Insider Update

Broker blog from Delta Dental

2023 updates for health care exchange plans

Update, 9/22/23: 2023 HCR plan brochures are now available! Just click the dropdown menu for your state to see the brochures.

Fall is nearly here, and open enrollment for the health care exchanges is just around the corner. Before you start selling for 2023, here’s a refresher about plans available through Affordable Care Act exchanges to help you make the most of this year’s open enrollment period. We’ll also take a closer look at Covered California plans.

What to know about exchange-based plans

  • Dental plans come in two categories, preferred and basic. Preferred plans have higher premiums but offer lower copayments and deductibles. Basic plans have lower premiums but come with higher copayments and deductibles.
  • Dental insurance is an essential benefit for kids. Insurers must make dental coverage, either in the form of a standalone plan or as part of a bundled or embedded health plan, available for children 18 and younger. Make sure your clients are aware of this.

Dates to know

  • November 1, 2022: Open enrollment for 2023 begins.
  • December 15, 2022. Last day to enroll in or change plans for coverage that begins on January 1, 2023. Please note that this date may be subject to extension.
  • January 1, 2023. Coverage begins for those who enrolled by the December due date and have paid their first premium.
  • January 15, 2023. Last day to enroll in or change plans in the following states: AL, DE, FL, GA, LA, MD, MS, MT, TX, UT, WV.
  • January 31, 2023. Last day to enroll in or change plans in DC.

As of publication, the last enrollment days have yet to be announced for the following states: CA, NV, NY, PA.

What about Covered California?

There are some unique differences between the Covered California exchange and other states’ offerings. One of the biggest differences is that California requires brokers to obtain additional certification to sell Covered California plans. Beyond the regular licensing requirements to sell insurance, brokers must also complete an online course, pass an exam and submit paperwork to receive certification as a Covered California agent.

Here are some considerations to make sure your California clients are aware of:

  • Covered California offers both PPO and HMO plans.
  • California requires that children get dental benefits under health plans at no extra cost. Additionally, children under 19 can be added to family dental plans for coverage of services such as fillings and crowns.

Where can I go for more information about on-exchange plans?

If you have more questions, check out Delta Dental’s health care exchange resources to find useful information, see plan brochures and get appointed. 

Exchange-based plans are a great way to reach underserved markets and receive a 10% premium per member commission. Plus, there’s the pride that comes from knowing you’re helping those without employer-based coverage take charge of their oral health.

Help your clients find a Delta Dental dentist

Finding a dentist doesn’t have to be a hassle. With Delta Dental’s online dentist directory, your individual clients and group enrollees can quickly and easily find an in-network dentist who suits their needs.

How to search for a dentist

A screenshot from the Delta Dental website. Text reads "Find a dentist. Visit a dentist in your network to get the most savings. Search for a network dentist near your home or work."

Members can access the dentist directory by visiting and selecting Find a dentist. All they need to do then is enter their location and dentist network.

The returned results will list the dentists in their area who participate in the selected network.

An entry from the online dentist directory for a dentist named Susanna Cheng.
An example of an entry in the dentist directory

What information is included in directory listings

Members can select View next to the dentist’s name for more detailed information about the dentist or practice, like:

  • What languages they speak
  • What Delta Dental networks they participate in
  • DentaQual quality scores and Yelp ratings
  • Education and licensure
  • Specializations

They can also see information about the dentist’s office, like:

  • Hours of operation
  • Location
  • Contact details
  • Accessibility information
  • Languages spoken in the office

How to refine search results

If the initial results are too broad, your clients can refine the search results by using the optional search bar at the top of the page or by clicking the Refine Search button.

This allows users to sort the results by either distance or best matches and then filter the results based on several metrics:

  • Distance. Allows users to set the maximum distance prospective dentists can be from their input location.
  • Networks. Clients can select one or more dentist networks. This lets members search for both Delta Dental PPO™ and Delta Dental Premier® dentists simultaneously.
  • Accepting new patients. This means that only dentists accepting new patients will show up in results.
  • Provider specialties. This allows your clients to filter for specialists like orthodontists, oral surgeons or pediatric dentists. “General dentist” is the default selection.
  • Specialized care. Unlike specialties, this field filters by dentists who are familiar with patients who need special considerations, like those with cognitive or physical disabilities.
  • Languages. Your clients can choose their preferred language and see only dentists who have indicated they speak that language.
  • Extended office hours. If your clients have tight schedules and need an office with extended hours, they can choose dentists with weekend, morning or evening hours.
  • Office access. This option refines search results to offices that offer free parking, have internet access, are accessible by public transit or are wheelchair accessible.
  • Board-certified. When this is selected, only dentists who are board certified will show up in results.

Resources to share

Delta Dental has resources ready for you to share with your group enrollees and group benefits administrators to help them find the information they need.

Your individual clients and group enrollees never have to stress about finding an in-network dentist again. The Find a Dentist tool makes it easy for them to find a nearby dentist who fits their needs, in less than the time it takes to brush their teeth.

Addressing the insurance needs of seniors

When it comes to maintaining their oral health, seniors face unique challenges.

One issue is dental coverage. As people retire, many of them lose the dental coverage their jobs provided. Medicare, the federal health insurance program for people 65 or older, offers only limited dental benefits, and nearly half the seniors who receive Medicare have no dental coverage.

Not surprisingly, many seniors fail to visit the dentist consistently. Only about half of seniors 65 and older have visited a dentist in the past year, and nearly a quarter haven’t visited a dentist in the past five years. These numbers are even worse for Black and Hispanic seniors and those with lower incomes.

This situation is particularly dire because regular dental visits are critical for seniors. As we age, our mouth becomes more susceptible to a number of oral health issues, making proper dental care more vital than ever. 

If you have clients who are at or approaching retirement age, here are some dental conditions they should be aware of and a variety of individual plan options you can offer them to help them address these conditions.

Seniors face unique dental health risks

Did you know that as we age, we become more susceptible to certain dental issues? Oral health problems common among seniors include the following:

  • Cavities. More than a quarter of people aged 65 or older have untreated tooth decay.
  • Gum (periodontal) disease. About two-thirds of people 65 and older have some form of gum disease, which is the leading cause of tooth loss in seniors. Gum disease includes gingivitis, an early stage of gum disease caused by the bacteria found in plaque, and the more serious periodontitis, in which bacterial infection causes the gums and bone supporting the teeth to break down.
  • Oral cancer. Cancers of the mouth, including oral and pharyngeal cancer, are most commonly diagnosed in seniors, with a median age at diagnosis of 64 years old.
  • Tooth loss. More than 10% of people between 65 and 74 have lost all their teeth, and that number increases to nearly a quarter for people more than 75 years old.
  • Dry mouth. Many of the prescription and over-the-counter medications seniors take can decrease saliva, which can lead to tooth decay. Saliva helps prevent tooth decay by neutralizing acids and rinsing away bacteria and food particles.
  • Difficulty brushing and flossing. Older patients with physical impairments such as arthritis, or mental impairments such as dementia, may have difficulty brushing, flossing and maintaining their oral hygiene.
  • Limited dentist access. Seniors may have difficulty visiting the dentist because of medical or mobility issues, or because they don’t access to transportation.

Your clients don’t have to give up their dental coverage

Your senior clients should have dental coverage that addresses their unique needs. Here are some individual plans that you can offer your senior clients.

Individual plans

individual dental plans, including Delta Dental PPO™ and DeltaCare® USA plans, are a great choice for retirees. These plans include the services seniors need most, including preventive care like routine cleanings and exams at no out-of-pocket cost.

  • Our PPO plan offers two options: Premium and Basic. Our Premium option offers low out-of-pocket costs and coverage for procedures that many seniors need, such as crowns, dentures, denture repair and implants. The Basic plan offers less comprehensive coverage and a lower annual maximum than the Premium plan, but at a lower monthly premium.
  • DeltaCare USA is our fixed copayment plan and offers low-cost preventive dental care and coverage for a broad range of services, including crowns, dentures and implants, at a more affordable price than either of our PPO plans.

To make selling a snap, we’ve created a variety of helpful resources that you can offer your senior clients to help them learn more about why Delta Dental’s individual plans are a great choice. You can find plan brochures, links to informative videos and access to our online Find a Dentist tool, which can help seniors find a dentist that meets their unique needs. You can also let them know about value-added features retirees will love.

Delta Dental’s commitment to seniors

We’re dedicated to protecting seniors’ oral health. Through our Senior Oral Health Program, we partner with community-based coalitions to focus on improving access to dental care, particularly for those seniors in marginalized communities. Our goals are to reduce oral care disparities, address the causes of poor oral health among older adults, particularly those living in poverty, and create a replicable model for oral health solutions.

Help ensure that your senior clients’ smiles remain bright and healthy long into retirement with these great individual plan options.

How Delta Dental is battling the opioid crisis

Opioid addiction has skyrocketed over the past two decades, with half a million people in the U.S. dying from opioids during that time, according to the Centers for Disease Control and Prevention (CDC). Prescriptions for opioids were a major contributor to the problem, and about one out of every 10 of those prescriptions is written by a dentist.

Let’s look at how Delta Dental is helping dentists battle opioid addiction among their patients and what you can do to help your group clients prevent, recognize and treat opioid abuse.

What are opioids?

Opioids are powerful pain relievers that block pain signals between the brain and other parts of the body. Opium has been long used as a natural pain reliever, and morphine became widely prescribed during the Civil War.

Synthetic opioids were created as early as the 1930s, and with the introduction of oxycodone in 1996, medical professionals began prescribing them to help patients manage pain. These synthetics, which also included hydrocodone, hydromorphone and oxymorphone, were just as addictive, though, and today, 2 million Americans become dependent on opioids every year.

The total number of opioid prescriptions peaked in 2012 at more than 255 million, but the CDC estimates that there are still about 43.3 prescriptions written per 100 people. Although the U.S. represents 4.4% of the world’s population, we use more than 80% of the world’s opioids. And dentists have contributed to that number. Let’s find out why.

Opioids and dental health

Dentists have long prescribed opioids to ease any pain and discomfort from tooth extractions, dental surgery and dental implant procedures. Many teens and young adults receive their first opioid prescription from the dentist, typically for wisdom tooth removal. But that practice is starting to change.

Dr. Daniel Croley, chief dental officer for Delta Dental, said there’s growing evidence that non-steroid anti-inflammatory drugs such as ibuprofen are an effective first line of defense in managing post-treatment pain.

“Dentists must consider the standard use of NSAIDs and long-acting anesthetics first before prescribing any opioids,” he said. “They can also take advantage of available state prescription drug monitoring programs to prevent overprescribing to patients that may be seeking opioids.”

Although Delta Dental plans don’t cover prescriptions, we recognize the role our national dentist networks can play in the fight against opioid abuse and help dentists create responsible pain management practices:

  • Dentists advise patients on reasonable post-surgical pain expectations and management. They also write opioid prescriptions that don’t exceed the recommended dosage, and keep the prescription lengths at a short duration.
  • We can partner with large-group customers and health carriers to help pinpoint prescription patterns.

How to prevent opioid abuse in the workplace

Since an estimated 40% of opioid overdose deaths were from prescription medication, opioid abuse is sometimes referred to as “white-collar substance abuse.” But the opioid crisis isn’t just limited to office workers. Overuse of opioids affects all races, crosses all age groups and is present in all classes and income brackets.

Based on a survey conducted by the National Safety Council, 75% of employers report that opioid use has affected their workplace, but only 17% report being extremely well prepared to address the issue.

Encourage your clients to establish a strong substance abuse policy and program to prevent, recognize and treat opioid problems among employees. Steps include:

  • If the company has a drug testing policy, it should give employees the details of that policy, as well as what employee protections are in place. Management can also provide employees with information about substance abuse, its warning signs and its effects on their work.
  • Share prevention resources such as health and wellness programs, helplines and other community resources. For example, the U.S. Substance Abuse and Mental Health Services Administration offers a national helpline at 800–662-HELP (4357) or 800–487-4889 (TDD) with free, confidential help 24 hours a day for people with substance abuse problems.

Working to end the opioid crisis

Signs are pointing toward a turnaround in opioid abuse. The number of prescriptions for opioids declined by 6.9% from 2019 to 2020, as medical professionals have become more aware of the problems of abuse.

Delta Dental continues to encourage dentists to refrain from prescribing opioids, and education and prevention efforts are vital to stopping the epidemic.

“Patients trust dentists to prescribe medications safely,” Dr. Croley said. “We urge our dentists to avoid opioids to minimize exposure to this addictive drug that is causing so much pain to so many people.”

Updates to Small Business Program plans for 2023

Get ready for more choice and more competitive plan designs in Delta Dental’s Small Business Program. Updated for 2023, our enhanced dental portfolio makes it easier for you to find the right coverage for your small group clients.

What’s changing for 2023

Here’s a quick look at the key changes for the upcoming plan year.

  • Higher maximums. Select plans are getting a new maximum option — to $3,000 per person per year.
  • Expanded availability of orthodontics. Adult orthodontic coverage will now be available for employer-paid groups of five and up. With this reduction in the participation requirement, more small groups than ever before will now be eligible for this optional adult benefit.
  • Updated plan designs. Say hello to a revamped Core plan — and more options in our dual choice and Core/Buy-Up PPO plans.

Why choose Delta Dental’s Small Business Program

No matter the group’s size, Delta Dental offers benefits that employers and employees can trust. Our Small Business Program delivers plans designed for groups of two to 99 employees. You can select from a wide variety of plans and options that provide easy access to the quality care and savings available through our large networks. Vision coverage through DeltaVision is also available.

How to sell Delta Dental’s plans

Ready to start selling? Reach out to Delta Dental for a quote.

If you’re currently selling Small Business Program plans with us, contact your Sales representative or general agent for new marketing brochures to help you understand and sell these updated plans.

With Delta Dental’s Small Business Program, you can help your small groups keep their employees healthy and happy — at predictable rates that small business budgets can count on. We’re here to help you shine.

How high out-of-network reimbursement could be hurting your group enrollees

When it comes to designing Delta Dental PPO™ plans for groups, it can be difficult to find the balance between what employees want and what’s most cost-effective for the employer. You may think that allowing for high out-of-network reimbursement will keep group enrollees happy. But high out-of-network reimbursement could actually be hurting your groups and their enrolled employees in unexpected ways.

What is out-of-network utilization?

Out-of-network utilization is when a covered enrollee visits a dentist who isn’t in a Delta Dental network. It may seem trivial, but when a high percentage of enrollees start receiving care outside of their network, there can be unexpected consequences. On an individual level, your group’s enrollees may experience higher costs and miss out on quality guarantees, and high out-of-network utilization can make plans more expensive for everyone to account for the higher cost of care.

What is out-of-network reimbursement?

Reimbursement is the amount that your plan bases its payment on, also known as the maximum plan allowance. This is separate from the percentage at which certain services are covered. 

Under most PPO plans, Delta Dental PPO dentists are reimbursed at PPO fees, and Delta Dental Premier® dentists are reimbursed at Premier or PPO fees. Reimbursement for non–Delta Dental dentists varies by plan. Paying non–Delta Dental dentists based on the 80th percentile or above is considered high reimbursement.

Percentiles are calculated by ranking a set of given fees from lowest to highest. On a list of 10 given fees, the eighth ranked fee would be considered the 80th percentile. There isn’t a set amount of space between percentiles, meaning that some percentiles may have the same fees.

In this simplified example, the 80th percentile is $27 and the 50th, 60th and 70th percentile are all $25. At the 80th percentile, 80% of dentists’ fees are paid as billed. Dentists whose fees are above this percentile are charging more than most dentists in their market.

Dr. A10$20
Dr. B20$20
Dr. C30$23
Dr. D40$24
Dr. E50$25
Dr. F60$25
Dr. G70$25
Dr. H80$27
Dr. I90$30
Dr. J100$35

How high out-of-network reimbursement drives up costs

Reimbursement rates are customizable by plan, dependent on your enrollees’ needs. But having high reimbursement rates for out-of-network dentists can bump up costs across the board. Non–Delta Dental dentists can set their prices wherever they want without being subject to contractual obligations. This not only allows them to charge higher prices but also discourages Delta Dental dentists from staying in network.

Example: the difference between in-network and out-of-network dentist costs

To illustrate, let’s assume the PPO contracted fee for a procedure is $600. If your plan covers that procedure at 50%, one of your enrollees visiting a PPO dentist would only need to pay $300, and your plan would pay the other $300. For the same procedure, an out-of-network dentist could cost your employee $538.

If your plan’s reimbursement for out-of-network dentists is based on the 90th percentile (which, let’s say, amounts to $925), your plan would pay 50% of $925, or $463. Your enrollee would pay $538.

Delta Dental PPO dentistNon–Delta Dental dentist
Dentist charges$1,000$1,000
Accepted fee$600$1,000
Reimbursement allowed by plan (MPA)$600$925
Reimbursement based onPPO fee90th percentile
Delta Dental plan pays
(50% of maximum plan allowance)
Member pays
(Difference between “accepted fee” and “Delta Dental plan pays”)
Plan savings
(Difference between “dentist charges” and MPA)
This table is for illustrative purposes only. 

Not only do group enrollees who go out of network pay more at the time of service, they also run the risk of hitting their annual plan maximum much more quickly. In the long term, a plan with a high rate of out-of-network utilization may also drive up premium costs by increasing claim expenses.

What’s more, high out-of-network reimbursement lowers the incentive for dentists to join or stay in Delta Dental’s networks. By staying out of our networks, dentists can charge higher prices and avoid quality monitoring like credential checks and in-person audits.

Ultimately, your groups don’t benefit from high out-of-network reimbursement.

Why should your enrollees visit Delta Dental dentists?

While choosing an in-network primary care physician has become almost routine, many people seeking dental care are less aware of the value of choosing an in-network dentist and the disadvantages of visiting an out-of-network dentist.

Avoid inconvenient charges

When your enrollees choose to visit a non–Delta Dental dentist, they run the risk of being balance billed. That means their dentist may charge them more than the maximum plan allowance, and they’ll need to foot the rest of the bill. Delta Dental can’t predict enrollees’ out-of-pocket costs when they go out of network.

Since out-of-network dentists aren’t always paid directly by Delta Dental, your enrollees may be charged the full price of a procedure upfront, even if their coinsurance is less than the full price. After paying at the dentist’s office and submitting a claim to Delta Dental, they’ll receive a check in the mail for the portion of their procedure’s cost that’s covered by their plan.

When your enrollees visit a Delta Dental dentist, they’ll only be expected to pay their share and they won’t need to submit claims.

Guarantee of quality care

To participate in a Delta Dental network, dentists are held to high standards to ensure they provide consistent, quality care to their patients. These standards include:

  • Rigorous credential checks. Delta Dental dentists must be legally credentialed and must submit their credentials to Delta Dental for verification every three years.
  • Quality management program. Delta Dental dentists may be subject to onsite audits to assess hours and availability, treatment outcomes, facility and equipment, infection control, documentation and more. Dentists who perform poorly in audits are put on improvement plans and may be dismissed from our network if quality concerns are not addressed after improvement programs are completed.

When your enrollees visit non–Delta Dental dentists, we cannot guarantee that the practice meets Delta Dental’s rigorous credentialing and safety standards. Since these dentists are out of network, we have no mechanism to ensure they provide quality care and services to our members.

How to promote in-network visits

Luckily, there are a few things you can do to help your enrollees get the care they deserve.

Educate your enrollees on the advantages of staying in network

The easiest way you can help today is by educating your group administrators and enrolled members about the advantages of in-network dentists. Delta Dental has materials about the importance of staying in-network that are ready for you to share, including flyers and videos:

There are also more specific, customizable flyers available for request through your sales contacts.

Create plan incentives for staying in network

To encourage in-network visits long term, work with your Delta Dental Sales representative and benefits administrators to build incentives into plan designs that encourage visiting in-network dentists. 

For example, these options (not available in all states) can help boost in-network utilization:

  • Maximum and deductible network differentials. Reward enrollees who stay in network with a higher maximum and lower (or no) deductible for in-network visits. If your plan includes maximum or deductible waivers for diagnostic and preventive services (D&P), consider setting these up to apply only when members choose an in-network dentist.
  • Greater coverage levels for in-network services. For example, you might cover a specific benefit at 80% at a Delta Dental dentist and 60% out of network.

Reevaluate your plan’s reimbursement levels

Collaborate with your Delta Dental Sales contacts and group benefits administrators on updating your plans’ reimbursement levels to encourage in-network utilization. If one of your group’s plans reimburses non–Delta Dental dentists at a high level, such as the 80th percentile, Delta Dental’s sales team can help you determine the appropriate level to meet a group’s needs.

By visiting Delta Dental network dentists, your group enrollees receive the predictable, quality care that they deserve. Set up a meeting with your Delta Dental Sales representative today to develop a plan to encourage long-term network utilization.

Note: This post was updated to clarify the illustrative example.

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