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Questions and Answers
What is the purpose of the product guide?
What is the purpose of the product guide?
Training or reference tool
When was the most recent update to the product guide?
When was the most recent update to the product guide?
February 2023
Guardian recognizes common law marriage as the equivalent of a ceremonial marriage.
Guardian recognizes common law marriage as the equivalent of a ceremonial marriage.
True
Which types of plans does Guardian offer for group dental insurance?
Which types of plans does Guardian offer for group dental insurance?
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What is the minimum number of insured lives for a group to offer retiree coverage?
What is the minimum number of insured lives for a group to offer retiree coverage?
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What are the participation percentage requirements for a Non-Contributory plan?
What are the participation percentage requirements for a Non-Contributory plan?
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Under a DHMO plan, members pay a set dollar amount known as a ______.
Under a DHMO plan, members pay a set dollar amount known as a ______.
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Late entrant penalties apply to preventive services.
Late entrant penalties apply to preventive services.
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What is the name of Guardian's PPO network?
What is the name of Guardian's PPO network?
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Which of the following is NOT a feature of an Indemnity plan?
Which of the following is NOT a feature of an Indemnity plan?
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Which states include coverage for diagnostic, non-surgical, and surgical treatment as a Major service?
Which states include coverage for diagnostic, non-surgical, and surgical treatment as a Major service?
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In New Mexico, a separate TMJ maximum can be applied per state regulation.
In New Mexico, a separate TMJ maximum can be applied per state regulation.
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In Washington, TMJ coverage is required for ______ group plans.
In Washington, TMJ coverage is required for ______ group plans.
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Monthly Switch allows members to switch plans only once annually.
Monthly Switch allows members to switch plans only once annually.
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What do DHMO and PPO stand for?
What do DHMO and PPO stand for?
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Guardian handles eligibility, billing, premium collection, and commission payments for Dominion, Liberty Dental, and TDA.
Guardian handles eligibility, billing, premium collection, and commission payments for Dominion, Liberty Dental, and TDA.
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What is the maximum benefit year limit mentioned for TMJ coverage in Washington?
What is the maximum benefit year limit mentioned for TMJ coverage in Washington?
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Which factors impact Guardian's dental rates?
Which factors impact Guardian's dental rates?
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What does 'Underwriting' mean in the context of insurance?
What does 'Underwriting' mean in the context of insurance?
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What does a fully insured planholder do?
What does a fully insured planholder do?
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In Administrative Services Only (ASO) plans, Guardian pays claims and is reimbursed by the planholder.
In Administrative Services Only (ASO) plans, Guardian pays claims and is reimbursed by the planholder.
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What is the liability of Guardian as the insurer in a fully insured plan?
What is the liability of Guardian as the insurer in a fully insured plan?
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A planholder in an ASO plan holds __% of the risk.
A planholder in an ASO plan holds __% of the risk.
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Match the following terms with their definitions:
Match the following terms with their definitions:
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What determines the premium rates for the next plan year in a fully insured plan?
What determines the premium rates for the next plan year in a fully insured plan?
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Guardian issues an Administrative Services Only Agreement (ASA) to the planholder in a fully insured plan.
Guardian issues an Administrative Services Only Agreement (ASA) to the planholder in a fully insured plan.
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What is one of the financial liabilities for a fully insured plan?
What is one of the financial liabilities for a fully insured plan?
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Under a check writing option, Guardian continues to fund claims for the employer for the first __ months.
Under a check writing option, Guardian continues to fund claims for the employer for the first __ months.
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What does a Level-Funded ASO plan offer?
What does a Level-Funded ASO plan offer?
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What is a key feature of a Voluntary ASO plan?
What is a key feature of a Voluntary ASO plan?
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What is the 90th percentile in dental fees?
What is the 90th percentile in dental fees?
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Which of the following is a feature of Guardian's 95th schedule?
Which of the following is a feature of Guardian's 95th schedule?
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What is balance billing?
What is balance billing?
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How does lowering the percentile affect claims costs?
How does lowering the percentile affect claims costs?
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What is the most common deductible amount for Guardian's plans?
What is the most common deductible amount for Guardian's plans?
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What does coinsurance represent in dental plans?
What does coinsurance represent in dental plans?
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Which PPO plan provides a higher in-network benefit year maximum than out-of-network?
Which PPO plan provides a higher in-network benefit year maximum than out-of-network?
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What reimbursement method is used for non-contracted dentists?
What reimbursement method is used for non-contracted dentists?
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Guardian utilizes UCR terminology for all dental plans.
Guardian utilizes UCR terminology for all dental plans.
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Match the plan types with their features:
Match the plan types with their features:
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What is the coinsurance percentage for Category 2 - Basic services in the DentalGuard Preferred plan?
What is the coinsurance percentage for Category 2 - Basic services in the DentalGuard Preferred plan?
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What is the annual maximum benefit for categories 1-3 in the out-of-network plan?
What is the annual maximum benefit for categories 1-3 in the out-of-network plan?
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What is the deductible for both the DentalGuard Preferred and Out-of-Network plans?
What is the deductible for both the DentalGuard Preferred and Out-of-Network plans?
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The Guardian Choice Plan allows you to choose between two dental plans with different rates.
The Guardian Choice Plan allows you to choose between two dental plans with different rates.
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What are the options available in the Guardian Choice Plans?
What are the options available in the Guardian Choice Plans?
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How often can members switch between Value Plan and NAP?
How often can members switch between Value Plan and NAP?
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How frequently must dentists be re-credentialed?
How frequently must dentists be re-credentialed?
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Grievances are not logged or tracked through the grievance program.
Grievances are not logged or tracked through the grievance program.
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The missing tooth exclusion means Guardian does not pay for a prosthetic device that replaces lost teeth unless the device also replaces one or more natural teeth lost or extracted __________ the covered person became insured by the plan.
The missing tooth exclusion means Guardian does not pay for a prosthetic device that replaces lost teeth unless the device also replaces one or more natural teeth lost or extracted __________ the covered person became insured by the plan.
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Which guideline must be satisfied for buy-up plans?
Which guideline must be satisfied for buy-up plans?
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What is required for a group to qualify for a buy-up plan?
What is required for a group to qualify for a buy-up plan?
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What is the primary role of an underwriter in insurance?
What is the primary role of an underwriter in insurance?
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Which of the following best describes a non-transferred or virgin group in dental insurance?
Which of the following best describes a non-transferred or virgin group in dental insurance?
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Dental procedures typically have higher costs than medical procedures.
Dental procedures typically have higher costs than medical procedures.
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What is the range for a dental benefit maximum offered by Guardian?
What is the range for a dental benefit maximum offered by Guardian?
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What kind of structures are available for group dental rates?
What kind of structures are available for group dental rates?
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What is a common deductible amount for Guardian’s dental plans?
What is a common deductible amount for Guardian’s dental plans?
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Which of the following types of deductible requires a separate amount for in-network and out-of-network services?
Which of the following types of deductible requires a separate amount for in-network and out-of-network services?
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The split category deductible requires the member to satisfy a deductible for ______ services and another for Basic and Major Services.
The split category deductible requires the member to satisfy a deductible for ______ services and another for Basic and Major Services.
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What is the main purpose of a dental plan deductible?
What is the main purpose of a dental plan deductible?
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Guardian's dental plans impose a deductible for preventive care when received from a contracted dentist.
Guardian's dental plans impose a deductible for preventive care when received from a contracted dentist.
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What benefit does the Maximum Rollover feature provide?
What benefit does the Maximum Rollover feature provide?
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What is a key feature of the Preventive Advantage benefit?
What is a key feature of the Preventive Advantage benefit?
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Study Notes
Product Overview
- The Group Dental Product Guide serves as a training and reference tool effective from August 2024.
- Updates include a comprehensive rebranding of the guide in February 2023.
eLearning Courses
- A suite of self-paced eLearning courses is available on the Guardian Learning platform.
- Courses cover various knowledge levels for Dental Benefits and Features, including inforce plans that are no longer marketed.
Plan Types
- Guardian offers three main types of group dental insurance:
- Indemnity Plans: Fee-for-service without a provider network; dentists paid at a set reimbursement rate.
- Preferred Provider Organization (PPO) Plans: Access to a network of providers; offers reduced fees through contracted dentists.
- Dental Health Maintenance Organization (DHMO) Plans: Requires members to choose a primary care dentist for a flat monthly fee; members pay copays per service.
Provider Network
- Guardian's PPO network includes over 139,000 providers across more than 378,000 locations nationwide.
- DHMO plans are provided in multiple states, sometimes via subsidiaries and partnerships with other dental administrators.
Plan Eligibility
- Eligibility for enrollment depends on factors including employment length, job status, and dependent criteria.
- Members must enroll during designated periods unless a qualifying event occurs.
Common Law Marriage and Domestic Partnerships
- Common law marriage is recognized; parties must agree on marriage, live together, publicly represent themselves as married, and reside in a recognized state.
- Domestic partnerships are acknowledged without additional documentation or rate increase requirements.
Late Entrant Penalties
- A late entrant fails to enroll within 31 days of eligibility, incurring penalties on various service types:
- 6 months for Basic Services
- 12 months for Major Services
- 24 months for Orthodontia
- Preventive Services are exempt from these penalties.
Retiree Coverage
- Groups must have a minimum of 50 insured lives to offer retiree coverage, with certain criteria around employee contribution.
- Retiree criteria include a minimum 10 years of service and enrollment within 31 days of eligibility.
Plan Contributions and Funding Types
- Dental plans are categorized as Non-Contributory (employer pays all), Contributory (employer pays more than 20%), or Voluntary (employer pays 20% or less).
- Participation requirements vary; higher enrollment reduces insurance risk.
Funding Options
- Two funding types are available:
- Fully Insured Plans: Guardian covers all claims regardless of premium amounts.
- Administrative Services Only (ASO) Plans: Planholders accept a portion of claims risk with reduced initial fees, while Guardian provides administrative support.
Key Comparisons
-
Fully Insured:
- Employers pay monthly premiums; all claims covered by Guardian.
- Risks are entirely borne by Guardian.
-
Administrative Services Only (ASO):
- Planholder pays monthly fees; Guardian administers the plan.
- Claims are reimbursed by the planholder; risks are held by the planholder rather than Guardian.### Benefits, Eligibility, and Exclusions
-
Fully Insured and ASO plans have different guidelines and risk assessments.
-
Example requirement: In Washington and New Hampshire, fully insured plans cover general anesthesia for dental procedures for children under seven.
Financial Liabilities
- Fully Insured plans have premiums based on claims, expenses, and profit; ASO charges a monthly fee or fixed costs.
- ASO plans can include Aggregate Stop Loss to limit claim liability; no year-end accounting needed for both plans.
Contacts
- Guardian serves as the insurer for Fully Insured plans, handling claims and liability for misinformation.
- In ASO, Guardian administers claims following guidelines; liability for misinformation is limited unless Guardian acts as Fiduciary.
Renewals
- Underwriting reviews for Fully Insured premiums based on past expenses and claims trends.
- ASO fee increases range from $.10 to $.30 or 3% to 10%, whichever is greater.
Cancellations
- Fully Insured plan cancellation allows Guardian to pay claims from collected premiums prior to cancellation.
- ASO cancellation can lead to continued claims processing for a defined period depending on terms met.
Dental ASO Options and Cost Comparison
- Various Dental ASO options include Direct Banking, Guardian assuming Fiduciary responsibility, and tiered plans based on dependents.
- Level-Funded ASO plans provide stable funding for groups with budget constraints, combining PPOs with ASO flexibility.
Voluntary ASO
- Subject to ERISA unless specified otherwise; planholders must establish a trust for fund management.
Underwriting
- Involves accepting liability for specified losses and determining risk levels for dental benefits.
- No evidence of insurability is needed; low-risk associated with dental compared to medical insurance.
Plan Design and Rating
- Rates are influenced by claims experience, demographics, and design elements like deductibles and coinsurance.
- Different rate tier structures are available, including four-tier, three-tier (rostered and non-rostered), and two-tier.
PPO Plan Foundations and Deductibles
- Deductibles manage upfront costs; typically waived for preventive services received from contracted dentists.
- Common deductible amount is $50 per member, capped at three members per family; non-contracted services may incur deductibles.### Deductible Options
- Individual deductibles range from $0 to $300, with $50 being the most typical.
- Individual deductibles must be met annually on each plan.
- Family plans have a standard limit of three deductibles per year; optional family limits can be set at two or removed altogether for a discount.
- Split deductibles require different amounts for in-network and out-of-network services (e.g., $50 in-network, $100 out-of-network).
- Split category deductibles entail separate deductibles for Preventive Services and combined Basic and Major Services.
- A lifetime deductible option allows members to not satisfy annual deductibles once met, commonly ranging from $25 to $300.
- Deductible credit applies when transitioning from a previous plan, reducing the new deductible based on prior plan usage.
- Diminishing deductibles decrease over a three-year coverage period to encourage plan loyalty.
Coinsurance
- Coinsurance indicates the member's share of costs after the deductible is met, differing by type of dental service.
- Services are categorized into Preventive, Basic, Major, and Orthodontic.
- Four coinsurance plan options are available: Preventive Only, Preventive Plus, Incentive Coinsurance, and Bundled Coinsurance.
- Preventive Only plans focus solely on preventive services, while Preventive Plus includes basic fillings and extractions.
Maximum Rollover
- Maximum Rollover allows members to carry over unused annual maximums into a personal Maximum Rollover Account (MRA).
- MRA assists members in saving for extensive future dental care, with limits based on unused amounts.
- Maximum Rollover is available for groups with at least two employees and cannot be used on specific plan types.
- Members must not exceed a threshold of paid claims to qualify for the rollover.
- Bonus Rollover Rewards are given when all claims are with contracted dentists.
Reimbursement Level
- The reimbursement level determines payment amounts based on Reasonable and Customary (R&C) fees for out-of-network providers.
- R&C is based on percentile comparisons of dentist charges in a geographic area, with the common threshold at the 90th percentile.
- Members bear costs exceeding the reimbursement limit, known as balance billing.
- Additional reimbursement options at the 95th percentile or 135% of the 90th percentile can reduce balance billing incidents for higher fees.
Indemnity Plans
- Indemnity plans lack access to a network of providers and are becoming less common compared to PPO plans.
Preferred Provider Organization (PPO) Plans
- PPO plans provide access to a network of dentists with discounted fees through Guardian's DentalGuard Preferred (DGP) network.
- Members can access non-network dentists at higher costs, similar to indemnity plans.
- Key components of PPOs include deductibles, coinsurance, benefit maximums, and reimbursement levels.
- Benefit maximums typically range from $500 to $5,000, with common maximums at $1,000 and $1,500.
- In PPOs, preventive services often have waived deductibles to encourage regular dental care.
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Description
This product guide serves as a comprehensive training and reference tool for the Group Dental Product. Users can utilize the Table of Contents or the 'Find' feature in Adobe Acrobat for efficient navigation. It includes up-to-date information to assist with product-related queries.
