Q & A Changes in Dental Carriers
Questions and Answers on the Change in Dental Carriers
By law, the State is required to competitively bid state employee and retiree health, pharmacy and dental plans every three to five years. The last time the dental plans were competitively bid was in 2009 and United Healthcare took over providing coverage under the Basic and Enhanced plans from the Anthem. This is the year for bidding on the company or companies to provide the coverage required by our contractual dental benefits. The questions and answers below cover the results of that competitive bidding. These results are effective July 1, 2014.
|1. What are the three plans that are required by the SEBAC Agreement?||They are called Basic, Enhanced, and the DHMO. Their description can be found on the Comptroller’s website at http://www.osc.ct.gov/benefits/docs/SOCActvEmpl2013finlrev51413.pdf
beginning at page 20. Generally speaking, the Basic plan has the narrowest benefit package, but the largest network, and little or no additional costs for using out of network dentists. The Enhanced plan has a better benefit package, a smaller network of providers than the Basic plan, and usually has substantial additional costs for the use of an out- of-network provider. The HMO has the richest benefit package, but a very narrow network of providers and no out-of-network coverage.
|2. As a result of this year’s bidding process; did we eliminate or fundamentally change any of these plans?||No. As has happened in the past, there will be some change in which carriers provide the plans, but the plans are fundamentally unchanged. See Answer 6 for the only changes in benefits which will occur on July 1st.|
|3. Could you be more specific? Which are the current providers, and how will that change?||As of now, United Healthcare provides coverage for the Basic and Enhanced plans. CIGNA provides coverage for the HMO. In the recent competitive bidding CIGNA was awarded the contract to providecoverage under all three State dental plans.|
|4. Will CIGNA’s network of providers for the Basic and Enhanced plans be as large as the United Healthcare network?||CIGNA’s networks will be substantially larger than United’s current network.|
|5. But what about disruption? What if my current provider is not in CIGNA’s network?||A change in carriers always causes some confusion, but there are a number of safeguards to help make sure any disruption is minimal. First, there is already a high degree of overlap between the CIGNA network and United’s. About 92% of United providers are also CIGNA providers right now, and CIGNA is contractually required to raise that to 100% under both plans. Just as important, however, are the following:
(1) In the Basic plan, “balance billing” is forbidden by the contract with CIGNA even for out of network dentists. That means for any service, the member pays whatever the co-pay is that is required by the plan, and pays no more than that, even if the dentist is not in the network.
(2) While this “no balance billing” rule does not normally apply to the Enhanced plan, it will apply for the first 90 days of CIGNA’s being awarded the contract for members seeing providers who are in United’s network but not in CIGNA’s. So for those 90 days, even participants in the Enhanced plan pay only the co-pay is that is required by the plan, and no more than that, even if their United network dentist is not yet in the CIGNA Enhanced network.
(3) By the end of those 90 days, CIGNA is contractually required to insure that all providers currently participating in United’s Enhanced plan network also participate in CIGNA’s Enhanced plan network.
|6. Does that mean there are no benefit changes at all as a result of the bidding process?||No, the parties took advantage of the opportunity presented by the bidding process to clarify a couple of issues, and to modernize and improve
benefits. Here’s how:
(1) The Basic plan currently provides only 80% coverage of dental cleanings. While in 2011, these cleanings were made free twice a year for participants in the HEP, these free cleanings were tied to the HEP’s rule that all required screenings be free, and reflected the fact that originally, the HEP required that participants get two cleanings per year in order to remain compliant. This was not a feature of the Basic plan itself. Based upon best medical evidence, the HEP dental cleaning requirements have been lowered to only one per year. However, the Basic plan will now provide two free cleanings per year, regardless of HEP requirements.
(2) The Basic plan currently does not cover sealants (which are recommended for all children up to age 16). Only the Enhanced plan provides that coverage. The Basic plan will now also provide coverage for sealants for children up to age 16.
(3) None of the plans currently cover implants. Implant coverage, up to $500 per year, will be added to the Enhanced plan, but only in for participants in the Enhanced plan who use in-network providers.
(4) The Basic plan, unlike the Enhanced plan and the HMO, currently provides no coverage for getting dentures. While dentures will not be made a covered feature, Basic Plan participants using in-network providers will be able to get dentures at the in-network discount.
(5) All plans currently allow dentists to replace crowns every 5 years, even if those crowns are perfectly functional. Dental experts now recommend crown replacement for functional crowns only after 7 years. This change saves money for both the member and state, and the state’s savings helped fund the improvements in sealant and implant coverage. This change does not affect coverage for crown failures.
(6) All plans currently provide coverage for 360 degree panoramic X-Rays every 3 years. Dental experts now recommend against this, in part because of radiation risk, and suggest panoramic X-Rays only ever 5 years, and the plans have been modified to reflect this recommendation. This change also saves money for both the member and state, and the state’s savings helped fund the improvements in sealant and implant coverage.
|7. Are the small numbers of dental providers under the CIGNA dental HMO the only providers CIGNA will have under the Basic and Enhanced plans?||No, CIGNA has much larger networks under both the Basic and Enhanced plans. In fact as we mentioned above, CIGNA’s networks that will cover the Basic and Enhanced plans will be substantially larger than United’s networks for those plans.|
|8. Do I have to reenroll in the dental program and chose one of the three State plans during the open enrollment period?||No, you only need to make a change during open enrollment if you want to switch your current choice of Basic, Enhanced, or HMO.|
|9. Will my dental HEP compliance records be affected by the change from United Healthcare to CIGNA?||No.|