BENEFITS BUSINESS
Reduced benefits and specialized
services mark renewals
By Len Strazewski
"If agents want to make an accurate coverage analysis, they are going to have to make a deep reading of each policy."
-- Alan Vogel, DMD, MetLife National Dental Director
Group dental insurance used to be one of the easiest ancillary employee benefits products to market to employers. Simple and inexpensive, dental benefits were a popular addition to group health plans during the 1980s and 1990s when employers were looking for ways to distinguish themselves in a competitive human resources environment.
Most plans were alike in design, featuring three classes of coverage: preventative care and annual examinations covered at 100%, routine "drill and fill" at 80% and advanced care such as root canals, orthodontics and replacements at 50%.
Today, dental insurance is still popular, covering nearly 110 million individuals, according to dental insurance providers; however, the costs are rising steadily and coverage terms are becoming increasingly complicated.
As a result, independent agents who market group dental insurance are challenged to shop dental insurance policies at every renewal and communicate a broader set of policy terms to their clients.
"Dental insurance prices are going up, but usually [at] a controllable rate--7 or 8% a year," explains Alan Vogel, DMD, national dental director at MetLife in Bridgewater, New Jersey. "But medical insurance is going up much faster, making employers extremely sensitive to costs. Employers are looking for any and all ways to control their overall costs, and if they believe they can save money by changing dental plans and carriers, they are going to ask their agents to shop around."
Small and medium-sized employers (fewer than 1,000 employees)--the group most often represented by independent agents--have been hit hardest by medical insurance price increases and also are the hardest hit by dental plan cost increases, Vogel says.
Following the lead of medical insurance carriers, insurers are responding to the competitive pressure by increasing cost controls, building managed care networks of preferred providers and introducing new Web-based claims technology to expedite coverage verification and claims processing, Vogel notes.
For example, MetLife sponsors a network of 44,500 preferred dental providers who have agreed to provide services at 10% to 30% below the average cost in their communities. Other large dental insurers, including Aetna and Cigna, have built similar discount networks or dental maintenance organizations (DMOs) that help manage costs.
However, some insurers are also rewriting dental insurance policies to shift costs to employees and reduce total coverage in subtle ways, Vogel says. This complicates the annual remarketing of policies and creates pressure on agents to analyze each coverage proposal and communicate each coverage variation to their clients.
"Dental insurance policies are no longer all alive. In order to reduce the premium, some insurers are creating a closed list of services that are covered by plan. If a service is not on the list, the insurer may not pay, essentially shifting the cost to employees. Employers may not be aware of the change in coverage--until employees begin to complain about services that were covered under the previous insurer, but aren't any longer," he says.
X-rays, bitewings and other diagnostic services, previously covered at 100% more than once a year, may become limited. Services previously available once a plan year may become available only once in 12 continuous months, preventing dental patients from using the services as they choose. Orthodontics, usually subject to a lifetime dollar cap, may also be restricted by policy period, barring payment for treatment that began in a previous policy year.
Some treatments previously covered at 80% are being moved into the 50% coverage category and are being identified with more restrictive terminology.
"If agents want to make an accurate coverage analysis, they are going to have to make a deep reading of each policy," Vogel says. "I'd recommend they create a spreadsheet identifying the terms and conditions of each carrier they represent so they can communicate clearly to their clients exactly what they are covering. Nobody likes these kinds of surprises."
Agents also may have some expanded terms and conditions to communicate--specialized services designed to target high-risk individuals. Vogel says insurers are experimenting with creating new types of dental plan coverage that is consistent with current dental medical research.
Twentieth century dental insurance was designed to be treat all patients alike, with equal terms of coverage, Vogel notes, However, dental medical research indicates that not all dental patients are alike with similar risk factors.
"Health insurers have been exploring individual risk assessment for several years, providing extensive health education and disease management programs for individuals with unusual risk, including asthma, diabetes and cardiac disease," Vogel says.
"Many of these special patients also pose special dental risks, as well. Diabetics, for example, are particular vulnerable to infection and periodontal disease. For these individuals, an annual examination and cleaning is simply insufficient. Without quarterly periodontal cleanings, these patients risk complications that in the long run could be very expensive.
"Some special medical patients take medications with side effects--such as dry mouth--that prevent proper lubrication in the mouth, leading to a greater propensity for decay. These patients may require more than a single annual examination and basic dental care," he says.
As a result, insurers are beginning to conduct formal risk assessments for individual policyholders and are tailoring preventative coverage for them that matches their unusual risk. Last year, MetLife announced a pilot program, called Disease Management Through Risk Assessment, with the University of Connecticut and University of North Carolina dental schools that will help prepare dentists to design individual preventative measures for each special-risk patient.
Selected patients complete a self-assessment questionnaire that inquires about sugar intake, brushing and flossing habits, and fluoride exposure, among other risk factors.
"The success of an approach to oral health care that emphasizes risk assessment, early recognition, prevention and intervention when treatment needs are minimal can be enhanced by an active involvement of patients, In addition, a heightened awareness of risk should serve to encourage patients to undertake the behavioral changes conducive to improved oral health," says James Kennedy, dean emeritus of the University of Connecticut School of Dental Medicine and chair of the MetLife dental advisory council.
The insurer has also made the self-assessment questionnaire available in an electronic form to group plan customers for use on employer intranet Web sites.
Aetna in Hartford, Connecticut, is also experimenting with dental disease management. In February, the insurer announced a partnership with Columbia University School of Dental and Oral Surgery in New York, funded by a $50,000 grant from the Robert Wood Johnson Foundation, to research the impact of tobacco use on oral health.
The partners will create a CD-ROM-based interactive tool for dentists to use in assisting patients to quit the use of tobacco. The interactive software will be used to provide education on tobacco control, identification of patients who smoke, setting cessation targets and developing health plan performance measures
Technology is also an important factor in the new dental insurance, and agents need to be aware of the new ways in which dental coverage can be verified and claims can be processed. Both MetLife and Aetna have selected Irvine, California-based Dentalxchange, an Internet communications company that provides Web-based practice management and payer connectivity to the dental industry. Dentalxchange allows dentists to access eligibility and plan design information, claims and pre-treatment estimate status or history and other information about plans provided by participating insurers. For MetLife, the company is hosting a special dental provider's portal (http://www.MetDental.com).
Vogel says the portal site will expedite claims and reduce coverage denials caused by inaccurate plan data--leading to faster reimbursement for dentists and improved satisfaction for patients. *
The author
Len Strazewski has been covering employee benefits issues for more than 20 years and is employee benefits editor of Human Resource Executive magazine. He has an M.A. in industrial relations from Loyola University.