Network Access Plan 2

Transcription

1 Group PPO Dental Underwritten by The Guardian Life Insurance Company of America (GLIC) Network Access 1 Network Access 2 Network Access 3 Value 1 Value 2 Value 3 Coinsurance Preventive Services 80% 100% 100% 80% 100% 100% Coinsurance Basic Services 60% 50% 80% 60% 50% 80% Coinsurance Major Services 40% 50% 50% 40% 50% 50% Optional Orthodontic Services 40% 50% 50% 40% 50% 50% Comparisons Network Access s (NAP): These plans give employers an option in situations where the employer finds higher premiums more acceptable than restricting non network benefits. Out-of-network (OON) benefit payments are based on usual, customary and reasonable rates. Value (VP): These plans control costs and encourage network utilization in areas where PPO network providers are prevalent. Employers can save an average of 15 to 20% compared to a typical PPO plan. In-network member costs are based on negotiated rates. Out-of-network (OON) benefit payments are based on the difference over network negotiated rates. Features Product is Guarantee Issue (GI) if enrolled when first eligible* Choose from a total of 6 dental plans based on desired coinsurance, and out-of-network reimbursement $50 calendar year deductible, (3 per family limit) on all plans for in- and out-of-network services; deductible is waived for Preventive Services for NAP 1 & VP 1 (in-network only), NAPs 2 & 3, and VPs 2 & 3 (in- and out-of network) All plans have a $1,000 annual maximum benefit, with Maximum Rollover Account & Preventive Advantage Benefits are paid on a Calendar Year (CY) basis NAPs use UCR 90 th percentile If in Network, no balance billing the insured for the difference between the fee schedules and the actual charge ID cards are provided to enable both confirmation of benefits and assignment of benefits Product utilizes GLIC s DentalGuard Preferred Network providers Premiums may be deducted pre-tax (Section 125) or post-tax Employer can contribute all, part or none of the premium Credit towards the 12-month Major Services waiting period will be given to current members with appropriate dental coverage (major services) under the employer s immediate ** prior carrier. Employer s immediate prior carrier last month bill is used to identify current members. For an additional cost, an employer option is available to waive the waiting period for future members. Rates are guaranteed for 12 months Coverage is COBRA eligible *See Underwriting for Late Entrant Penalty. **As of the day before Group PPO Dental coverage is effective. Optional Coverage (employer-level plan option) A $1,000 Lifetime Limit Orthodontic benefit can be added to the plan for an additional cost for dependents under age 19. Option is Guarantee Issue (GI) if enrolled when first eligible; late entrants will have to satisfy an additional waiting period of 12 months unless plan is part of a Section 125 with annual enrollment and the member enrolls during the annual enrollment ABJ (04/13) Page 1 of 6

2 This benefit is paid at the coinsurance level consistent with Major Services of the dental plan selected by the employer No deductible Benefit is paid on a quarterly basis Orthodontic benefits are not charged against the dental benefit year maximum limit that applies to all other dental services Credit towards the 12-month Orthodontic Services waiting period will be given to current members* with appropriate dental coverage (orthodontic services) under the employer s immediate prior carrier. For groups with 25+ eligible, for an additional cost, the waiting period can be waived for future members. * As of the day before Group PPO Dental coverage is effective. Value Added Benefit (MRA included in all standard plans at no additional cost) Maximum Rollover Account (MRA) allows employees to rollover a portion of their unused annual maximum benefit into an MRA up to $1,000. Treatment must be obtained from a provider for covered services for which a benefit payment is issued in excess of any deductible or copay Calendar year claims may not exceed $500 to rollover An amount of $250 is put into an MRA; an additional $100 can be rolled over by only using DentalGuard Preferred Network providers The employee can use the MRA in the future when they have reached the dental plan s annual maximum benefit The employee must be eligible for Major Services for the Maximum Rollover benefit to start If the plan, employee or dependent has a coverage year effective date between October and the end of the year, the MRA benefit will begin January of the next year Orthodontic Services are not subject to MRA Preventive Advantage.allows employees to receive covered Preventive Services without it being deducted from their annual maximum benefit. Benefit is embedded in all standard plans, except for groups sitused in MT, NH or VT Applies to both in- and out-of-network covered Preventive Services Refer to the policy for the complete list of 25 covered Preventive Services that qualify Non-bitewing x-rays are considered Basic Services and apply toward the annual maximum benefit Although no covered Preventive Services are applied to the annual maximum benefit, they do count as a paid claim and apply toward the insured s MRA threshold amount Eligibility Employer determines the eligible class of employees for this coverage. Issue ages are 18 and over Employee, spouse (or domestic partner)*, and children can be covered Dependent children are covered to age 26, unless states mandate higher limits Employees and dependents who do not enroll within 31 days of their eligibility date, are considered late entrants, unless they have a Qualifying Event (QE) If the plan has a Section 125, the employee and dependent may enroll during the annual enrollment without a late entrant penalty Changes in coverage due to QEs must be submitted within 31 days of the QE Please review Guidelines tab on the Group PPO Dental Rate Generator located on the Agent Website under Agent Resource Center > Rate Generators > Group PPO Dental for additional information *Only if employer requests domestic partner coverage or required by state law. ABJ (04/13) Page 2 of 6

3 Underwriting Group PPO Dental will not be available to new or existing Group Indemnity Medical (GIM) or existing AHL minimedical accounts; only Heritage Choice Dental (HCD) will be available for these groups Groups must have at least 5 eligible employees, with 5 enrolled in coverage to install Minimum participation requirement: Eligible Employees Participation Requirements No Prior Coverage or Prior Coverage without Major Services Prior Coverage 5-21 Minimum 5 enrolled employees % or more* % or more* 25% or more* % or more* 35% or more *35% participation is required for plans sitused in Vermont. Only 1 plan may be offered by an employer Product is available to associations and unions which requires AB Group Underwriting quotation Insureds with no prior dental coverage will satisfy a 12-month waiting period for Major services Credit for dental coverage under a prior carrier used to reduce 12-month waiting period for Major services and Orthodontic (if applicable) Takeover groups, the employer s current employees will not be subject to the 12-month waiting period for Major and Orthodontic services. A copy of the most recent prior carrier s bill and booklet are required to support proof of appropriate dental coverage under the employer s immediate prior carrier. An employer option is available to waive the 12-month period for future employees, for Major services, and Orthodontic services for groups of 25+ eligible employees. Takeover groups with 100+ eligible employees - Employer option to reduce the 12 month waiting period at a member level for appropriate dental coverage (orthodontia and/or major services) under the employer s immediate prior carrier. Credit available for members covered by the employer s dental plan with no gaps in coverage. Employer s immediate prior carrier report/bill required. Late entrants will have to satisfy a 6-month waiting period on Basic services and a 12-month waiting period on Major and Orthodontic services, if applicable; this is in addition to the 12 month waiting period assessed for no prior coverage for Major and Orthodontic, if applicable. Late entrant waiting period does not apply to members of a Section 125 with an annual enrollment when the member enrolls during annual enrollment, or when the member has a Qualifying Event. s implemented as part of a Section 125, must conduct their annual enrollment within a 3 month period prior to the plan s renewal/anniversary date, with a transfer date to match the plan's renewal/anniversary date Takeover groups with 100+ eligible employees will receive credit for deductible, annual maximum and MRA reward* with employer s immediate prior group claim report, and rollover report from immediate prior carrier report. MRA reward report must be within 3 months of group transfer effective date. The employee must be eligible for Major Services for the Maximum Rollover benefit to start. For employees subject to the 12-month waiting period and/or late entrant waiting period, their eligibility for MRA rewards does not begin until they are eligible for Major Services. MRA rewards are based on all claims incurred during the calendar year, even when a claim is submitted after the calendar year ends. Late claim submissions can affect the MRA reward earned by an insured. When a MRA reward is initially calculated in a calendar year and a claim with dates of service in that calendar year is subsequently paid, the insured s eligibility for the MRA reward may change and the reward amount may be changed or removed from the insured s MRA. When a claim incurred in the next year has already been paid using the initially calculated MRA Reward dollars, that amount paid becomes a negative dollar amount in the insured s MRA. This negative amount will be recovered by deducting the amount paid for the claim from future claims. AFLAC: Groups less than 100 lives, or 100+ lives with AFLAC s Basic or Standard plans, or Premier plan with less than 24 months of continuous coverage are not deemed as having prior coverage. ABJ (04/13) Page 3 of 6

4 Product is available for sale in New York; state specific rate generator & forms are posted at NY- Benefits/PPODental.com MA sitused groups will have NAPs available, AK sitused groups will have NAPs 2 & 3; NV sitused groups will have NAPs 2 & 3 and VPs 2 & 3; WA sitused groups will only have NAP 3 & VP 3; MT, SD & WY will have indemnity plans (R&C with no PPO network) available and will require quoting from AB Group Underwriting. NM work location (zip 879XX) will require quoting from AB Group Underwriting. Groups with current Heritage Choice Dental coverage that install Group PPO Dental will be allowed to keep the Heritage Choice Dental coverage in force; however, no new enrollments into the Heritage Choice Dental will be accepted Groups with current Guardian Dental coverage are not eligible for the Group PPO Dental through AB Groups with current Guardian coverages, require a letter from the employer agreeing to a Group PPO Dental proposal through AB. Arkansas and Washington State Law requires insurers to offer an employer optional dental benefit for the treatment of Temporomandibular Joint Disorders (TMJ) and, for groups sitused in Arkansas coverage for Craniomandibular Disorders is included. Proposal rates include these benefits. Employers are required to complete form GG AR or GG WA, respectively, regardless of whether they elect to include or exclude the benefit. Premiums Group premiums are composite rated, based on the employer s home office location (situs state), industry and additional work locations (if applicable) Employee premium is based on coverage level and benefits selected Four tier rate structure Employee, Employee + Spouse, Employee + Child(ren), Employee + Family Premium modes available are: monthly, semi-monthly, bi-weekly, weekly, ninethly or tenthly Premiums are billed to the employer via postal mail (paper statement) or electronically (EasyBill Online) Appointments GLIC only appoints individual agents or brokers; there are no agency appointments All agents or brokers must be appointed with American Heritage Life (Allstate Benefits or AB) prior to AB submitting GLIC appointment All agents and brokers must be appointed with GLIC prior to marketing Group PPO Dental to groups sitused in PA GLIC will not process any new business through their system until the AB agent or broker has been appointed with GLIC All GLIC appointments will be processed by Group New Business (GNB), GroupNewBusiness@allstate.com All 17 pages of the GLIC appointment form must be submitted to GNB for processing GLIC agent numbers will be reported back from GNB to the agent and/or regional office All agents and brokers must have their GLIC agent number in order to enroll Group PPO Dental using AllApp Installation Guidelines All policy effective dates will be the 1 st of the month To ensure that coverage is in force on the effective date of the policy, all installation/enrollment paperwork must be in AB s Group New Business department by the 15 th of the previous month Installation/enrollment must be received in AB s Group New Business department the last day of the month prior to the requested effective date All enrollment material, and the employer application must be dated earlier than the policy effective date Use ABJ16858 Group PPO Dental New Business Checklist when submitting new groups Arkansas and Washington (state) sitused groups are required to submit form GG (suffix AR or WA) identifying employer s election regarding TMJ coverage ABJ (04/13) Page 4 of 6

5 Groups with current Heritage Choice Dental coverage that install Group PPO Dental will be allowed to keep the Heritage Choice Dental coverage in force; however, no new enrollments into the Heritage Choice Dental will be accepted Policy / Certificate / ID Card Delivery Employer will receive electronic delivery of the policy and certificate; except in Texas where the employer has the option to receive a hard copy from GLIC Employer is responsible for distributing certificates to employees via or hard copy Employer will receive Welcome Letter, benefit administration information and a notice to distribute to their employees for access to electronic plan level ID cards from GLIC (within 20 business days from GLIC s receipt of installation paperwork). (GA sitused groups receive member level ID cards.) Employer is responsible for distributing a notice to employees on how to access their electronic ID cards Electronic versions of the ID cards and certificates are available on Confirmation of Benefits & Claims Processing Benefit confirmation and claims processing/payments are administered by Guardian Life Insurance Company of America. Online services available 24/7: Dental Member Services: The customer service phone number listed on the ID card Out of country care is available using GLIC s International Dental Assist program; (international) call collect or from within the US COBRA Policyholder (employer) is responsible for administering COBRA or hiring an outside party to administer COBRA coverage Policyholder (employer) or the policyholder s COBRA administrator will be responsible for communicating COBRA elections to AB s Group New Business department and remitting premiums to Group Premium Accounting department Policyholders (employers) with other Allstate Benefits COBRA eligible coverage or those currently without a COBRA administrator may consider contracting directly with COBRAGuard, a Third Party Administrator specializing in COBRA administration services Portability This coverage is NOT portable. Policy Provisions (Policy form GP-1-DG2000) Group PPO Dental is underwritten by The Guardian Life Insurance Company of America, headquartered in New York. The company has been rated A++ (Superior) by A.M. Best Company. Exclusions and Limitations See policy pages for complete details Areas of Responsibility & Contacts Product Training Appointments Product Sales & Support (pre-installation, installation, marketing & enrollment materials) AB s Training Department, AB Regional Sales Office or Allstate Field Sales Office AB Regional Sales Office or Allstate Field Sales Office AB s Group Marketing Sales Support or groupunderwriting@allstate.com fax: Eligibility, Enrollment, Changes, Court Orders, AB s Group New Business Group Terminations, ID Cards, Policies, or groupnewbusiness@allstate.com Certificates, COBRA Elections fax: ABJ (04/13) Page 5 of 6

6 Billing, Employee Terminations, Commissions, COBRA Premiums Confirmation of Dental Benefits, Claims Processing, Locating a Provider AB s Group Premium Accounting or grouppremiumadmin@allstate.com fax: Guardian s Dental Member Services or ABJ (04/13) Page 6 of 6