Dental Reference Guide_SWandAK.docx

{#section.Coverpage-Title} {#section-1.Coverpage-Title} Group Dental Product {#group-dental-product.Coverpage-Title} ==================== Product Guide {#product-guide.Coverpage-Subtitle} ------------- August 2024 {#august-2024.Coverpage-Subtitle} ----------- About This Product Guide ======================== This product guide can be used as a training or reference tool. Use the Table of Contents or "Find" feature in Adobe Acrobat to quickly locate specific information. Update History ============== Recent revisions to this guide are listed and described below. Page(s) Revised Reason for Revision Date Revised ----------------- ------------------------------------ --------------- Rebranded and Updated Entire Guide February 2023 Self-paced eLearning Courses ============================ There is a suite of courses available that provides a spectrum of knowledge (base through advance level) for Dental located within the Guardian Learning platform. To access these courses, click on the link below: [Group Benefits Dental Product eLearning Courses.pdf](https://glic.sharepoint.com/:b:/r/sites/GroupProductGrowthSolutionsTraining/Released%20Training%20Materials/Dental/Group%20Benefits%20Dental%20Product%20eLearning%20Courses.pdf?csf=1&web=1&e=Yaw39o) These courses also provide information on Dental Benefits and Features for our inforce plans that are no longer marketed. {#section-2.Coverpage-Subtitle} Table of contents {#table-of-contents.TOCHeading} ================= [About This Product Guide 2](#about-this-product-guide) [Update History 3](#update-history) [Self-paced eLearning Courses 3](#self-paced-elearning-courses) [Product Description 8](#product-description) [Introduction to Dental Insurance 8](#introduction-to-dental-insurance) [Plan Eligibility 9](#plan-eligibility) [Eligibility Guidelines 9](#eligibility-guidelines) [Plan Contributions & Funding Types 10](#plan-contributions-funding-types) [Plan Contributions 10](#plan-contributions) [Participation Requirements 11](#participation-requirements) [Plan Funding Types 12](#plan-funding-types) [Underwriting 17](#underwriting) [Risk Selection 17](#risk-selection) [Rating 17](#rating) [Risk Tier Structures 18](#risk-tier-structures) [PPO Plan Foundations 19](#ppo-plan-foundations) [Deductibles 19](#deductibles) [Deductible Options 19](#deductible-options) [Coinsurance 20](#coinsurance) [Coinsurance Options 20](#coinsurance-options) [Maximum Credit 21](#maximum-credit) [Maximum Rollover 21](#maximum-rollover) [High Maximum Plan Features 25](#high-maximum-plan-features) [Preventive Advantage 25](#preventive-advantage) [Reimbursement Level 26](#reimbursement-level) [Indemnity Plans 27](#indemnity-plans-1) [Preferred Provider Organization (PPO) Plans 27](#preferred-provider-organization-ppo-plans-1) [PPO Components 28](#ppo-components) [PPO Plan Types 29](#ppo-plan-types) [Quality Management Program and Network Leasing 35](#quality-management-program-and-network-leasing) [Buy-Up Plans 36](#buy-up-plans) [Guidelines 37](#guidelines) [Options 38](#options-1) [Multi State Cases 38](#multi-state-cases) [Tiered Network 38](#tiered-network) [Overview of Tiered Network 38](#overview-of-tiered-network) [Provider Tier 38](#provider-tier) [How Tiered Network Plans Work 39](#how-tiered-network-plans-work) [DentalGuard Contracts 41](#dentalguard-contracts) [Contract Limitations 41](#contract-limitations) [Contract Exclusions 41](#contract-exclusions) [Contract Provisions 43](#contract-provisions) [Coordination of Benefits 44](#coordination-of-benefits) [DentalGuard 7 Contract: 45](#dentalguard-7-contract) [Deferred Services 46](#deferred-services) [Enhanced DentalGuard Options 46](#enhanced-dentalguard-options) [Orthodontia & Other Optional Benefit Features 47](#orthodontia-other-optional-benefit-features) [Orthodontia Benefit 47](#orthodontia-benefit) [Other Optional Features 47](#other-optional-features) [Dental Health Maintenance Plans (DHMO) 48](#dental-health-maintenance-plans-dhmo) [Managed Dental Care Plans 48](#managed-dental-care-plans) [How does a DHMO work? 49](#how-does-a-dhmo-work) [Quality Management 50](#_Toc128576135) [Advantages of a DHMO (Managed Dental Care) 51](#advantages-of-a-dhmo-managed-dental-care) [Definitions and Terms 52](#definitions-and-terms) [Plan Features 53](#plan-features) [DHMO National Plan Type Features & TPA's 56](#dhmo-national-plan-type-features-tpas) [Underwriting 57](#underwriting-1) [Risk Selection 57](#risk-selection-1) [Rating 58](#rating-1) [Risk Tier Structures 58](#risk-tier-structures-1) [Selling Tips/Positioning Points 59](#selling-tipspositioning-points) [Getting Started 59](#getting-started) [Plan Design 59](#plan-design-3) [Plan Type 59](#plan-type) [Contracts 59](#contracts) [Pricing & UW 60](#pricing-uw) [DHMO 60](#dhmo) This page is intentionally left blank Product Description =================== This section provides an overview to our Dental product. Introduction to Dental Insurance -------------------------------- Dental insurance programs have become a common feature of employee benefit plans. Employers recognize the importance of access to high-quality, economical dental care; and everyone, employers, and employees alike, understand the benefits that good dental health can bring to their overall health and well-being. The basis of any dental insurance plan is to cover the prevention, diagnosis, and treatment of dental disease, defect, or injury. Dental plans are designed to include a substantial out-of-pocket cost shared by the individual. This helps ensure that the employee chooses and uses care appropriately. In this regard, dental plans are "consumer directed." Guardian has a long history of providing dental benefits. Employers are given the choice to empower their employees with making the right decision to improve their oral and overall health. Guardian has one of the largest preferred provider organization networks with over 139,000 providers at more than 378,000 locations nationwide. ### Guardian Dental Plans Guardian's dental plans are flexible and may be adjusted to fit the planholder's needs. Guardian offers three broad types of group dental insurance plans: Indemnity, Preferred Provider Organization (PPO) and Dental Health Maintenance Organization (DHMO) plans. #### Indemnity Plans An Indemnity plan is a fee for service offering that doesn't include access to a provider network. Because there is no network access, all dentists are paid at the same plan benefit. These plans are rarely sold today due to expanded network coverage and have largely been replaced with Passive Preferred Provider Organization (PPO) or Network Access Plan (NAP) plans. The plan covers the amount charged by the dentist for each covered service up to a set reimbursement amount called Reasonable and Customary (R&C). #### Preferred Provider Organization (PPO) Plans Preferred Provider Organization plans, or PPO plans, provide members access to a network of contracted dentists who have agreed to accept discounted fees for services provided. Guardian's PPO network is called DentalGuard Preferred (DGP). Under a PPO plan, members are still free to see a non-contracted dentist however their out-of-pocket costs may be higher. Contracted dentists agree to a discounted fee for each service they provide Guardian refers to Passive PPOs using the term Network Access Plans (NAP). These plans offer identical plan benefits while active PPOs offer richercoverage for services performed by a contracted dentist. #### Dental Health Maintenance Organization (DHMO) Plans Dental Health Maintenance Organization, or DHMO, plans require members to select their primary care dentist from a panel of dentists who have agreed to accept a flat fee per month from Guardian for each member in their care. Guardian's DHMO products are offered under the product brand name Managed Dental Care. Managed Dental Care Plans are offered in the following states: California, Texas, New Jersey, New York, Ohio, Florida, Colorado, Illinois, Indiana, Michigan, and Missouri. In some states, the network is powered by various subsidiaries which were created or acquired by us and are wholly owned subsidiaries of Guardian. In addition, Guardian has entered TPA arrangements and have partnered with Dominion Dental Inc., Liberty Dental Plan and Total Dental Administrators, Inc. (TDA) to offer Managed Dental Care Plans in Maryland, Virginia, District of Columbia, Pennsylvania, Delaware, Nevada, and Arizona. Unlike Indemnity and PPO plans, under a DHMO plan, dentists receive a flat fee that covers all care given to the member regardless of the number or the type of services provided. Instead of coinsurance, members are responsible for a set dollar amount for each type of service, known as a copay. Plan Eligibility ================ Eligibility is defined as the circumstances or conditions that define the guidelines of when an employee may qualify to enroll in a group dental plan and/or a specific category of covered services. These circumstances or conditions may include length of employment, job status, length of time an enrollee has been covered under the plan, dependency, child, and student age limits, etc. Eligibility is managed by the employer and defined in the Certificate of Coverage or Member Guide. An eligible member must enroll in the time period allowed or upon a qualifying event as specified in plan documents. Once an employee becomes eligible, they must be actively at work, performing the major duties of their regular job and working the required number of hours at the location required by the Planholder/employer. Eligibility reports can be sent to the broker or Planholder when requested. Eligibility Guidelines ---------------------- ### Common Law Marriage Guardian recognizes common law marriage as the equivalent of a ceremonial marriage in all respects. The following criteria must be satisfied for common law marriage to be established: - The parties agree that they are married - They must live together as a married couple - Hold themselves in the public as married - Reside in a state that recognizes common law marriage ### Domestic Partnership Guardian acknowledges domestic partnership as any couple that is not traditionally married. Coverage is available on cases with two or more insured under Dental coverage and there is no increase to the rates. Domestic partners are covered in all state and no employee forms or copies of the employer's domestic partnership policies are required. ### Late Entrant Penalties A late entrant is any person who did not enroll in the plan within 31 days after they are first eligible or any person who becomes insured again after his or her coverage has lapsed due to non-payment of premium. The only exception to the rule is for covered charges due solely to an accident suffered while insured. Guardian does not pay benefits for any charges incurred by the late entrant in the first: - 6 months for Basic Services - 12 months for Major Services - 24 months for Orthodontia (when included on the plan) Late entrant penalties are not applied to Preventive Services. The total combined amount of time for late entrant penalties and deferred services cannot exceed 24 months. ### Retiree Coverage For a group to be considered eligible to offer retiree coverage, they must have a minimum of 50 insured lives, with a limit of 10% for the entire group on retirees being covered. Retiree coverage cannot be offered on a Dental Voluntary plan and the employer contribution should be at least equal to that of the actively at work employees. A minimum of 50% employer contribution would be preferred. When a group is requesting a Dental retiree-only plan, it can be considered if the group has 250 or more insured lives, and they provided a claims experience. ### Insured Eligibility For retirees to be eligible for Dental coverage, the following criteria must be satisfied: - He or she must have a minimum of 10 years of service and a minimum retirement age of 55 - He or she must enroll for retiree coverage within 31 days of becoming eligible Any retiree that previously dropped Dental coverage is **[not]** eligible to re-enroll. ***Note:*** Retiree benefits typically terminate at age 75. Underwriting approval is always required when providing coverage to retirees. Plan Contributions & Funding Types ================================== Plan Contributions ------------------ Dental insurance can be offered on a Non-Contributory, Contributory or Voluntary basis. Each option is dependent upon the percentage the planholder contributes towards the premium. The percentages of eligible employees that enroll in the plan are known as the "participation" percentage. In general, higher participation means that the insurance risk is spread out and reduced. The lower the participation in coverage increases Guardian's risk. When participation in coverage falls below 65%, a rate surcharge is applied to accommodate the increased risk. ### Non-Contributory Under a Non-Contributory plan, the employer pays the entire cost of the insurance; no contributions towards the cost of coverage are required by the employee. Guardian requires all employees be enrolled for coverage when the employer pays the entire cost for insurance. ### Contributory Under a Contributory plan, the employer pays more than 20% but less than 100% of the cost of the coverage. ### Voluntary Under a voluntary plan, the employer contributes 20% or less, or does not contribute at all to the cost of coverage. The chart below summarizes the differences between the plan contribution types: Method of Plan Funding Description ------------------------ ------------------------------------------------------------------------------------ Non-Contributory The employer pays the entire cost of the premiums for insurance. Contributory The employer pays more than 20% but less than 100% of the cost of the coverage Voluntary The employer contributes 20% or less (or nothing at all) to the cost of insurance. Participation Requirements -------------------------- A Group must meet minimum participation levels to provide Guardian with acceptable risk levels on the plan. The charts below describe the participation requirements for Dental. Required Participation ------------------------ ----------------------------------------- ---------------------- **2 to 24 lives and Small Group Sales** **25 or more lives** **Non-Contributory** 100% 100% **Contributory** 40% with a minimum of 2 enrolled 25% **Voluntary** 30% with a minimum of 4 enrolled 25% Plan Funding Types ------------------ Guardian offers two funding options: Fully Insured, and Administrative Services Only (ASO). The premiums/fees of an ASO group are normally lower than a Fully Insured Plan because the planholder agrees to accept a portion of the claim's payment risk. Fully Insured plans are available for all Dental plan types with groups of 2 or more eligible employees. ASO Plans with a Dental Indemnity or Preferred Provider Organization (PPO) Plan types are available on groups with 25 or more eligible employees. ### Dental Fully Insured vs. ASO The Dental product can besold as Fully Insured or Administrative Services Only (ASO). A fully insured funding type is available to all Dental plan types with groups with two or more eligible employees. An Administrative Services Only (ASO) funding type is available to a Dental Indemnity or Preferred Provider Organization (PPO) plan type that have twenty-five or more eligible employees. A Dental ASO plan is where the planholder self-funds the claims and in exchange for a fee Guardian will administer the plan. Guardian will provide flexible plan designs, process the claims, allow access to our dental networks, supply id cards, certificate booklets, customize enrollment materials, offer customer service, and provides actuarial and underwriting services, such as claims budgets and COBRA rates. +-----------------------------------+-----------------------------------+ | Insurance | | +===================================+===================================+ | **Fully Insured** | **Administrative Services Only | | | (ASO)** | +-----------------------------------+-----------------------------------+ | - Planholder pays monthly | - Planholder pays monthly fees | | premiums | | | | - Guardian administers the plan | | - Guardian administers the plan | benefit defined by the | | by confirming eligibility | planholder | | | | | - Guardian is responsible to | - Guardian pays claims and is | | pay claims regardless of | reimbursed by the planholder | | whether premium paid by the | | | planholder covers the actual | - Planholder holds 100% of the | | cost of the claims | risk | | | | | - Guardian holds 100% of the | | | risk | | +-----------------------------------+-----------------------------------+ | Contracts | | +-----------------------------------+-----------------------------------+ | **Fully Insured** | **Administrative Services Only | | | (ASO)** | +-----------------------------------+-----------------------------------+ | - "Plan of benefits funded by | - Guardian issues an | | Guardian" | Administrative Services Only | | | Agreement (ASA) to the | | - Contract addresses several | planholder | | items | | | | - The ASA states the | | a. Plan and benefit specifics | responsibilities of each | | for the coverage | party, specifically the | | | services the planholder wants | | b. States the following | from Guardian and the | | information: | corresponding fee they will | | | be charged for such services | | | | | | | | i. Terms of the insurance | | | determined by the insurance | | | and legislative entities | | | | | | ii. Mandated plan provisions | | | | | | iii. Provisions of underwriting | | | policies | | | | | | iv. Benefits, eligibility, and | | | exclusions | | | | | | v. Termination conditions | | +-----------------------------------+-----------------------------------+ | Plan Design | | +-----------------------------------+-----------------------------------+ | **Fully Insured** | **Administrative Services Only | | | (ASO)** | +-----------------------------------+-----------------------------------+ | - Guardian offers a full range | - Guardian offers a full range | | of plan designs that are | of plan designs that are | | subject to guidelines, | subject to guidelines and | | underwriting risk assessments | underwriting risk assessment; | | and state legislation. | in most cases, state | | | legislation does not apply. | +-----------------------------------+-----------------------------------+ | **For example:** Fully Insured | | | plans in the state of Washington | | | and New Hampshire must cover | | | general anaesthesia for dental | | | procedures for children under age | | | seven (and any other specified | | | individuals). This benefit may be | | | excluded under an ASO plan. | | +-----------------------------------+-----------------------------------+ | Financial Liabilities | | +-----------------------------------+-----------------------------------+ | **Fully Insured** | **Administrative Services Only | | | (ASO)** | +-----------------------------------+-----------------------------------+ | - Premiums are made up of | - Consists of one monthly fee | | claims plus expenses and | or fixed costs, unless an | | profit | Aggregate Stop Loss\* (ASL) | | | is selected or applied | | - Billing has several different | | | rate structures available to | - ASO fixed costs consist of | | a planholder | expenses and billing | | | | | - There is no year-end | - Billing has several different | | accounting | rate structures available to | | | a planholder | | | | | | - ASL premiums consist of risk | | | charge, administration, and | | | billing | | | | | | - There is no year-end | | | accounting | +-----------------------------------+-----------------------------------+ | Contacts | | +-----------------------------------+-----------------------------------+ | **Fully Insured** | **Administrative Services Only | | | (ASO)** | +-----------------------------------+-----------------------------------+ | - Guardian as the insurer: | - Guardian as the Plan | | | Administrator: | | a. Adjudicates claims based on | | | the plan benefits | a. Processes claims in | | | accordance with established | | b. Pays claims incurred during | claims administration | | the plan year | practices | | | | | - Liable for misinformation, | b. Pays claims incurred during | | incorrect payments and can be | the plan year | | sued for errors | | | | c. Provides a monthly statement | | | of paid claims to the | | | planholder | | | | | | d. Receives monthly | | | reimbursements from the | | | planholder for claims paid | | | | | | e. Has limited liability for | | | misinformation, incorrect | | | payments, etc. | | | | | | - When the ASO plan is sold | | | with "Guardian as Fiduciary," | | | Guardian does become liable | | | for misinformation, incorrect | | | payments, etc. | +-----------------------------------+-----------------------------------+ | Renewals | | +-----------------------------------+-----------------------------------+ | **Fully Insured** | **Administrative Services Only | | | (ASO)** | +-----------------------------------+-----------------------------------+ | - Underwriters determine the | - ASO fee increases are based | | premium rates for the next | on current inforce fee | | plan year | relative to current book fee | | | | | During the renewal process, | - Increases can range from | | underwriting reviews expenses, | \$.10 to \$.30 or 3% to 10%, | | trends and claims evaluations | whichever is greater at case | | based on credibility | level | | | | | | Underwriting is involved to | | | provide projections, COBRA rates | | | and renewal package | +-----------------------------------+-----------------------------------+ | Cancellations | | +-----------------------------------+-----------------------------------+ | **Fully Insured** | **Administrative Services Only | | | (ASO)** | +-----------------------------------+-----------------------------------+ | - Planholder decides to | - If the planholder or Guardian | | terminate their contract | decides to terminate | | | contract, we have two | | a. Guardian pays all run out | options: | | claims incurred prior to the | | | cancellation date from | a. After 31 days of written | | premiums collected | notice, Guardian will provide | | | an Explanation of Benefits | | b. Guardian has some | (EOB) for claims incurred | | administrative | under the self-funded plan | | responsibilities | prior to termination, for up | | | to 24 months | | - Non-payment of premium can | | | cause the contract to | b. Under a "check writing" | | terminate | option, Guardian continues to | | | fund claims for the employer | | | (and then bills) for the | | | first 3 months, then EOB only | | | for the next 21 months. This | | | option requires financial | | | review and an additional fee | | | at time of termination | | | | | | - Guardian may continue to | | | process claims by EOB only or | | | by the banking agreement for | | | the following situations: | | | | | | a. Inadequate funds in the | | | Benefit Funding Account | | | | | | b. Meeting specified obligations | | | within the contract | | | | | | c. Service fees unpaid from 31 | | | days of billing date | | | | | | d. Bankruptcy or insolvency | +-----------------------------------+-----------------------------------+ \*Aggregate Stop Loss is protection that limits the planholder's self-funded paid claim liability for all claims paid during a benefit period. The planholder must self-fund all claims. However, Guardian will reimburse the planholder for all claims that exceeded the Aggregate Stop Loss limit. ### Dental ASO Options and Cost Comparison Guardian's Dental ASO has several different options available to provide flexibility and price variances. ###### *Options:* - Direct Banking vs. Direct Billing - Planholder distributes employee benefit booklets - Guardian Anytime or Electronic Funds Transfer (EFT) - Guardian assumes Fiduciary responsibility - Multiple year rate guarantees - Discounts for cross selling and billed to required (BTR) guidelines - Run out or run in for claims - Two, three and four tier plans allow employers to include a separate ASO fee applied to dependents Example of a Cost Comparison of Full Insured vs. ASO #### Level-Funded ASO The Dental Level-Funded ASO plan is designed to fill the void for those who want an ASO/ASL plan but are tied to strict budgets where month to month volatility is not a variable (for example school districts). A Level-Funded ASO plan offers either a 105%, 110%, 115% or 120% Aggregate Stop Loss, where the plan is funded at the maximum employer liability. In other words, if any claims exceed this, Guardian will pay the claims. This type of plan mimics a fully insured plan and allows a planholder to combine a Preferred Provider Organization (PPO) plan with an ASO in areas where PPOs are not available as fully insured such as Texas and Georgia. This allows groups to move into ASO and keep the comfort level of lower risk than the typical 125%. Offering a Dental Level-Funded ASO plan has several advantages: - Great for states where we cannot offer a fully insured active PPO - Provides a stable platform for school groups and other budget driven employers that can't handle claim variability month to month - There's always a struggle with ASO for voluntary business - When claims exceed expected, employer must fund it, with a 105% it's not an issue. ###### *[Cost Comparison of ASO, Fully Insured vs. Level-Funded]* Guardian's Level Funded program offers the network, service, and products our fully insured plans are known for - with the flexibility and cost savings of an Administrative Services Only (ASO) plan. **This example shows the savings for a group with 180 employees comparing Fully Insured and Level Funded plans.** ![](media/image3.png) #### Voluntary ASO A Voluntary Dental ASO is another way to fund a Dental ASO plan. This type of plan is subject to ERISA, unless Guardian is notified otherwise by the planholder. If notified these plans would be treated like a contributory plan. Because they are subject to ERISA, the planholder is required to establish a trust. Expectations to this would apply to cafeteria or section 125 plans. ***Note:* Employee Retirement Income Security Act (**ERISA) was primarily enacted to affect pension equality and a Section 125 plan, also legally known as a \"cafeteria plan\", allows health contributions and deposits to flexible spending accounts to be made with pre-tax dollars, within guidelines established for such plans in Internal Revenue Code Section 125. Underwriting ============ To Underwrite can mean several different things. From an insurance company's perspective our meaning is to sign and issue an insurance policy thus accepting liability if specified losses occur, to insure the risk, and to accept liability up to a specified amount in an insurance policy. An underwriter is a person who handles the underwriting of the policies of insurance. They determine the level of risk Guardian is taking and the cost or premiums for dental benefits. Risk Selection -------------- With the Dental product it's not as complicated. Risk selection is a factor when determining Dental rates, but it is minimal. A non-transferred or virgin group is assumed to have accumulated neglect and would, therefore, receive a rate load spread over specific time periods based on the group\'s size. No evidence of insurability or other health statements are required. The industry factor loads the rates for only a handful of industries that have a proven increased risk over other industries. The Dental product simply doesn't carry the high level of risk that accompanies other insurance products. When comparing Dental to Medical, Dental procedures have a lower cost. These lower procedural costs allow for lesser benefit maximums. A Dental benefit maximum can range from \$500 to \$5000 in comparison to a medical maximum of either unlimited or one million dollars. Rating ------ Guardian's dental rates vary based on risk factors. Depending upon the type of risk underwriting may need to manually adjust rates. ###### *Claims Experience with Prior Carrier* For new business quotes on takeover cases with more than 100 enrolled employees, our underwriters use the case's claims experience with their current carrier to help set the premium rates that would be necessary for the proposed Guardian dental plan. ###### *Demographics* Demographics refers to characteristics of the group which affect the amount and cost of dental care that its employees and their dependents will use. These include the geographic area where they are located, their industry or occupation, and their age and gender. ###### *Plan Design* Rates are also adjusted for the deductible, coinsurance, annual maximums, and other elements of plan design selected by the employer. Risk Tier Structures -------------------- Group dental rates vary by the number of dependents who are covered. There are three different types of rate structure tiers available. Guardian's standard rate structure is a four tier. This rate structure includes rates for employees only, employee and spouse, employee and one or more children, and employee, spouse, and one or more children. We also sell two types of three tier rate structure, rostered and non-rostered. A rostered structure is used when the number of children for each employee is known. This structure includes rates for employees only, employee and spouse or employee and one child, and employee, spouse, and one or more children or employee and two or more children The non-rostered is used when the number of children for each employee is unknown. This includes rates for employees only, employee and spouse or employee and one or more children, and employee, spouse, and one or more children. The last rate structure is two tier rates. This combines all the dependent tiers. The two structures are employee only and employee and dependent(s). Meaning, employee and spouse or Employee, spouse, and one or more children or Employee and one or more children. Tier 2 Tier 3 Tier 4 --------------------------- --------------------------------------------------------------------------------- ---------------------------------------------------------- -------------------------------------------- **Rostered** **Non-Rostered** Employee only Employee only Employee only Employee only Employee and dependent(s) Employee and spouse or employee and one child Employee and spouse or employee and one or more children Employee and spouse Employee, spouse, and one or more children or employee and two or more children Employee, spouse and one or more children Employee and one or more children Employee, spouse, and one or more children PPO Plan Foundations ==================== Deductibles =========== This section provides details about Dental deductibles. Deductibles are an up-front share of dental expenses in any plan year that must be paid by the member before any benefits are payable by Guardian. The main goal of a Dental plan deductible is to manage risk to adjust cost of the product. Deductibles are often waived for Preventive Services.. Guardian's Dental plans are designed to encourage members to get Preventive Care, thereby avoiding the need for more intensive corrective dental care down the road. To encourage preventive care, Guardian typically does not impose a deductible when care is provided by a contracted dentist. Guardian does, however, offer plans that apply a deductible for Preventive Care received from a non-contracted dentist. These plans cost less and are intended to steer members to utilize one of our many contracted dentists. ***Note:*** The most common deductible is \$50 per covered member, limited to three members per family. Deductible Options ------------------ Guardian offers multiple types of deductible options under the Dental product. ### Individual and Family Deductible Individual deductibles range from \$0 (or no deductible) to \$300, with \$50 historically being the most common. Once the individual deductible has been satisfied, Guardian will issue benefits. **Note:** The individual deductible must be met in every plan year. Our standard plan has a family limit of three deductibles per year. This means that once three family members satisfy their deductible, the other family members are not required to meet theirs. For an additional cost, the planholder may choose a family limit of two individual deductibles per year. Also, for a discount, the family limit can be removed, obligating each family member to meet the deductible. Some of our competitors sell an aggregate family deductible which uses a dollar amount as the family limit. The aggregate family deductible is slightly easier for a family to meet because the combination of all individual deductibles counts toward the family limit. ### Split Deductible Another type of deductible is a split deductible. This type requires the member to satisfy one deductible for in-network services and a higher deductible for out-of-network services. For example, instead of a \$50 deductible for the plan, there would be a \$50 deductible for in-network services and a \$100 deductible for out-of-network services. ### ### Split Category Deductible (Not available on DG7 contract) Another type of deductible is a split category deductible. This type requires the member to satisfy one deductible for Preventive Services and a separate deductible for Basic and Major Services combined. For example, instead of a \$50 deductible for the plan, there would be a \$25 deductible for Preventive Services and a separate \$25 deductible for a combination of Basic and Major Services. ### Lifetime Deductible Guardian offers a lifetime deductible that relieves members from having to satisfy the deductible every plan year. Once the lifetime deductible has been satisfied, no additional deductible is taken as long as the member stays enrolled, and the plan remains inforce. Lifetime deductibles range from \$25 to \$300, with \$100 being the most common deductible chosen. Family lifetime deductible limits of two or three are available options. ### Deductible Credit If Guardian is replacing a prior dental plan, in the first plan year, we will reduce the deductible amounts applied under the prior plan from Guardian's deductible amount. A deductible report from the prior plan must be provided in order to apply the deductible credit. **Note:** The maximum amount paid under the prior plan will also be deducted. Documentation must be provided. ### Diminishing Deductible Diminishing Deductible was launched in 2022 only on the DG7 contract. This offering allows the member level deducible to decrease over a 3-year coverage period. This product is designed to encourage plan loyalty. There are 3 deductible options available: **Starting Deductible** **Year 2** **Year 3** **Year 4** ------------------------- ------------ ------------ ------------ **\$75** \$45 \$30 \$0 **\$50** \$30 \$15 \$0 **\$25** \$15 \$10 \$0 All members and new hires begin coverage at the "starting deducible" and move to the next deductible level at either the calendar or policy year accumulation period as defined by the plan. Dependents of an employee will always match the employee's deductible level based on the plan effective date of the employee. Coinsurance =========== Coinsurance refers to the percent of the benefit that Guardian will pay for services after the deductible has been met. After Guardian pays their portion of the covered charges, the member will be responsible for the remaining amount. The coinsurance amount will vary based on the dental service performed. Dental services are separated into categories, Preventive, Basic, Major, and Orthodontic. Coinsurance Options ------------------- Coinsurance options are designed to provide cost savings for the employer. Guardian offers four coinsurance plan options: Preventive Only, Preventive Plus, Incentive Coinsurance and a Bundled Coinsurance Plan. ***Note:*** The availability of all coinsurance plan options may vary by state, contract and/or group size. ### Preventive Only Preventive-Only is designed to only cover Preventive Services. This plan is available at a very lost cost since it only covers one type of service. The Preventive-Only plan option is available on DentalGuard 2000, DentalGuard 6 and DentalGuard 7 plans. ### Preventive Plus Like the Preventive-Only Plan option, Preventive Plus adds coverage for fillings and simple extractions as a Basic Service. Maximum Credit -------------- Maximum Rollover ---------------- Maximum Rollover is a value-added enhancement feature to Guardian's Dental product that allows the member to roll over a portion of his or her unused annual dental maximum into a personal Maximum Rollover Account (MRA) for future use. This allows the member to "save up" annual dollars in the event the need for extensive dental care arises later. Members can save annual maximum dollars up to a set dollar limit and use his or her personal MRA when he or she has reached the plan's annual maximum. Guardian also offers a Maximum Rollover Lite that is a lower cost version with lower Maximum Rollover amounts and limits. Maximum Rollover Lite helps cost conscience planholders control escalating costs at future renewals. ### Availability Maximum Rollover is available to groups with a minimum case size of two employees. It is available on new business and can be added to most in force plans at renewal. Maximum Rollover is not available on Monthly Switch Plans, PERKS plan or on plans that do not include coverage for Major Services. ### Terminology #### Threshold The threshold is the maximum benefit a member may receive during a benefit year and still receive a Maximum Rollover Amount. The threshold is based on the plan's annual maximum amount and will not change from year to year unless the plan's maximum amount is amended. #### Maximum Rollover Amount The Maximum Rollover Amount is the amount credited to a member's Maximum Rollover Account when their claims do not exceed the threshold. Each member and each dependent can qualify for a Maximum Rollover Amount based on his or her own paid claims. #### Bonus Rollover Reward The Bonus Rollover Reward is an additional amount that is credited to a member's Maximum Rollover Account (MRA) when all his or her claims during the benefit year are performed by a contracted dentist. This is available for PPO, Value and NAP plans. #### Maximum Rollover Account (MRA) The Maximum Rollover Account is the total accumulated Maximum Rollover Amount. This amount increases and/or decreases as Maximum Rollover Amounts are credited and claims are paid. #### Maximum Rollover Account Limit The Maximum Rollover Account limit is the maximum amount of accumulated Maximum Rollover Amounts a member may store in his or her MRA over a series of benefit years. ### Qualifications for Maximum Rollover To qualify for a Maximum Rollover Amount: - The member cannot exceed the threshold for paid claims during the benefit year. - The member must have at least one paid claim during the benefit year. - The member must be eligible for Major Service coverage. ### Available Maximum Rollover Plans Offered *The table below lists Guardian's Maximum Rollover options.* Plan Annual Maximum Threshold Maximum Rollover Amounts Maximum Rollover Account Limit --------------------- ----------- -------------------------- -------------------------------- ---------- ----------------------- --------- ------- Rollover Bonus Rollover Reward Rollover Bonus Rollover Reward Standard Lite Standard Lite \$500 \$200 \$100 \$150 \$50 \$75 \$500 \$250 \$750 \$300 \$150 \$200 \$75 \$100 \$500 \$250 \$1,000 \$500 \$250 \$350 \$125 \$175 \$1,000 \$500 \$1,200 \$600 \$300 \$400 \$150 \$200 \$1,200 \$600 \$1,250 \$600 \$300 \$450 \$150 \$225 \$1,250 \$625 \$1,500 or \$1,750 \$700 \$350 \$500 \$175 \$250 \$1,250 \$625 \$2,000 \$800 \$400 \$600 \$200 \$300 \$1,500 \$750 \$2,500 \$900 \$450 \$700 \$225 \$350 \$1,500 \$750 \$3,000 or higher \$1,000 \$500 \$750 \$250 \$375 \$1,500 \$750 #### Maximum Rollover Example #### Annual Plan Maximum Maximum Rollover Amount Maximum Rollover Amount Limit Threshold Bonus Rollover Reward --------------------- ------------------------- ------------------------------- ----------- ----------------------- \$1,000 \$250 \$1,000 \$500 \$350 High Maximum Plan Features -------------------------- A High Maximum Plan is a bundled option that combines a. A higher plan maximum, b. A higher deductible that would cover a catastrophic dental situation, c. Is lower in cost and d. Works well with a Health Savings Account (HSA) or Flexible Spending Account (FSA). Guardian offers nine different high maximum plan types. For our Small Group Business with employees from 2 to 24 lives the maximum is limited to \$3,000. A Buy-Up option is available on a High Maximum Plan. There are restrictions with offering a Buy-Up, please refer to the underwriting resources. ***Note:*** The High Maximum Plan is not available in all states, please refer to your underwriting resources for state approvals. Preventive Advantage -------------------- The Preventive Advantage benefit allows coverage for preventive services without reducing the annual maximum. The annual maximum applies only to Basic and Major Services. Preventive Advantage Lite was introduced in 2022 only on the DG7 contract. Preventive Advantage Lite is a lower cost option that exempts only cleaning and exams from the plan maximum for a lower rate load than Preventive Advantage. The Preventive Advantage and Preventive Advantage Lite benefit is an incentive for members to get their regular preventive dental services performed All covered preventive services will still be covered even after the annual maximum has been reached. Preventive services are subject to the Preventive Coinsurance and plan limitations. For DentalGuard 2000 and DG7 plans, it is available as an in-network only option or as an in and out of network option. Reimbursement Level =================== The reimbursement level is the allowable payment amount for any service provided. Out of network benefits and Indemnity plans utilize Reasonable and Customary (R&C) to determine the reimbursement amount of all claims while PPO plans use reimbursement level to determine allowable on out of network claims R&C is a dollar amount deemed to be an appropriate fee to pay the dentist for the services provided. Guardian's Dental Schedule Reimbursement as of 2020, Guardian utilizes data from internal claims and external 3^rd^ party vendors in determining out of network reimbursement levels. Previously, we only used data from a 3^rd^ party vendor, FAIR Health but when compared to major competitors, Guardian's out-of-network reimbursement option had shown to be generous. While this could seem like a differentiator for us in the marketplace, it often led to comparatively higher rates with little added value to the customer. The amount submitted for a dental service and the number of times a service is submitted in a geographic area is used to calculate the R&C percentiles. The 90^th^ percentile means that 90% of the dentists in a specific geographic area charge the same fee or less for a specific service. The remaining 10% of dentists charge more than that fee. Guardian's Dental Schedule Reimbursement details: - For customers desiring a higher reimbursement, Guardian's 95th schedule can be quoted which equates to current FAIR Healthdata. - When quoting this methodology, Guardian can no longer use the term UCR. Instead, we must use Guardian Reimbursement language or R&C. - Guardian's Schedule isn\'t available on Indemnity or HCR plans. **Percentile's Available** The most common percentile applied is the 90^th^ percentile. However, the 50^th^, 70^th^, 75^th^, 80^th^ and 85^th^ percentiles are also available. Lowering the percentile also lowers the cost of claims. This decreases the planholder's premium rates and places more of the cost-sharing burden on the members. Guardian will not pay for any charges over the reimbursement amount therefore the member is responsible for the difference between the dentist's charge and the reimbursement amount, which is referred to as Balance Billing. Guardian offers two levels above the 90th percentile to decrease the member's cost or "balance-billing." - For an extra charge of 1.5% for Indemnity plans or 1.0% for Preferred Provider Organization (PPO) plans, planholders can elect the 95th percentile, which cuts the incidence of balance-billing in half. - For an extra 4% for indemnity plans or 2.7% for Preferred Provider Organization (PPO) plans, planholders can elect 135% of the 90th percentile, which virtually eliminates balance-billing. ***Note:*** As these options may not be available in all states, please refer to your underwriting resources for guidelines. **Determining a Reimbursement Level** Charges Data Ranked Lowest to Highest -------------- -------------------------- --------- --------- Dentist Charges Dentist Charges 1 \$69 9 \$40 2 \$57 7 \$49 3 \$52 3 \$52 4 \$80 5 \$56 5 \$56 2 \$57 6 \$75 10 \$57 7 \$49 1 \$69 8 \$76 6 \$75 9 \$40 8 \$76 10 \$57 4 \$80 Percentile ------------ ------ 50th \$57 70th \$69 80th \$75 90th \$76 Indemnity Plans =============== Indemnity Plans are insurance plans that are not supported by access to a network of contracted providers. These programs have largely been replaced by PPO plans and are rarely sold today because they do not access provider network discounts to control costs. Preferred Provider Organization (PPO) Plans =========================================== Preferred Provider Organization, or PPO, Dental Plans provide members access to a network of participating dentists who have agreed to accept discounted fees for services provided. Guardian's primary national PPO network is called **DentalGuard Preferred (DGP)**. In 2022, Guardian Launched the Local Elite network, which is a smaller, deeply discounted network only available in specific markets. Under a PPO plan, members can see a non-network dentist, but at a higher out-of-pocket cost. Since participating dentists are paid for each service they provide, PPOs are like Indemnity plans in that they are often also referred to as "fee for service" plans. PPO Components -------------- There are four main components that make up a PPO Plan: deductible, coinsurance, benefit maximum and reimbursement level. ### Deductible Deductibles are an up-front share of dental expenses that must be paid by the member before any benefits are payable by Guardian. The goal of a deductible is to act as a deterrent for unnecessary or frivolous dental care forcing the member to pay before any benefits are issued. Deductibles are often waived for Preventive Services. Guardian's plans are designed to encourage members to get Preventive care, thereby avoiding the need for more extensive dental care down the road. ***Note:*** The most common deductible is \$50 per individual, limited to three members per family (even if more than three family members may visit the dentist). ### Coinsurance Coinsurance refers to the percent of the benefit that Guardian will pay for services after the deductible has been met. After Guardian pays their portion of the covered charges, the member pays the balance. Coinsurance varies based on the type of dental care. Dental care is separated into Preventive, Basic, Major and Orthodontic Services. ### Benefit Maximum The benefit maximum is the total dollar amount that Guardian will pay for covered services received by a member in a benefit year. Because Guardian shares the dental cost with the member, benefits are limited to a maximum amount. Benefit maximums range from \$500 to \$5,000; the most common maximums are \$1,000 and \$1,500. ### Reimbursement Level The reimbursement level is the allowable payment amount for any service provided. Reasonable and Customary (R&C) is used to determine the reimbursement amount for non-contracted dentists. R&C is a dollar amount deemed to be an appropriate fee to pay the dentist for the services provided. Guardian does not pay for any charges that exceed the R&C amount, which forces the member to accept responsibility for these "balance-bills." **\ ** PPO Plan Types -------------- Guardian offers several Plan Types to compete in the marketplace. For details regarding options for plan types, please refer to the [IMS - Dental PPO Lookup](https://glic.sharepoint.com/sites/IMS/Pages/Guardian%20Group/NBBS/DentalPlanTypeGrid.aspx). Below is a chart that illustrates the differences between offerings: **Basic Plan Design** **Reimbursement OON** **Do coinsurances differ INN and OON?** **Do maximums differ INN and OON?** **Do deductibles differ INN and OON?** ---------------------------------------- ----------------------- ----------------------------------------- ------------------------------------- ---------------------------------------- **Network Access Plan (NAP)** Guardian or R&C No No No **Enhanced NAP (ENAP)** Guardian or R&C No No Optional **Split Maximum Enhanced NAP (ENAP)** Guardian or R&C No Yes Optional **Standard PPO** Guardian or R&C Yes No Optional **Split Maximum PPO** Guardian or R&C Yes Yes No **Split Deductible Split Maximum PPO** Guardian or R&C Yes Yes Yes **Value Plan** Fee Schedule No No No **Flex Value/Enhanced Split Value** Fee Schedule No Optional Optional **Split Value Plan** Fee Schedule Yes No Optional **Split Maximum Split Value Plan** Fee Schedule Yes Yes Optional ### Network Access Plan (NAP) The Network Access Plan (NAP) is a simple and commonly sold type of PPO that is often referred to as "passive PPO" in the industry. When a member visits a DentalGuard Preferred dentist, charges are reimbursed at the in-network discounted fee level. Which reduces the member's out-of-pocket costs. A NAP plan consists of three other key plan elements, coinsurance, deductibles, and annual maximums. These do not vary between contracted and non-contracted dentists. **Below is a typical NAP design showing differences for in-network and out-of-network.** DentalGuard Preferred Out-of-Network ---------------------------------- ----------------------- ------------------------- Deductible: \$50 \$50 Coinsurance: Category 1 -- Preventive 100% 100% Category 2 -- Basic 80% 80% Category 3 -- Major 50% 50% Category 4 -- Orthodontics 50% 50% Annual Maximum (Categories 1-3): \$1,500 \$1,500 Lifetime Maximum (Category 4): \$1,000 \$1,000 **Reimbursement Level:** **Fee Schedule** **90th Percentile R&C** #### Enhanced NAP An Enhanced NAP plan operates like a NAP Plan; however, this type of plan offers an incentive for members to use contracted dentists. This is done by reducing or eliminating the in-network deductible or increasing the in-network annual benefit maximum. **Below is a sample of a NAP that eliminates the in-network deductible.** DentalGuard Preferred Out-of-Network ---------------------------------- ----------------------- ------------------------- **Deductible:** **\$0** **\$50** Coinsurance: Category 1 -- Preventive 100% 100% Category 2 -- Basic 80% 80% Category 3 -- Major 50% 50% Category 4 -- Orthodontics 50% 50% Annual Maximum (Categories 1-3): \$1,000 \$1,000 Lifetime Maximum (Category 4): \$1,000 \$1,000 **Reimbursement Level:** **Fee Schedule** **90th Percentile R&C** **\ ** **Split Maximum Enhanced NAP** **The "split maximum" feature provides a higher in-network benefit year maximum than out-of-network benefit year maximum.** **Below is an example of a Split Maximum Enhanced NAP** DentalGuard Preferred Out-of-Network ---------------------------------- ----------------------- ------------------------- **Deductible:** **\$50** **\$50** Coinsurance: Category 1 -- Preventive 100% 100% Category 2 -- Basic 80% 80% Category 3 -- Major 50% 50% Category 4 -- Orthodontics 50% 50% Annual Maximum (Categories 1-3): \$1,500 \$1,000 **Reimbursement Level:** **Fee Schedule** **90th Percentile R&C** **Standard PPO** A standard PPO plan type includes the four components described earlier: deductible, coinsurance, benefit maximum, and reimbursement level. **Below is an example of a standard PPO plan with dollar and percentage amounts shown for each component.** ------------------------------------------------------------------------------------------- DentalGuard Preferred Out-of-Network ---------------------------------- ----------------------- -------------------------------- Deductible: \$50 \$50 Coinsurance: Category 1 -- Preventive 100% 100% Category 2 -- Basic 100% 80% Category 3 -- Major 60% 50% Category 4 -- Orthodontics 50% 50% Annual Maximum (Categories 1-3): \$1,000 \$1,000 Lifetime Maximum (Category 4): \$1,000 \$1,000 **Reimbursement Level:** **Fee Schedule** **90th Percentile\ Reasonable & Customary (R&C)** ------------------------------------------------------------------------------------------- ### Split Maximum PPO The Split PPO Maximum is a feature that provides a higher in-network benefit year maximum than out-of-network benefit year maximum. Any applicable reimbursement from Guardian is accumulated toward both maximums. However, if the member uses a contracted dentist, a higher benefit will be available. In-Network Maximum Out-of-Network Maximum -------------------- ------------------------ \*\$1,000 \$ 500 \*\$1,250 \$ 750 \$1,500 \$1,000 \$2,000 \$1,000 \$2,000 \$1,500 \*Availability is based on size and plan design **Note:** Guardian offers plans of \$2000/\$1500 and \$1500/\$1000 for groups as low as 2 lives. The \$1,000/\$500 and \$1,250/\$750 plans are generally available for groups with as low as 10 lives and all other plans are available on cases with 25 or more lives. The Orthodontia maximum, if applicable, is the same for both in- and out-of-network. ### ### Split Deductible Split Maximum PPO This plan type uses R&C for the out-of-network reimbursement level. It also has different coinsurance percentages and maximums for in and out-of-network benefits. Deductibles are the same. **\ ** **Below is an example of a Split Deductible Split Maximum PPO** ------------------------------------------------------------------------------------------- DentalGuard Preferred Out-of-Network ---------------------------------- ----------------------- -------------------------------- Deductible: \$50 \$50 Coinsurance: Category 1 -- Preventive 100% 100% Category 2 -- Basic 100% 80% Category 3 -- Major 60% 50% Category 4 -- Orthodontics 50% 50% Annual Maximum (Categories 1-3): \$1,500 \$1,000 **Reimbursement Level:** **Fee Schedule** **90th Percentile\ Reasonable & Customary (R&C)** ------------------------------------------------------------------------------------------- ### Value Plan The Value Plan is known in the industry as a *Maximum Allowable Charge* or *MAC plan*. In a Value Plan, the in-network fee schedule is also used as the out-of-network reimbursement level. Members who have treatment performed by a non-contracted dentist will pay the difference between the fee schedule amount and the dentist's charges. Coinsurance, deductible and maximums are the same in- and out-of-network. **Below is a sample of a Value Plan design** DentalGuard Preferred Out-of-Network ---------------------------------- ----------------------- ------------------ Deductible: \$50 \$50 Coinsurance: Category 1 -- Preventive 100% 100% Category 2 -- Basic 80% 80% Category 3 -- Major 50% 50% Category 4 -- Orthodontics 50% 50% Annual Maximum (Categories 1-3): \$1,000 \$1,000 Lifetime Maximum (Category 4): \$1,000 \$1,000 **Reimbursement Level:** **Fee Schedule** **Fee Schedule** #### #### Flex Value/Enhanced Split Value The Flex Value/Enhanced Value Plan is a PPO plan type designed to help control out-of-network claims costs by offering an incentive to use in network provider by using split deductibles or maximums. Coinsurance is the same for in and out of network. This plan reimburses out-of-network claims based on a fixed schedule of maximum allowable charges. DentalGuard Preferred Out-of-Network ---------------------------------- ----------------------- ------------------ Deductible: \$25 \$50 Coinsurance: Category 1 -- Preventive 100% 100% Category 2 -- Basic 80% 80% Category 3 -- Major 50% 50% Category 4 -- Orthodontics 50% 50% Annual Maximum (Categories 1-3): \$1,500 \$1,000 Lifetime Maximum (Category 4): \$1,000 \$1,000 **Reimbursement Level:** **Fee Schedule** **Fee Schedule** #### Split Value Plan The Split Value Plan allows the in- and out-of-network coinsurance levels to be different. Deductibles may or may not differ in- and out-of-network. Maximums do not vary in and out of network. **Below is a sample of a Split Value Plan design** DentalGuard Preferred Out-of-Network ---------------------------------- ----------------------- ------------------ Deductible: \$50 \$50 Coinsurance: **Category 1 -- Preventive** **100%** **100%** **Category 2 -- Basic** **90%** **80%** **Category 3 -- Major** **60%** **50%** **Category 4 -- Orthodontics** **50%** **50%** Annual Maximum (Categories 1-3): \$1,000 \$1,000 Lifetime Maximum (Category 4): \$1,000 \$1,000 **Reimbursement Level:** **Fee Schedule** **Fee Schedule** ### Guardian Choice Plan The Guardian Choice Plan is a type of Dual Choice Plan that allows an insured the ability to choose between two dental plans that have the same rate or cost at point of enrollment. Available choices consist of either a Value Plan with higher coinsurance levels or a Network Access Plan with lower coinsurance levels. The out-of-network reimbursement for the NAP Plan is based on the 90^th^ percentile. There are seven Guardian Choice Plans available known as the "J" series: - **J1** = 100/100/60 ValuePlan with a 100/80/50 NAP - **J2** = 100/80/50 ValuePlan with a 100/60/40 NAP - **J3** = 100/80/50 ValuePlan with a 100/50/25 NAP - **J4, J5,** **J6 and JA** = Similar coinsurance options to J1 and J3; more in- and out-of-network deductible options ***Note:*** Within the design of these plans, Orthodontia is available with a coinsurance percentage up to 50%. #### Product Details - Employee decisions are based upon the benefit, not the price - The goal is to move employees away from a Network Access Plan (NAP) to a plan that creates network steerage - An employee with a dentist that is currently in Guardian\'s network is expected to choose the Value Plan - A single blended rate applies to both plans - The members may switch between Value Plan and NAP each year only at open enrollment Quality Management Program and Network Leasing ---------------------------------------------- **Through our** detailed PPO quality management program, we can assess the quality of care and service that members receive from participating dentists. Guardian leases access to a subset of the DentalGuard Preferred Network to other payers or leasing clients. The network the leasing clients have access to is called the DentalGuard Preferred Select Network. The DGP Select Network does not include the other networks that Guardian leases for its own business. Leasing our network allows us to compete with another carrier's. ### PPO Quality Management #### Credentialing and Re-Credentialing Credentialing and re-credentialing of the dentist involves verifying a dentist's license, education, Drug Enforcement Administration (DEA) certificate, malpractice insurance and state license sanctions. A dentist must be re-credentialed in the same manner every three years (some states require re-credentialing every two years). #### Grievance Program Our grievance program is designed to analyze, evaluate, and resolve member issues concerning quality of care, administration of benefits, accessibility of participating dentists and network adequacy. Grievances are logged, tracked, and responded to within certain time frames. #### Utilization Management Program Our utilization management program is designed to monitor and analyze each participating dentist's utilization profile in order to evaluate the utilization and billing patterns to prevent abuses such as over-utilization, up-coding, inappropriateness of treatment, etc. ### PPO Network Leasing The leasing clients/payors include third party administrators, self-administered union groups, and even some other insurance companies. Typically, payors need to have at least 2,500 lives to be eligible to lease the network. The leasing clients pay a per-employee, per-month fee for access to the DentalGuard Preferred Select Network along with the negotiated fee schedules that Guardian has contracted with those dentists. Guardian assumes no risk in such arrangements, nor is it responsible for claim administration or customer service. Sales offices that refer leasing clients are paid a commission for all successful referrals. Buy-Up Plans ============ A buy up Dental plan consists of a low-cost base plan and an option for employees to "buy up" to a more generous plan design at a difference in price between the two plans. Illustration Sample of Base Plan Benefit vs. Buy Up Benefit Base Plan Benefit Buy Up Plan Benefit -------------------------- --------------------------- \$500 Maximum \$750 Maximum \$750 Maximum \$1,000 Maximum \$1,000 Maximum \$1,500 Maximum 100%/80%/50% Coinsurance 100%/100%/50% Coinsurance 80%/50%/25% Coinsurance 100%/80/50% Coinsurance For virgin groups, all aspects of the buy up plan must be equal to or exceed the base or core plan parameters, including maximum, deductible and coinsurance. When coverage is transferred, aspects of the base plan are allowed to be better than the buy-up plan. This includes deductible, maximum, and coinsurance. To qualify for a buy up plan, the group must have a minimum of ten eligible employees. Base Plan Benefit Buy Up Plan Benefit ---------------------------------------------------------------------------------------- ----------------------------------- Illustration Sample of Base Plan Benefit vs. Buy Up Benefit \$1,000 Maximum Value Plan \$1,500 Maximum Value Plan \$1,500 Maximum Value Plan \$2,000 Maximum Value Plan \$1,000 Maximum NAP \$1,500 Maximum NAP \$1,500 Maximum NAP \$2,000 Maximum NAP \$50/\$50 deductible only Split Value Plan \$0/\$50 deductible only PPO Plan There is increased risk in buy up plans due to potential adverse selection of employees choosing a plan that best fits their needs with the intent to maximize their use of the benefits. Using specific plan designs and satisfying the required guidelines are necessary when administering these types of plans. Guidelines ---------- There are three levels of guidelines that must be satisfied: non-voluntary/voluntary, participation requirements and plan design. ### Non-Voluntary/Voluntary There is no difference in guidelines between non-voluntary and voluntary plans. Buy up plans are available to groups with ten or more eligible employees. When an employee is enrolled for Dental coverage, he or she can switch between the base/core plan and the buy up plan on an annual basis. Considering these plans provide a choice of a lower or higher cost Dental plan, they work well when offered on voluntary Dental plans because the member is paying more towards the premium for their Dental coverage. ### Participation Buy up plansuse standard participation loads. When a Dental plan is sold with Preventive Only or Preventive Plus, the required participation is 75%. A minimum of one enrolled employee in the base/core and buy up option is required for all case sizes. ### Plan Design For virgin groups, all aspects of the benefits under a buy up plan must equal or exceed the core plan parameters. Different guidelines may apply based on the type of Dental plan offered. For example, a Dental plan with split deductibles must be equal to or lesser than the core plan deductible. When the case has split maximums, the buy up plan must be equal to or greater than the core plan maximum. When coverage is transferred, aspects of the base plan are allowed to be better than the buy-up plan. This includes deductible, maximum, and coinsurance. **Note:** Rates may be impacted based on the specific situation and/or guideline. Options ------- Buy up plans may have different options, including offering Orthodontia benefits as a buy up option. However this cannot be the only plan difference and the orthodontia is still subject to standard guidelines. Another type of buy up is major and orthodontia services. When major or orthodontia service is not covered under the base plan, these services would be available under the buy up option. This type of buy up is available on Indemnity and Preferred Provider Organization plans. **All plan types vary by cost and consist of a rate increase for both the base and buy up plan. Depending upon the type of dental being offered, not all plan types are available.** Multi State Cases ----------------- Multi-state cases mean the planholder has an employment location that falls into a region other than the main region. For example, the main location (situs) is in New York and an employment location (or affiliate) is in California. There are times when an employment location must be broken out and given the benefits of its own region and depending upon the situation, we may even need to produce multiple certificate booklets. This is done for pricing reasons and so that employees have plan options designed for their local market conditions. Refer to your underwriting resources for specific state details. ### Classing Out Texas Members Within the multi-state guidelines for Dental, when a case is sitused outside of Texas but has employees residing in Texas, the Texas employees will need to be classed out due to the extra-territorial guidelines. Guardian has processes and procedures in place for these Texas employees to ensure their claims are paid in accordance with the Texas state requirements. Previously, the guideline was to class out the Texas employees only if the case had a physical Texas location. This guideline was changed with the implementation of the new Dental Rate Calc and the discontinuation of the PPO Wizard rating tool. Tiered Network ============== Overview of Tiered Network -------------------------- The Tiered Network strategy allows employers to choose a 3--Tier benefit structure that steers members to use lower cost providers to help fit their employee's dental needs. Giving employees the ability to go in-network for higher savings, but still use an out-of-network if their provider isn't in the network. Provider Tier ------------- Guardian's Preferred Provider Organization consists of Dentists in the DentalGuard Preferred (DGP) network. These tiers represent specific benefit levels and network access that will vary by geographic location and zip code. The chart below illustrates the Provider Tier name and the network assignment. In 2021 Guardian was notified by some states that we could not use metal terminology in the naming of our plans or network, please note the following changes to Network Tier names. New Label Old Label Network Notes ----------- ----------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Alliance Platinum Alliance is only available in select markets, greater discount than standard fee Elite Gold Dentists who are on a standard fee schedule (no negotiation) Connect Silver Dentists who are on a negotiated or custom fee schedule (we refer to internally as Admin Fee Schedule) or contracted thru a lease arrangement -- Aetna, UHC, Dentemax, Connection Dental, etc. How Tiered Network Plans Work ----------------------------- There are two configuration options available in the 3-Tier benefit structure that provide even more ways to move benefit levels around to shift costs. The term Freedom Plan only appears on DG2000 contracts. Purpose of Tiered Plans is to allow Employers to [choose between a broader network vs. a lower price point] by ***shifting*** the Tier Level for which each provider group is mapped. - The "Network Configuration Code" will be used to define which network groups are included within each tier level - Employees incentivized to seek care from providers in more favorable tier levels (e.g., less member coinsurance, no balance billing) - Please note, the Local Elite Network is not a tiered product. Local Elite is a standalone network and is not related to the Elite tier of DentalGuard Preferred providers ### DentalGuard Alliance Tiered Plan DentalGuard Alliance tier plans are available in select markets. DG2000 contracts refer to these plans using the term "Freedom Plan." Members can go to a DentalGuard Alliance dentist for deeper discounts and greater in-network incentives. They also have the choice of seeing a DentalGuard Preferred dentist or a non-contracted dentist. Alliance dentists are part of the DentalGuard Preferred Network. A dentist must be contracted as a DentalGuard Preferred dentist before they can become an Alliance dentist. For the CPS proposal of a DentalGuard Alliance plan, it shows the services and options displayed by the three tiers. Tier 1 represents Alliance; tier 2 represents non alliance DentalGuard Preferred and tier 3 represents out of network. Table Description automatically generated DentalGuard Contracts ===================== Guardian has in-force plans on several different Planholder contracts. To compare the standard benefits, frequencies across the DG2, DG3, DG4, DG2000, DG6, and DG7 contracts, refer to the PPO Comparison Chart found here: [IMS - PPO Comparison Chart](https://glic.sharepoint.com/sites/IMS/Pages/Guardian%20Group/Dental%20Claims/PPO-Comparison-Chart.aspx) Contract Limitations -------------------- ### Teeth Lost Prior to the Effective Date (Missing Tooth Exclusion) The missing tooth exclusion means a covered person may have lost one or more teeth before becoming insured by the plan. Under this limitation, Guardian does not pay for a prosthetic device that replaces such teeth unless the device also replaces one or more natural teeth lost or extracted **[after]** the covered person became insured by the plan. Guardian's standard contract waives the missing tooth exclusion for groups with 25+ lives. ### Alternate Treatment If more than one type of service can be used to treat a dental condition, Guardian has the right to base benefits on the least expensive service that is within the range of professionally accepted standards of dental practice. **Example:** A composite filling on a posterior tooth, the benefit will be based on the corresponding amalgam filling benefit, unless the plan specifically covers posterior composites. ### Treatment in Progress When treatment is in progress, Guardian considers the fee for a service to be incurred on the date it is rendered. Generally, except for orthodontic treatment, a service that began prior to the member's effective date with Guardian will **[not]** be covered. Contract Exclusions ------------------- ### Oral Hygiene and other services Oral hygiene, plaque control, diet instructions and precision attachments are excluded from Dental coverage. ### Experimental Treatment Treatment that does not meet accepted standards of dental practice or treatment that is experimental in nature are excluded from Dental coverage. ### Work-Related Injuries Treatment needed due to an on-the-job or job-related injury or a condition for which benefits are payable by Workers' Compensation or similar law is typically excluded from Dental coverage. ### Excluded Appliances or Prosthetics Our DentalGuard contract excludes any appliance or prosthetic device used to change vertical dimension, restore or maintain occlusion, splint or stabilize teeth for periodontal reasons, replace tooth structure lost as a result of abrasion or attrition, or treat disturbances of the temporomandibular joint (unless the TMJ rider has been added to the plan). ### Replacement of Appliances or Prosthetic Devices Replacing an appliance or prosthetic device with a like appliance or device is excluded from Dental coverage unless it: - Meets the replacement age limitation and cannot be made usable, or - Is damaged, while in the covered person's mouth in an injury suffered while insured and cannot be fixed\* \*This exception does not apply to all mouth injuries. The injury must be due to an outside force and not due to a chewing injury. ### Lost or Stolen Appliances and Spares Replacing a lost, stolen, or missing appliance or prosthetic device or making a spare appliance or device is excluded from Dental coverage. ### Cosmetic Services (unless the plan provides specific benefits) Most services performed for cosmetic reasons, including, but not limited to, characterizing, and personalizing prosthetic devices and making facings on prosthetic devices for any teeth in back of the second bicuspid, are excluded from Dental coverage. #### TMJ The temporomandibular joint, or TMJ, is the joint of the jaw that facilitates mandibular movement, located between the head of the mandible and the temporal bone. TMJ is excluded under our standard contract unless required by state mandate. +-----------------------------------+-----------------------------------+ | | TMJ | +===================================+===================================+ | **Texas** | Coverage includes diagnostic and | | | surgical treatment. Covered as a | | | Major service. If the plan has no | | | Major coverage, the TMJ services | | | will be covered at the 50% | | | coinsurance. Subject to the | | | benefit year deductible and | | | maximum. | +-----------------------------------+-----------------------------------+ | **Georgia** | Coverage includes diagnostic, | | | non-surgical and surgical | | | treatment. Covered as a Major | | | service. If the plan has no Major | | | coverage, the TMJ services will | | | be covered at the 50% | | | coinsurance. Subject to the | | | benefit year deductible and | | | maximum | +-----------------------------------+-----------------------------------+ | **Minnesota** | Coverage includes diagnostic, | | | non-surgical and surgical | | | services. Covered as a Major | | | service. If the plan has no Major | | | coverage, the TMJ services will | | | be covered at the 50% | | | coinsurance. Subject to the | | | benefit year deductible and | | | maximum. | +-----------------------------------+-----------------------------------+ | **New Mexico** | Coverage includes diagnostic, | | | non-surgical and surgical | | | services. Covered as a Major | | | service. If the plan has no Major | | | coverage, the TMJ services will | | | be covered at the 50% | | | coinsurance. Subject to the | | | benefit year deductible and | | | maximum. A separate TMJ maximum | | | cannot be applied, per state | | | regulation. | +-----------------------------------+-----------------------------------+ | **Washington** | **WA Large Group Plans** (51+): | | | We must offer TMJ coverage. If | | | elected, coverage includes | | | diagnostic, non-surgical and | | | surgical services. Covered at the | | | 50% coinsurance. Subject to a | | | separate \$1,000.00 benefit year | | | maximum with a \$5,000.00 | | | lifetime maximum. | | | | | | **WA Small Group Plans** (\ 3. Specialty referral and emergency claims, 4. Commissions, 5. Administrative expenses; and 6. Profit Monthly payments, rates, and commissions are a fixed cost. Guardian's risk is on the claims for specialty, out of area claims, and supplemental payments. Another risk is the expense for administrative costs. Because of this, we can only make or lose money on a relatively small portion of the premium. ###### **Composite Rates** DHMO's can support two, three, and four tier rates. The dependent rate is a \"composite\" or combined single age regardless of the number of dependents as rates vary by tier. Composite rates are also known as standard rates. ### Orthodontia Coverage Managed Dental Care orthodontic benefits vary by plan type and may either be equal to the fee schedule amount or may be supplemented by the plan, like other specialist services. If the plan is not making any payment; then the member gets the benefit of a discounted fee. If the plan supplements the payment, this further reduces the members out of pocket expenses. Further discounts may be available for an additional premium ### Switching Plans ###### *[Dual Choice]* Managed Dental Care Plans (DHMOs) are a restricted choice of primary care dentists and may not be ideal for everyone. Most employers opt to offer DHMO plans together with PPO or Indemnity plans, allowing each employee to choose the type of plan that is best for them and their family members. This arrangement is known as *dual choice*. ###### *[Monthly Switch]* Monthly Switch is an enhancement to the dual choice product line and is available on the U series plan designs only. This feature allows members to switch between the Managed Dental Care (DHMO) and PPO or Indemnity plans on a monthly basis. With a traditional dual choice plan it only allows for one switch annually. The monthly switch feature is available in certain states, please refer to the Group Products/Underwriting manual for state specifics. Whether it's a traditional dual choice or monthly switch, when a member switches plans, the selection of the plan applies to the entire family. The member and their dependents are always covered by the same plan. Once a member switches, all the terms and conditions of the new plan will apply. ***Note:* Monthly Switch and Maximum Rollover cannot be used on the same case.** ### Rates When a plan is sold with a Monthly Switch dual choice option, the rates for both the DHMO and PPO plans are blended so billing administration is seamless for the planholders. When a member switches plans, we do not recalculate the monthly bill. ***Note:*** Monthly switch and blended rates are not available for our DHMO TPA arrangements with Dominion (MD, DC, VA, PA, and DE), Liberty (NV) and TDA (AZ). ### Renewal Rates At renewal time, the blended rate is separated into DHMO and PPO components. The actual DHMO versus PPO participation is reviewed against the original assumptions, and the DHMO and PPO rates are adjusted and re-blended. **Blended Rate:** A single blended rate is when there are two plan options available, and each plan has the same rate. DHMO National Plan Type Features & TPA's ---------------------------------------- ### National DHMO **National DHMO plans (U and N series)** allow Guardian to have a common Managed Dental Care brand that can be sold to a single situs group or multi-state employer groups with a blended rate. This type of DHMO is more competitive and has benefit enhancements that mirror our PPO plans. The difference with a National Managed Dental Care Plan is that the DHMO portion of the Dual Choice can be written on either Guardian paper or one of its affiliates and all locations can have the exact same benefits, regardless of situs or affiliate) ### Dominion, Liberty Dental & TDA Through separate co-marketing agreements with Dominion, Liberty Dental & TDA, Guardian can market its Preferred Provider Organization (PPO) Dental plan alongside their Dental Health Maintenance Organization (DHMO) plans. Dominion Dental has one of the largest dual choice networks in the Mid- Atlantic. Partnering with Dominion allows our sales force to strengthen our market presence in Delaware, Maryland, Pennsylvania, Virginia, and Washington D.C. Liberty Dental supports our Nevada market and has a substantial presence in Clark County (Las Vegas). TDA's partnership allows us to strengthen our market presence in the state of Arizona with standalone DHMO sales and the ability to support a dual choice offering. Guardian handles the eligibility, billing, premium collection, and commission payments. DHMO claims and ID cards will be processed by Dominion, Liberty & TDA. ### Triple Option Plans The Triple Option Plan has three different options available for plans with greater than 100 lives. Two PPO options written alongside a Managed Dental Care option, One PPO plan with two Managed Dental Care options and Three PPO choices. #### Two PPO options written alongside Managed Dental Care Having two PPO options written alongside a Managed Dental Care option could provide a selective package. Certain risk parameters must be considered on a case-by-case basis, which could increase the rates. #### One PPO plan with two Managed Dental Care options On the option for one PPO plan with two Managed Dental Care options, if Dual-Choice Underwriting requirements are met then there is no increase to the rates. #### Three PPO choices While the three PPO choices can create real opportunities for adverse selection, an Underwriter may need to be consulted with on the appropriate pricing adjustment. Underwriting ============ To Underwrite can mean several different things. From an insurance company's perspective our meaning is to sign and issue an insurance policy thus accepting liability if specified losses occur, to insure the risk, and to accept liability up to a specified amount in an insurance policy. An underwriter is a person who handles the underwriting of the policies of insurance. They determine the level of risk Guardian is taking and the cost or premiums for dental benefits. Risk Selection -------------- With the Dental product it's not as complicated. Risk selection is a factor when determining Dental rates, but it is minimal. A non-transferred or virgin group is assumed to have accumulated neglect and would, therefore, receive a rate load spread over specific time periods based on the group\'s size. No evidence of insurability or other health statements are required. The industry factor loads the rates for only a handful of industries that have a proven increased risk over other industries. The Dental product simply doesn't carry the high level of risk that accompanies other insurance products. When comparing Dental to Medical, Dental procedures have a lower cost. These lower procedural costs allow for lesser benefit maximums. A Dental benefit maximum can range from \$1500 to \$1000 in comparison to a medical maximum of either unlimited or one million dollars. Rating ------ Guardian's dental rates vary based on risk factors. Depending upon the type of risk underwriting may need to manually adjust rates. ### Claims Experience with Prior Carrier For new business quotes on takeover cases with more than 100 enrolled employees, our underwriters use the case's claims experience with their current carrier to help set the premium rates that would be necessary for the proposed Guardian dental plan. ### Demographics Demographics refers to characteristics of the group which affect the amount and cost of dental care that its employees and their dependents will use. These include the geographic area where they are located, their industry or occupation, and their age and g

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