Dental (Indemnity or PPO) - ArlenGroup

WHAT IS IT?
ArlenGroup Fact Sheet DENTAL (INDEMNITY OR PPO)
Dental services are reimbursed based on a coinsurance schedule after the insured has met the annual plan deductible
(typically $50) up to the calendar year maximum (typically $1,000 to $2,000 per member). Under a standard benefit
schedule, the carrier would provide coverage as follows:
� Preventive (exams, cleanings & diagnostic x-rays): 100%, deductible waived
� Basic (fillings & extractions): 50% to 100%
� Major (crowns, bridges & dentures): 50% to 80%
� Orthodontia (child and/or adult): 0% to 50%
Indemnity and PPO plans allow participants to go to any dentist and receive benefits. PPO plans offer access to
discounted fees and may be structured to pay a higher level of benefits if a PPO dentist is utilized. Non-network benefits
are typically reimbursed based on usual and customary charges (UCR). Reimbursement may also be based on a
maximum allowable fee or charge (sometimes referred to as a “MAC” plan). MAC plans help an employer reduce out-ofnetwork
costs by restricting reimbursement of claims to a set agreed upon fee. Members utilizing out-of-network
providers will likely have higher out of pocket costs.
WHY OFFER IT?
� Basic component of a competitive benefit package. Approximately 90% of large employers offer some type of
dental benefit.
� Dental indemnity or PPO plans offer employees freedom of choice in selecting a dentist, and are relatively easy
to access and administer.
WHAT TYPES OF EMPLOYERS OFFER IT?
All types of employers.
WHAT SIZE EMPLOYERS OFFER IT?
All size employers. Typically, carriers need 25 or more employees to offer Orthodontia coverage.
WHAT ARE THE CRITICAL UNDERWRITING OR PARTICIPATION REQUIREMENTS?
� Plan design
� Employer location, industry, and level of funding
� Employee demographics
� Rates may be age-rated for employers with

ArlenGroup Fact Sheet DENTAL (INDEMNITY OR PPO)
WHAT'S NEW IN THIS AREA?
Dental PPO networks have grown considerably over the past few years and continue to develop. Many carriers now
offer a "passive PPO" plan which offers employees access to network discounts without plan design incentive to use
these providers. Some carriers also offer “Freedom of Choice” or “Swing” plans in which employees select between an
HMO and a PPO and may change their election each month. To combine the dental plan with a medical consumer
directed plan, some providers also offer consumer directed dental plans.
HOW MUCH DOES IT COST?
Average 2010 monthly premium costs (source: Radford Benefit Survey)
� Indemnity: $49 Employee only; $138 Family
PPO: $47 Employee only; $156 Family
INFORMATIONAL LINK(S)
DENTAL PROVIDERS:
� Delta Dental
� MetLife Dental
� Assurant Dental
� Guardian Life
� American Dental Association
� E-dental
PROS AND CONS
PROS
CONS
� Aids in retention and recruiting
� Compared to dental HMOs, employees have greater flexibility and provider choice
� Dental PPOs are typically more expensive than dental HMOs
� “Swing plans” require additional administration and communication
Rev. 03/2011 2

NOTES
ArlenGroup Fact Sheet DENTAL (INDEMNITY OR PPO)
When considering various dental plan proposals, employers should carefully review the covered benefits and plan
provisions. Important details that often get overlooked are:
� Does the plan impose a waiting period on Major and/or Orthodontic services?
� Are there age limitations on particular services such as Orthodontia?
� Are there late entrant restrictions?
� Does the insurer allow for an annual open enrollment period?
� How are periodontics and endodontics covered (under Basic or Major services)?
� At what percentage of usual and customary charges will out of network services be reimbursed?
This Fact Sheet is designed to provide a general overview of the benefit program, service, or
regulatory act it describes. The information included in this document is not a substitute for legal
or professional opinion relative to a plan sponsor’s particular fact pattern. Your ArlenGroup
consultant can answer more specific questions relative to its application for your organization.
Rev. 03/2011 3