Group Dental Product Guide 2024

Questions and Answers

What is the purpose of the product guide?

Training or reference tool

When was the most recent update to the product guide?

February 2023

Guardian recognizes common law marriage as the equivalent of a ceremonial marriage.

True

Which types of plans does Guardian offer for group dental insurance?

All of the above Signup and view all the answers

What is the minimum number of insured lives for a group to offer retiree coverage?

50 Signup and view all the answers

What are the participation percentage requirements for a Non-Contributory plan?

100% Signup and view all the answers

Under a DHMO plan, members pay a set dollar amount known as a ______.

copay Signup and view all the answers

Late entrant penalties apply to preventive services.

False Signup and view all the answers

What is the name of Guardian's PPO network?

DentalGuard Preferred (DGP) Signup and view all the answers

Which of the following is NOT a feature of an Indemnity plan?

Access to a provider network Signup and view all the answers

Which states include coverage for diagnostic, non-surgical, and surgical treatment as a Major service?

Georgia Signup and view all the answers

In New Mexico, a separate TMJ maximum can be applied per state regulation.

False Signup and view all the answers

In Washington, TMJ coverage is required for ______ group plans.

large Signup and view all the answers

Monthly Switch allows members to switch plans only once annually.

False Signup and view all the answers

What do DHMO and PPO stand for?

Dental Health Maintenance Organization and Preferred Provider Organization Signup and view all the answers

Guardian handles eligibility, billing, premium collection, and commission payments for Dominion, Liberty Dental, and TDA.

True Signup and view all the answers

What is the maximum benefit year limit mentioned for TMJ coverage in Washington?

$1,000.00 Signup and view all the answers

Which factors impact Guardian's dental rates?

All of the above Signup and view all the answers

What does 'Underwriting' mean in the context of insurance?

To sign and issue an insurance policy, accepting liability for specific losses. Signup and view all the answers

What does a fully insured planholder do?

Pays monthly premiums Signup and view all the answers

In Administrative Services Only (ASO) plans, Guardian pays claims and is reimbursed by the planholder.

True Signup and view all the answers

What is the liability of Guardian as the insurer in a fully insured plan?

Responsible to pay claims Signup and view all the answers

A planholder in an ASO plan holds __% of the risk.

100 Signup and view all the answers

Match the following terms with their definitions:

Premiums = Claims plus expenses and profit Aggregate Stop Loss = Limits the planholder's self-funded paid claim liability Underwriting = Assessing risk and establishing premiums Voluntary ASO = Subject to ERISA unless otherwise notified Signup and view all the answers

What determines the premium rates for the next plan year in a fully insured plan?

Underwriters Signup and view all the answers

Guardian issues an Administrative Services Only Agreement (ASA) to the planholder in a fully insured plan.

False Signup and view all the answers

What is one of the financial liabilities for a fully insured plan?

No year-end accounting Signup and view all the answers

Under a check writing option, Guardian continues to fund claims for the employer for the first __ months.

3 Signup and view all the answers

What does a Level-Funded ASO plan offer?

A stable budget for varying claims Signup and view all the answers

What is a key feature of a Voluntary ASO plan?

Must establish a trust Signup and view all the answers

What is the 90th percentile in dental fees?

90% of dentists charge the same fee or less Signup and view all the answers

Which of the following is a feature of Guardian's 95th schedule?

Not available on Indemnity or HCR plans Signup and view all the answers

What is balance billing?

The difference between the dentist's charge and the reimbursement amount. Signup and view all the answers

How does lowering the percentile affect claims costs?

It lowers the cost of claims. Signup and view all the answers

What is the most common deductible amount for Guardian's plans?

$50 Signup and view all the answers

What does coinsurance represent in dental plans?

The percent of benefit that Guardian covers after deductible Signup and view all the answers

Which PPO plan provides a higher in-network benefit year maximum than out-of-network?

Split Maximum PPO Signup and view all the answers

What reimbursement method is used for non-contracted dentists?

Reasonable and Customary (R&C) Signup and view all the answers

Guardian utilizes UCR terminology for all dental plans.

False Signup and view all the answers

Match the plan types with their features:

Indemnity Plans = Not using a network of contracted providers PPO Plans = Access to participating dentists with discounted fees NAP = No variability in deductibles between contracted and non-contracted Value Plan = MAC (Maximum Allowable Charge) plan Signup and view all the answers

What is the coinsurance percentage for Category 2 - Basic services in the DentalGuard Preferred plan?

90% Signup and view all the answers

What is the annual maximum benefit for categories 1-3 in the out-of-network plan?

$1,000 Signup and view all the answers

What is the deductible for both the DentalGuard Preferred and Out-of-Network plans?

$50 Signup and view all the answers

The Guardian Choice Plan allows you to choose between two dental plans with different rates.

True Signup and view all the answers

What are the options available in the Guardian Choice Plans?

Value Plan and Network Access Plan Signup and view all the answers

How often can members switch between Value Plan and NAP?

Only at open enrollment Signup and view all the answers

How frequently must dentists be re-credentialed?

Every three years Signup and view all the answers

Grievances are not logged or tracked through the grievance program.

False Signup and view all the answers

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.

after Signup and view all the answers

Which guideline must be satisfied for buy-up plans?

All of the above Signup and view all the answers

What is required for a group to qualify for a buy-up plan?

Ten eligible employees Signup and view all the answers

What is the primary role of an underwriter in insurance?

To handle the underwriting of policies and determine the level of risk and cost for premiums. Signup and view all the answers

Which of the following best describes a non-transferred or virgin group in dental insurance?

A group that has accumulated neglect Signup and view all the answers

Dental procedures typically have higher costs than medical procedures.

False Signup and view all the answers

What is the range for a dental benefit maximum offered by Guardian?

$500 to $5000 Signup and view all the answers

What kind of structures are available for group dental rates?

Three tier structures including rostered and non-rostered Signup and view all the answers

What is a common deductible amount for Guardian’s dental plans?

$50 Signup and view all the answers

Which of the following types of deductible requires a separate amount for in-network and out-of-network services?

Split deductible Signup and view all the answers

The split category deductible requires the member to satisfy a deductible for ______ services and another for Basic and Major Services.

Preventive Signup and view all the answers

What is the main purpose of a dental plan deductible?

To manage risk and adjust cost of the product. Signup and view all the answers

Guardian's dental plans impose a deductible for preventive care when received from a contracted dentist.

False Signup and view all the answers

What benefit does the Maximum Rollover feature provide?

Allows member to roll over unused annual maximum into personal account Signup and view all the answers

What is a key feature of the Preventive Advantage benefit?

Coverage for preventive services without reducing the annual maximum. Signup and view all the answers

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.