– Hello and welcome. My name is Lisa Eggert andI'm the Account Manager for the MPSERS Retirement System. Today we have some goalsfor this presentation. Our goals are to provide you information on the plan changes for 2018. Provide you cost share information on covered dental services. Highlight the type of providers.
That offer you the best value. Illustrate some payment examples. Show you how to getinformation about your plan, and demonstrate the online tools. Starting off, the changeseffective January 1, 2018. The retirement system is introducing a $50 deductible per person. This is an annual deductible,and it only applies when the services are provided by dentists.
That are not in the PPO network, which means it will be applied when you go to a DeltaDental Premier provider, or a nonparticipating provider. This deductible only appliesto basic and major services. As we look at the benefiton the next slide here, you'll see how that tiesinto the benefit structure. As you can see on thisslide, for your coinsurance there are two columns here.
The Delta Dental PPO dentist, and the Dental Dental Premier,or nonparticipating dentist. And the first type of service, you have diagnostic andpreventative services. This covers your two cleaningsand exams per calendar year. As a reminder, this is twocleanings and exams per calendar year, so anywhere fromJanuary 1 to December 31st, you can have two cleanings and exams. They do not need to be acertain amount of time apart.
If you have your two… If you have a cleaning inJanuary and again in March, that's your two for the year, it gives you flexibilityin scheduling those exams. As you can see, when yougo to a PPO provider, you have a higher level of benefit, so you have 5% coinsurancewhen you go to a PPO provider, versus a 10% coinsurance when you go to a Delta Dental Premier ornonparticipating provider.
Also, covered under thiscategories are X-rays. And X-rays are covered at 5%, or you have 5% coinsurance when you go to a DeltaDental PPO provider. And when you go to a Delta Dental Premier or a nonparticipating provider, you have a 25% coinsurance. In the second category ofservice, the basic services, you can see here that these are referred.
To as restorative services. The restorative servicescover things like fillings, crowns, periodontal services,periodontal or anything that have to do with gum disease. Endodontic services, whichhave to deal with root canals, oral surgery, relines and repairs. All of those are consideredrestorative services. As you can see when yougo to a PPO provider, your fillings have a 20% coinsurance,.
So you have a higher level of benefit by going to a PPO provider. When you go to a Premier ornonparticipating provider, you have a 25% coinsurance. All of the other servicesthat are covered under this for the PPO that I've mentioned earlier are covered at a 25% coinsurance. You can see from thisgrid that the deductible is applied for the basicservices in the column.
When you see a Delta Dental Premier or nonparticipating provider. The last type of servicehere are the major services. These would be consideredprosthodontic services and implants. Prosthodontic services areanything that have to do with fake teeth. Bridges, dentures, partials, implants all fall into this category.
As you can see that there's a50% benefit coinsurance level on this benefit forgoing to a PPO provider and for Delta Dental Premieror nonparticipating provider. You will see on the columnfor the Delta Dental Premier or nonparticipatingprovider a 50% coverage or coinsurance and also the deductible is applied for the major services. So as a recap, the deductibleis applied when you go to a Delta Dental Premieror nonparticipating provider.
At the basic serviceand major service level. Otherwise, when you goto a a Delta Dental PPO or have preventative services,there is no deductible. Just a couple of notes on this slide. I often get asked abouthow much a service gets… How much a service cost. It depends on the area, thetype of provider you go to, those types of things. The best to find out how muchthat service is gonna cost.
Is to have a pre-estimate done. This pre-estimate would besubmitted to Delta Dental by your provider. When it is submitted to Delta Dental, we look at a variety of things. Essentially, your dentalprovider will send us the claim prior to it being completedwith all of the codes of service that are gonna be provided. We look at the contractthat you're covered under.
Which is the MPSERS contract. We look at your time limitations, there are certain services,like bridges, dentures, crowns, implants that all havea five year time limitation. So, for example, if I have acrown done on tooth number 10, I can't have another crowndone on tooth number 10 until five years have passed. And then lastly, we look atyour annual maximum available. We look to see how muchannual maximum you have left.
For that benefit year, and determine how that's gonna pay out. Having this pretreatment done, when this pretreatment isdone, we will send to you what looks like anexplanation of benefits, but it will indicate that it'sa pretreatment of estimate, so that you know howmuch is gonna be covered, and whether or not that service is covered prior to that service being done.
Your provider is alsoreceiving this communication or this information, sothat you're able to ask any questions of your provider before that service is being done. All of the services thatare listen on this page are subject to your maximums. So your annual maximum is $1,100. This is a per calendar year maximum. It's per person, so you, yourspouse and any dependents.
That you have under your planeach have their own $1,100. Every time the plan makes a payment, it's deducted from this $1,100. So, for example, if you go toa provider and have a service done, after that service orafter that claim has processed, you receive an explanation of benefits. That explanation of benefitshas information that says plan pays a certain amount, patient pays a certain amount.
It's the plan pay amount thatis deducted from the $1,100. Once the plan has paid atotal of $1,100 on your behalf over the year, all paymentsthat the plan makes will stop, you can continue to have treatment, but you're gonna pay a 100% out-of-pocket for that treatment. If you max… what we refer to as max out of your plan and you've reached that$1,100 during the year,.
No additional monies will be paid, but every January 1, everybody starts over with a brand new maximum, regardless of the amount thatyou've used the prior year. So each January 1, everybody starts with the new $1,100 annual max. This plan also has anorthodontic benefits. And the orthodonticbenefits are for dependents up to the age of 19.
So for those of you whostill have dependents that are under the age of 19, there is an orthodontic benefit. It's a 50% coinsurance level for Delta Dental PPOand Delta Dental Premier and nonparticipating providers. The orthodontic benefitis subject to a lifetime maximum amount, whichmeans that each dependent that's covered under you planthat's under the age of 19,.
Has access to a $1,200 lifetime maximum over the course of treatmentfor their orthodontic benefits. And then lastly, the deductible. This is new this year. It applies to basic andmajor services provided by dentists that arenot in the PPO network, which means the DeltaDental Premier providers and nonparticipating providers. This is a $50 per person deductible.
And it's an annual deductible. So once you've paid your$50 in that plan year, you're done for that yearin paying your deductible. Another note that I wanted to list here was with regards to your carve out… Carve out Coordination od Benefits. For those of you who havemore than one coverage, either you, yourself have two dental plans that you're covered under,.
Or you and your spouseboth have coverage of… a dental coverage from your own employers, the retirement system useswhat's called carve out Coordination of Benefits. This does limit how the planplays when it pays secondary. There is more informationon the Extranet site, there's a flier forCoordination of Benefits that you can check out,so that you can understand how this carve outCoordination of Benefit works.
So we've talked about yourchanges for next year, we've talked about thebenefits that you have. Really, the driving factorin how the claims process is the provider that you choose. So if you take all of theproviders that are available, you can put them into three categories. They're either Delta Dental PPO, Delta Dental Premier or nonparticipating. You have the freedom tochoose any of these dentists,.
But the plan is designed tooffer the maximum benefit and the lowest out-of-pocket when you use a Delta Dental PPO provider. That's because, under this program, all claims are reimbursedat the PPO approved fee. When you go to a DeltaDental Premier provider, or nonparticipating provider,you'll likely pay more. Let's take a look at each of these different types of providers.
As I mentioned previously,the Delta Dental PPO providers have agreed to acceptDelta Dental's PPO approved amount at payment in full. You only are gonna pay for yourcoinsurance portion of that. Because the providersparticipate with our PPO network, there is no balance billing. They cannot charge you thedifference between their… our PPO approved fee andtheir normal fee for services, they write that off.
In addition, they pay directly. You're responsible for yourcoinsurance on the front end, they bill Delta and we pay them directly. The providers also agree to accept Dental Dental's processing policies. And these processingpolicies are rules and edits that we have within our systemthat limited program abuses. So, for example, theycan't unbundle services to make their claim more expensive.
They can't charge certainservices within certain periods of time, which… Because they're essentialthe same service. An example of this would be a filling. If I have a filling doneon tooth number eight, and that filling fails within 24 months, that provider has to redothat filling at no cost. There's no cost to the retirement system, and there's no cost to the member.
So when the claim comesin processes, it will say plan pays zero, patient pays zero. That's just an exampleof our processing policy because we would expectthose fillings to last more than 24 months. When you go to a PPO provider, you also have thehighest level of benefit. As we saw on the screen thathad the benefits listed, there is a higher level ofbenefit or a lower amount.
Of out-of-pocket whenyou go to a PPO provider. And lastly, when you go toa PPO provider, there is no deductible for any of theservices under the dental plan. The second type of provider is the Delta Dental Premier provider. And this providersparticipate with Delta Dental, but they do not accept thelower PPO approved amount that each of these claims are paid at. So the provider is allowedto charge the difference.
Between that PPO approved fee and the Delta DentalPremier approved amount that they have agreed to accept. That's why you pay an additional amount when you go a DeltaDental Premier provider. Delta Dental Premierproviders cannot bill you the difference between the DeltaDental Premier approved fee and the amount that theynormally receive for services. That would be considered balance billing,.
And they are not able to balance bill you, or they're not allowed to balance bill you when they participate with ourDelta Dental Premier network. The providers are also paid directly here. So you're responsible foryour coinsurance portion on the front end and thenthe providers bill us and we pay them directly. They also agree to acceptthe processing policies, the same processing policies that we have.
For the Delta Dental PPO network, they've agreed to accept those, as well. And then lastly, the deductibledoes apply to the basic and the major services. One note that I would addhere has to do with the explanation of benefits. When you go and have a servicedone at a dental office and they submit that claim for service, we process that claim and send out to you.
An explanation of benefits. It's very important that youtake a look at these statements this explanation of benefitswill show you the services that were done, it will showyou the amount that plan is paying, and it will showyou the amount that you pay. It's very important tolook at that number… That dollar amount thatyou owe and make sure that that's the amount thatyou're paying the provider. If the provider is comingback to you and telling you.
That you own an additionalamount on something that they didn't bill or we didn't cover, all you need to do is call Delta Dental and let us know that yourprovider is telling you that you owe more than whatthe explanation of benefits is. The amount that's on theexplanation of benefits is the amount that you shouldbe paying for those services. So if you have that situation,please call Delta Dental and let them know and know wewill reach out to the dental.
Office to work that billing situation out. I often get asked whatthe difference is between the Delta Dental PPO and theDelta Dental Premier networks. I often get asked, “Well, the Premier is abetter network, right? Because it sounds better,Premier is ultimately better.” The answer to that question is no. These providers are credentialed and licensed in the same manner.
They have to have thecredentials to be able to practice in the dental. Delta Dental Premier is actuallyour original network name that was established yearsago, when we first started. Over time and as insurance changed, our competitors startedto add these PPO networks and PPO stands for preferredprovider organization. It's a term that's used in insurance, and you'll see it in themedical world and dental world.
It just means a… a group of providers that haveoffered additional discounts. With that, we added a PPO network, so that we could competewith our competitors. So the difference that wehave is we have two networks. We have the PPO networkand the Premier network. And those work together to provide you with access to network providers. As I mentioned earlier,they are not different.
In terms of the servicesthat they can offer. It ultimately comes downto the provider deciding what level of discount the PPO, that they're willing to offer, the PPO providers offer adeeper discount on their fees than the Premier. Both offer discounts, butthe PPO discounts are deeper. So ultimately, it's the provider's choice which network they participate with.
The last type of providethat we've talked about is nonparticipating. And nonparticipating are exactly that. They don't participate with Delta Dental, which means they don't have to listen to anything that we say. At the end of the day, whenyou go to a nonparticipating provider, you will paythe full cost of services. Whatever they charge forthat, you'll ultimately.
Pay that amount. They can balance bill you. Under this nonparticipating,the deductible also does apply to the basic and major services. Another note that I wanted to add here was that you may haveto submit the claims. Oftentimes, thesenonparticipating providers will submit the claim foryou as a courtesy to you, but when you go to anonparticipating provider,.
They usually have you payfor the full amount upfront when you have those services done. If they don't submit the claim for you and you don't submit it,we don't get anything and we can't reimburse you,so it's really important for you to ask who'sgonna submit the claim, whether the office willsubmit it on your behalf or if you need to. The only way that we can reimburse you.
Is if we actually receive the claim. So you to note, so that you can make sure that you're getting yourreimbursement when you go to a nonparticipating provider. When you go to a participatingprovider, the PPO and the Delta Dental Premier,it's in their contract to submit the claim, soyou don't have to worry about that with theother types of providers. This next slide, it's just a comparison.
We've talked about… You can see with the bullet points, we've talked about thosedifferent bullet points and the differencesbetween those networks. What I wanted to point out in this slide is the… The amount amount of…The number of locations and the number of uniquedentists that we have. As I've mentioned, DeltaDental's one of the few providers.
That has two contracted networks, both the PPO and the Delta Dental Premier. As you can see from this graphic, there is some overlap between these. I often get asked, or peoplewill come up to me and ask, “Well, when I was online or if I was looking in a book,I noticed that a provider was both Delta Dental PPOand Delta Dental Premier, what does that mean?”.
When a provider… A provider can participatein both of the networks. And when they participate in both of them, all that's important to you is that they're a DeltaDental PPO provider. When that claim comes in to process, we recognize that they have status or participating status inthe Delta Dental PPO network and we pay that claim accordingly.
So we give you the higher level, or you receive thehigher level of discount on that service, you getthe higher level of benefit. You don't need to ask theprovider office to do anything, and you don't need to contactus to tell us that they're PPO we'll automatically see that they're PPO and pay that accordingly. Delta Dental has a variety of programs that we offer to our clients,.
And so in some cases, itmakes sense for the providers to be participating in both. But when you see that they're in both, it's good news for you becausethat means they participate in PPO and you get thathigher level of benefit. So we've taken a look at the changes, we've taken a look at the benefit, and we've taken a lookat the provider types. So let's put all of this together now.
And take a look at the payment example. So we've got a couple ofpayment examples for you. And this first one is a major service, so it's in the major servicecategory, it's a crown, and this is with a deductible. So you can see here, the firstline there, the green line is the Delta Dental PPOnetwork, that PPO provider. They charge $950 for this crown. However, because theyparticipate with Delta Dental,.
They've agreed to accept675 as the PPO approved fee, which means they cannotbalance bill you the difference between the 675 and 950. Because this is a PPO provider,there is a zero deductible. The coinsurance on this service is 25%, so 25% of 675 is 168.75. And because this is a PPO provider, there's no additional cost.
This provider has agreed toaccept 675 is paid in full for this crown. So your out-of-pocket here is 168.75. The next row, when you go to aDelta Dental Premier dentist, they also charge $950, but they've agreed to accept $898, you can see that as theapproved amount is 898, that's the Premier approved amount. However, if you remember earlier, I said.
That all of the claims,regardless the provider that you go to, are reimbursedat the PPO approved fee, which means that 675 iswhat is being reimbursed on this claim. So because this is DeltaDental Premier provider, there's a $50 deductible. The coinsurance, the waythat the deductible works with the coinsurance, it's25% is the coinsurance of 625.
And 625 is 675, whichis the approved amount minus the $50 deductible, gets you to 625. So your coinsurance here is 156.25. Plus you have an additional cost of $223. The $223 is the difference between 898, which is the Premier approved fee and 675, which is the PPO approved fee. So your out-of-pocket withthe deductible coinsurance and additional cost is $429.25.
When you go to anonparticipating provider, their charge is 950. And remember what I said earlier, that when you go to anonparticipating provider, you're ultimately responsiblefor their full charge. So their approved fee there is 950, that's how much they'llreceive at the end of the day. However, 675 is still theamount that's being paid on this claim because theretirement system says.
We're gonna pay the sameamount on all the claims, regardless of the typeof provider you go to. So there is a $50 deductible here. Your coinsurance with thedeductible is the approved amount, which is 675 minus the $50 deductible, so that's 625, times a 25% coinsurance, so you have 156.25is your coinsurance portion, and your additional costfor this provider is 275, which is the differencebetween $950, which is the full.
Charge for this nonparticipatingprovider and 675, which is the PPO approved fee, so you pay an additional 275. So when you add up thedeductible, coinsurance and additional cost for thenonparticipating provider, your out-of-pocket is $481.25. As you can see on this slide, there was a 25% coinsurancefor all of these providers, but the type of provideryou chose determined.
The out-of-pocket that you paid. When you go to a PPO provider, you're gonna save the most money, get the highest level of benefit, and then the least out-of-pocketthat you can receive, you maximize your dental dollarby going to a PPO provider. So let's take a look atanother payment example. This one is a diagnosticand preventive service, so this would be without a deductible.
So if you look at the green line there with the Delta Dental PPO dentist, they charge $90 for this cleaning. The approved amount is $55. There is no deductible on this, so for a diagnostic preventative service for PPO provider, it's a 5% coinsurance, so 5% of 55 is 2.75. There's no additional costbecause the provider has agreed.
To accept $55 as payment in full, so you're gonna pay $2.75 out-of-pocket. With the Delta Dental Premier provider, they also, which is the next row, they also charge $90. They've agreed to accept $77, that's their Premier approved fee. However, all of the claims arebeing reimbursed at the PPO approved fee, which is $55,so there's still no deductible.
Because it's a preventative service. The coinsurance for a Premierand nonparticipating provider is 10%, so it's 10% of $55, which is $5.50 plus anadditional cost of $22. $22 is the difference betweenthe Delta Dental Premier approved fee, which is $77and the PPO approved fee, which is $55, so that's an additional $22, so you pay out-of-pocket $27.50. And the last line there,nonparticipating dentists,.
They also charge $90, and at the end of a day, you'll pay $90, or this dental office willreceive $90 for that service. There is still no deductible because it's a preventative service. It's a 10% coinsurance, so10% of $55, which is 5.50. And there's an additional cost of $35. 35 is the difference between$90, which is the full fee for this nonparticipating provider,.
And $55, which is the PPO approved fee, which is the amount that'sbeing reimbursed on this claim. So you pay an additional $35,so your total out-of-pocket is $40.50. In this example, you do havea higher level of benefit when you go to a PPO provider. But again, as you cansee, the type of provider that you choose determinesthe out-of-pocket that you're going to haveon each of these claims.
So now that we've talked about providers, you may be wondering, “Whattype of provider am I going to? Or how do I find a PPO provider?” First off, what type ofprovider you're going to. If you've recently gone to a dentist, then you have an explanation of benefits. It will tell you on theexplanation of benefits what type of provider… What network you're…
Or which type of provider you're going to, whether it's a PPO provider, Delta Dental Premier provider,or nonparticipating provider. So you can take a look there. You can always callcustomer service too and ask whether or not your provider. The other way is to look online. Going online is the bestway to look into the network to see who's available,whether your provider.
Is participating or where theparticipating providers are because this is constantly changing. We're always adding people to the network, there are people retiring. Or coming off of thenetwork, so looking online is the best way to look. In addition, when you look online, you can put in an address andit will do a radius search around that address.
So when you're online andyou choose find a dentist, it will take you to this pagethat says Finding a Provider. The very first thing you needto do is choose the network. And the network that you'regonna choose is the PPO, if you're looking for a PPO provider. If you don't care and you wanna look for a Delta Dental Premier provider, you're welcome to do that, too. But to save the most money,.
Choose the Delta Dental PPO option. Under the location, youcan put in your address. That will give you the best search, because it will tell youthe providers that are closest to your location. You can put any address inthe US here and it will give you participatingproviders that are nearby. Anywhere you are in the US,you can have services done all you need to remember isthat the claims need to be.
Send back to Delta Dentalof Michigan for processing. You have coverage evenoutside of the country, everything outside out of thecountry will be considered nonparticipating and youwould have to pay that cost of that claim upfront, but on your return, you couldsend in the claim to Delta and get reimbursement on that claim. So you have coverage nomatter where you are. So put your address in.
Further down on the screen, you'll see that you can tell how far you're willing to travel. Whether you're willing to go five miles, it might depend, if youlive in a more rural area, you may need to go farther out to find participating providers. You can tell it how manyresults you want it to stop at, it defaults to 50, but if youwanted to have more results,.
You could do that. In some of the areashave a higher populated with dentists, you'll beable to find lots of dentists within a very smallradius of your location. You'll notice there, you canput in the dentist's last name so if you are lookingfor a specific dentist, you can put that in there. The other thing is you canalways leave that blank if you just wanna do a search.
For a specific type of provider. Under specialty, it defaults to any. But if you're looking for aspecific type of provider, whether it's a generaldentist, or periodontist, oral surgery, endodontist, I would suggest to change that specialty to that type of specialty, so it'll further filter yourresults that you're getting. So, for example, if your provider says,.
“I wanna send to a specialistfor this root canal,” and gives you a name,you could look on this… You could go online here and look and see if they are participating in our network. Your provider's notrequired to send you to a PPO provider, so youmay wanna check what type of participating statusyou're being referred to, if you're being referredby your general dentist. And then lastly, there'sa couple more things.
That you can select herefor doing your search, language or gender. Extended hours. You can leave all those as they are, and then search for a dentist. The best way to do this, I would say, is to pull this listing up and print it out andthen just start asking around the people thatyou know that you live by,.
Ask them who they go to, who they like, who do they recommend andtry to get a word of mouth recommend that way, as well, kind of tying what you're hearing from your friends andneighbors and what you see, who is participating in the plan. For those of you who donot like to go online or who do not want to… Don't own a computer ordon't like using computers,.
You can always call us at Delta Dental, call our customer service number and ask the customerservice representative to send you a listing andthey'd be happy to do that. So if you wanna do it bygoing online, perfect, you can do that, but for those of you who don't, you always have an optionto call customer service and they will help youwith this process, as well.
Moving on here. We do have a ConsumerToolkit, I don't know… We've had this out for awhile, so I don't know, many of you probablyare already using this. This is something thatallows you to access to your personal information. So because it's your personal information, you have to validate who you are and set up a user name and password.
The very first time thatyou go on to this toolkit. It allows you to see your information, who's eligible under your… Your subscriber information. It allows you to confirmthe address that we have. It allows you to see the benefits, the benefit overview that'scovered under this plan. It allows you to checkhow much annual maximum you've used to date.
It will tell you how much you've used, how much you have remaining. All of your electronic, or all of your explanationof benefits are available for viewing and printing. So if you want to tell usto stop sending you paper… If you want us to stopsending you paper explanation of benefits, all you needto do is provide us an email address and sing up for electronic EOBs.
With the electronic EOB,once the claim has processed, we will send you an email that indicates the claim hasprocessed and is available for viewing on this Consumer Toolkit. You can also have accessto oral health information on this toolkit, so thisis really a great tool that allows you to have access everything about your dental plan,your specific dental plan at your fingertips.
The next tool that wehave is the Extranet site, and this site has been developedwith the retirement system at the link listed here. This gives you access tospecific plan information about the retirement system dental plan. For example, thispresentation is available on the Extranet site. The overview flier, the one-page document that you may have received at a seminar,.
That's available on this Extranet site. The plan booklet that hasmore details about the plan, exclusions and limitations,how to file an appeal, definitions, who's eligible, all of that informationis in the plan booklet, and that's also availableon the Extranet site. We try to put tools and tips and additional tools thatare available for you on this Extranet site.
We've also placed linksfor the Consumer Toolkit for the dentist directorysearch on this site, so it's really… You don't need to sign into this site, you can go directly to itand access the documentation because it's generalinformation about your plan. Another tool that we haveis our smartphone apps. So if you have an Applephone or an Android phone, you can go to those respectivestores and download this app.
This app does allow youto verify your eligibility and benefits. So because it allows you to do that, you do have to create auser name and password for this, because it'syour specific information. You can also find a dentist using the app. You can view your ID card, and it does have a toothbrushtimer on the app, as well. It may be no surprise toyou that your oral health.
And your overall health are connected. There are over 120 diseasesthat have signs and symptoms that show up in your mouth. By keeping your regular visitswith your dental provider, your provider may actuallynotice something that's happening before you or yourhealthcare provider know that something is wrong. So it's very important tocontinue to brush and floss. If you notice any changes orabnormalities in your mouth,.
Talk to your dentist about that, make sure that you're keepingup on your oral health, beucase it does, sa I mentioned earlier, affect your overall health. And then lastly, contacting Delta Dental. Delta Dental, the 800number is listed there. We have advisors that are available from 8:30 a.m. to 8:00p.m. Monday through Friday. Our call center is inFarmington Hills, Michigan.
We also have an automated system, this is available 24 hoursa day, 7 days a week. And that automated system can provide you access to benefits, claims,eligibility information, and give you names ofparticipating providers. And then lastly, that Extranet site, that is where all of theplan documentation is listed, if you wanna go online andaccess any of that information. Thank you for your timeand attention today,.
And I hope this has helped you understand your dental plan better. Thank you, have a great day.