low risk score helps you control your future.
One easy way to determine your oral-health risk is with a simple online questionnaire found on the Delta Dental of Wisconsin web site (http://www.deltadentalwi.com/) by clicking on the link titled “How does your smile score?” This self-assessment tool asks specific questions about your positive and negative risk factors, and questions related to the condition of your teeth and gums.
The results will give you an overall score from one (corresponding to very low risk ) to five (corresponding to very high risk), for tooth decay, gum (periodontal) disease, and oral cancer. It also provides scores on the same one-to-five scale for your gum health and tooth needs.
The assessment provides explanations of what the scores mean, and what you can do to maintain or improve each score. There is also a helpful library with information on how to control and improve your oral-health risk.
The questionnaire is age-specific, so you can complete it for yourself or your children, and you can repeat the assessment as often as you like. You can even print the results, take them to your next dental appointment, and discuss them with your dentist.
Knowing your risk is the first step in controlling your risk, and controlling your risk is controlling your future.
So much of the ACA-related talk in the marketplace has had to do with bundling health and dental benefits. But here’s a thought: If any of your clients have combined medical and dental plans, it may actually be time to separate these plans.
In official terminology, a dental plan divorced from a medical plan is called a separate offering. In general, separate offerings are characterized by 1) an independent decision to purchase and 2) a separate premium.
Let’s look at some reasons why a separate-offering approach makes sense.
One common characteristic of combined plans is single election. With single election, employees only have one choice when it comes to their combined plan: Enroll in both plans, or no plan at all.
By separating a combined plan with single election, an employer can:
If vision benefits are included in health benefit plans the same considerations may apply.
Another strategy to consider given the ACA health-plan environment is to exclude oral surgery from the medical benefit plan and include this benefit in the dental plan.
Benefits of this strategy include greater benefit-plan flexibility, avoidance of the Cadillac tax and improved management of the oral-surgery benefit with a specialty vendor such as Delta Dental.
Convenience is often cited as a reason not to separate plans. However, if the dental is placed with a carrier like Delta Dental that specializes is easy transitions and low-stress administration, the result may actual be a decrease in overall “noise” coming from the medical and dental plans.
Delta Dental has dental and vision plans to fit each employer’s ACA benefits strategy. Talk to your Delta Dental representative who will help you optimize each of your clients’ benefit plans.
This may or may not have been an intended consequence of the Affordable Care Act (ACA), but the ACA is prompting many small-business owners to ask, “Does dental have to be embedded in the medical plan? Should I keep my current dental plan? Am I required to purchase a pediatric oral Essential Health Benefit (POEHB) plan?”
In some states the decision has already been made; small-business owners in these states wanting to offer their employees dental-benefit plans face limited choices on how and for whom to purchase dental benefits, along with limited plan-design options.
Fortunately, in Wisconsin small-business owners still have a choice. They can keep buying the dental benefits that provide the highest value from whomever they trust. Don’t be misled; small-business owners are NOT required to embed POEHB coverage with their medical plan. In fact, employers aren’t required to purchase POEHB at all!
Delta Dental of Wisconsin has always offered easy-to-use, easy-to-implement, and easy-to-understand dental benefit plans that employers have come to trust. They work. There is nothing broken about dental benefits that the ACA could possibly fix, and there’s no need to complicate group dental benefits when Delta Dental plans have always accomplished the goals of the ACA – affordable, transparent, health-enhancing benefits for adults and children.
There are many compelling arguments for keeping a conventional group dental plan in place. First and most importantly, the coverage is better. Let’s define better: Better is not achieved by simply adding an out-of-pocket limit to a child-only dental plan. Better is a dental-benefits plan that is consistent, understandable, provides benefits for every member of the family, is affordable, and gives the customer the chance to save money on most dental procedures.
Second, consider the message that’s being sent to employees. The pediatric oral Essential Health Benefit only covers dependents up to age 19. Children’s oral health is vital, but adult oral health is equally important, especially for individuals who have periodontal disease or health conditions that benefit from regular and preventive oral healthcare. Given that, why would a small-business owner put a plan in place that only covers only the children of employees? What about the employees themselves?
For 50 years, Delta Dental has been working to maintain healthy communities and healthy teeth. As Wisconsin’s first not-for-profit dental-benefits provider, we are proud to support important oral-health causes statewide. Whether you looking for voluntary plans or PPO plans that reduce out-of-pocket costs, Delta Dental is here to help, with carefully designed products that make your benefit dollars go further and deliver the world-class service you’ve come to expect from Delta Dental.
The coming months are sure to be filled with change, disruption, confusion, and uncertainty. Through these trying times, you can continue to trust the Wisconsin dental plan that has advocated for oral-health initiatives and supported Wisconsin businesses and communities for more than 50 years.
Delta Dental of Wisconsin. Simple. Experienced. Trustworthy. Committed.
There’s been a whirlwind of activity around implementation of the Affordable Care Act (ACA), so this seems like a good time to update what’s happening with the ACA and dental.
A lot has happened. Last time, we discussed the “outside-the-exchange” waiver issue (i.e., standalone dental plans providing pediatric dental coverage instead of having it embedded in the medical plan). On April 2, the Wisconsin Office of the Commissioner of Insurance (OCI) clarified how medical plans can be in compliance off-exchange when pediatric dental coverage is excluded from the medical plan.
The OCI bulletin deals with pediatric dental coverage provided through standalone dental plans, and stipulates that all comprehensive small-group and individual health plans sold in Wisconsin (on- and off-exchange) have to disclose prior to sale whether they cover pediatric dental. This means the 98 percent of the market that buys medical and dental separately retains the ability to buy the dental coverage that best meets their family’s oral-health needs.
At the federal level, the Centers for Medicare & Medicaid Services (CMS) clarified some outstanding issues related to standalone dental plans. In past blogs, we’ve discussed what a “reasonable” out-of-pocket (OOP) limit for standalone dental plans might be, and how medically necessary orthodontia will be defined. Now we have answers!
What is a reasonable OOP limit for standalone dental plans? Price and OOP limit move in opposite directions – the higher the limit the lower the price, and vice versa – so ultimately, “reasonable” needs to balance the two. For federally facilitated exchanges (FFE), CMS has stated that “reasonable” is an OOP limit of $700 or less per child, with a 2x family limit. Since premium is excluded from the OOP limit, the maximum a family will spend annually on dental services for children under 19 is $1,400.
The guidance on medically necessary orthodontia lets each carrier define “medically necessary” as part of the coverage, meaning there will not be a common definition of medically necessary orthodontia. Different plans offered by different carriers could have different definitions of medical necessity. The good news is consumers will have choice; a broader definition will cover more children, albeit at a higher price point, while a narrower definition will cover fewer children but at a lower price point.
Finally, we have clarity on timelines. Wisconsin has a public exchange administered by the federal government, more commonly known as an FFE or FFM (federally facilitated marketplace). The filing deadline is fast approaching for products offered on-exchange in FFE/FFM states. The medical-plan filing window is April 1-May 3, and the standalone-dental filing window is May 15-May 31. Products must be filed during these dates to be available to consumers on the exchange for open enrollment. As you can imagine, this is keeping everyone very busy!
There is a lot of work to do as implementation of the ACA continues. You can count on Delta Dental of Wisconsin to stay engaged and informed, and to be your go-to resource for information on the ACA and the future shape of dental benefits in Wisconsin.
Approaching the right question from the right direction can save you money.
Case in point: Delta Dental’s dentist networks.
Let’s suppose you have Delta Dental and need to go the dentist. In the old days, you might have gone to the Yellow Pages, found some dentists close by, and started calling to find out if they were in your plan’s network.
Even today, out-of-network dentists might reply, “We accept all insurance,” but that doesn’t answer the question. They may accept insurance, but your out-of-pocket costs can be significantly higher when you see an out-of-network dentist. The difference can be hundreds or even thousands of dollars.
Similarly, a Delta Dental Premier dentist could say, “We’re a network dentist with Delta Dental” – which is true, but if your plan includes a Delta Dental PPO option, you’ll receive your best benefit when you see a Delta Dental PPO dentist.
You can see how calling around is an inconsistent and inefficient way of finding a Delta Dental network dentist.
Here’s a better approach: Use Delta Dental’s website and online dentist finder (www.deltadentalwi.com/provider-search/dental) to find a dentist.
The website tells you your benefits, and helps point out how you can benefit from seeing a Delta Dental PPO provider.
The dentist finder clearly shows the network affiliation(s) or each listed provider, and the maps let you pinpoint their location – and if you supply your street address, they even include driving directions!
This sort of high-quality information helps consumers make good choices.
So let’s segue to Delta Dental’s networks, and the differences between them.
Delta Dental of Wisconsin has two dentist networks to choose from. The Delta Dental Premier network is Wisconsin’s largest dentist network, and the Delta Dental PPO is Wisconsin’s second-largest network. (The situation is much the same nationally.) Together they save Wisconsin-based groups millions of dollars – almost $80 million in 2012 – and deliver the largest effective discount of any Wisconsin dental carrier.
One of the best things about this is that if a dentist isn’t in the Delta Dental PPO network, they’re probably in the Delta Dental Premier network. You save a little less, but you get treatment guarantees — and you don’t get charged more than the agreed-upon fee, no matter what the dentist charges.
Here’s an example of how that translates into dollars and cents:
| PPO Savings, With A “Safety Net” | Delta Dental PPO Dentist | Delta Dental Premier Dentist | Out-of-Network Dentist |
| Dentist’s Normal Fee* | $720 | $720 | $720 |
| Allowed Amount* | $590 | $680 | $680 |
| Dentist Fee Adjustment Due to Delta Dental Agreement* | $130 | $40 | None |
| 50% Benefit Paid by Plan* | $295 | $340 | $340 |
| Patient Responsibility* | $295 | $340 | $380 |
*Approximate fees and percentages for illustrative purposes
The Delta Dental Premier network (if your plan includes it) is a great safety net. With other dental-insurance companies, if you don’t see a PPO dentist, you pay more – sometimes a lot more – and it’s a big hassle.
Ninety percent of Wisconsin dentists are in a Delta Dental network, so chances are you’ll save money every time you see the dentist — no matter what dentist you see. But think of the extra you’ll save if you see a Delta Dental PPO dentist.
Being a savvy consumer is more important than ever. And while it starts with asking the right questions, it’s evolved into finding the right answers – and with the new website, it’s easier than ever.
The pieces continue to come together as we work to understand the full impact of the Affordable Care Act (ACA). A big piece fell into place when the Department of Health and Human Services (HHS) released its final rule on the Essential Health Benefits (EHB), Actuarial Value (AV) and Accreditation on Feb. 20. The rule lets us address some of the unknowns raised in past blogs as well as confirm some of the proposed rules.
The most important development for standalone dental is that HHS granted the long-requested “outside the exchange” waiver. Specifically, HHS said the pediatric-oral EHB (POEHB) can be offered on- and off-exchange through a standalone dental plan. Previously, the POEHB could be provided through a standalone dental plan on-exchange, but had to be embedded in the medical plan off-exchange.
This clarification clears the way for the separate choice and purchase of medical and dental coverage on- and off-exchange, meaning the 98 percent of the market that buys medical and dental separately can keep doing so. Standalone dental will be treated the same on- and off-exchange.
The waiver off-exchange also means childless adults who buy medical coverage off-exchange do not have to purchase the POEHB. Previously, any medical plan sold in the small-group or individual market off-exchange had to embed POEHB, meaning childless adults would be paying for coverage they didn’t need and couldn’t use. Now they can buy a medical plan and a standalone dental plan that mirrors their coverage needs.
As part of the final rule, “pediatric” is defined as up to age 19, with flexibility for states to extend pediatric coverage beyond this limit. This matches the definition in the proposed rule released last November.
HHS also confirmed and clarified coordination of benefits between medical and standalone dental plans. The POEHB will have a separate out-of-pocket limit if provided by a standalone dental offering, and will be subject to the medical out-of-pocket limit if it’s embedded in the medical plan.
The out-of-pocket limit for standalone dental plans providing the POEHB must be “reasonable,” but the final rule did not define what “reasonable” means. Instead, the limit will be defined by the exchanges. For states (like Wisconsin) with a Federally Facilitated Exchange (FFE), HHS anticipates issuing further interpretive guidance to define “reasonable.” Delta Dental of Wisconsin recommends an out-of-pocket limit of $1,000 as a balance between coverage affordability and member costs.
HHS confirmed as part of the final rule that only “medically necessary” orthodontia is covered as part of the POEHB. HHS further clarified in the rule that “cosmetic” was intended to mean “non-medically necessary,” meaning that “non-medically necessary” orthodontia is not covered as part of the POEHB.
In its ruling, HHS reaffirmed that standalone dental plans will calculate AV independently of the other EHBs and will be subject to separate AV requirements, whereas a POEHB embedded in a medical plan will be included as part of the medical AV.
The POEHB sold through standalone dental plans will be classified as either a high plan or a low plan. The November proposed rule set the AV of the high plan at 85% and the low plan at 75%, with a variance of +/- 2%. The final rule created more space between the two standalone dental options. The high AV remained at 85%, but the low AV was adjusted to 70%. The standalone dental AV still has an allowed variance of +/- 2%.
There’s still a lot of work to be done to get ready for ACA implementation. Delta Dental of Wisconsin continues to stay on top of all the latest developments; we remain your source for information on the ACA and the future shape of dental benefits in Wisconsin.
One of the signs that people’s oral health is improving is a higher percentage of dental claims stemming from diagnostic and preventive (D&P) procedures – cleanings, exams, X-rays, fluoride treatments, and sealants. The greater the percentage of D&P claims, the better the general oral health of your population.
The good news is that according to Delta Dental’s annual book-of-business norms study, in 2012 the company’s claims included a greater percentage of D&P claims than ever before.
Adding together diagnostic and preventive claims, 46.7 percent of Delta Dental’s claims fell into these categories. Compare that to 2002, when the total was 39.5 percent, or even 2008, when the total was 43.5 percent.
You can really see what’s happening in the graph below. There’s been a small amount of movement — a negative two-tenths of 1 percent — in the percentage of fillings (the green bar) since 2002. The percentage of claims coming from orthodontics (the rose-colored bar) has slipped 1.3 percent. The percentage of cast crowns (the blue bar) has slipped a substantial 3 percent — and D&P (the yellow and orange bars) has picked up the slack:
These movements may not seem huge from year to year; for instance, the 2011 D&P total was 46.4 percent, meaning the year-over-year movement was 0.3 percent. But when you consider that this is a 0.3 percent movement over millions of claims, suddenly the impact becomes clearer: More and more people are seeing their dentist for preventive care, and not the generally more expensive procedures like root canals and gum-disease treatment.
There are several reasons for this shift, according to Dr. Fred Eichmiller, vice president and science officer at Delta Dental of Wisconsin. Namely:
All of which is very good news for health care and dental benefits.
When it comes to getting an accurate rate quote on your dental benefits, the devil truly is in the details. The more details we get, and the better the quality of those details, the more accurate our quote can be. And accurate quotes usually deliver the best rates over time.
Here is some of the information we need, and a brief explanation of why we need it.
The legal name of the group helps tie a proposal to a group application, which normally asks for a legal business name. The legal business name and DBA are used in the group-benefits documents.
The DBA name of the group, if different from the group’s legal name, helps personalize the quote. A DBA name can also help distinguish companies within a corporate entity.
The physical address/location of the group helps identify whether or not the group can be “covered” under a Delta Dental of Wisconsin plan. It also helps distinguish companies with similar DBA names.
The SIC code or the nature of business ensures that we are providing accurate rates on the proposal, and eliminates the frustration of having to go back to a group and explain why the rates that were sold aren’t valid. SIC is one of the most important pieces of information in calculating an accurate rate.
The # of eligible employees helps determine the product that can be offered. This number is also used in the participation percentage and rating formula.
The # of employees enrolled in the incumbent plan is one data point that determines the final rate by factoring in the percentage of employees that participate in the dental plan currently in place. If there isn’t a current plan in place, it’s safe to estimate 30% to 40% of eligible employees will participate in a new dental plan.
The employer contribution to the premium, if any, is a key determinant of a final rate, when combined with the number of participating employees. A group with high participation and employer contribution percentages usually gets the best rate.
If you have questions on any of the information needed to deliver a quote, please contact any member of our Sales Team. We’re here to help!