Immediate Plans PPO & Indemnity Options

UHC • FL1
4/1/2016
Marketed by: Company Name
Presented by: Richard Alpert

MWG Dental Executive Summary

Dental coverage is one of the most attractive benefits a company can provide its members. That's why MWG Dental offers a wide variety of dental programs designed to meet the needs of employers and members alike.

The MWG Dental product portfolio includes:

MWG Dental Managed Indemnity
MWG Dental Options PPO
MWG Voluntary Dental Indemnity and PPO

Dental plans are developed and customized to meet changing marketplace needs, and the individual needs of customers. We are committed to providing quality dental care and customer satisfaction at affordable prices through a spectrum of diverse dental plans. MWG Dental members will have access to a network of over 180,479 dental access points, and we are continually developing this network to support our customers.

Our proposal includes a quote to administer MWG Dental PPO on a fully-insured basis.

Our dental product portfolio offers flexibility that promotes benefit plan choice to fit your budget and meet the needs of your members. We have almost 20 years of focused managed dental experience with an emphasis on maximizing cost savings while improving oral health outcomes. Within the portfolio, plans are developed and customized to meet the changing marketplace and the individual needs of customers.

Member Advantages: Dental Options PPO

Extensive national network of qualified and credentialed dentists
When visiting a network dentist, individuals receive substantial cost savings and eliminate the need to submit claim forms
Individuals have the flexibility to see a dentist outside the network at any time
Claim, dentist and eligibility information available 24 hours a day, seven days a week

Reduced Administrative Burden

We can streamline your benefits administration by providing consolidated account management, billing and reporting for your dental benefit offerings.

Overall Health and Productivity Benefits

Each year 164 million hours of work are lost because of dental problems, based on survey data from Oral Health America, a reknowned national non-profit organization. Through a dental benefit offering, you can encourage total health and well-being for your members and improve overall productivity for your business.

Claims Accuracy and Ease

Our claims system performs a variety of functions with speed and accuracy, while saving substantial amounts of money on duplicate, inaccurate or fraudulent claims. All functions are performed online, including benefit calculation and payment, claim files and treatment history. Financial and procedural accuracy benchmarks are established and maintained to ensure the claims adjudication process meets strict standards.

The software provides the claims processor with edits that determine procedural validity by maintaining historical claims data, as well as a tooth chart that is updated automatically as claims are processed.

Customer Service and Provider Relations Departments are trained to process basic claims adjustments while on the phone with the dentist or customer. Certain escalated issues are routed via an electronic form called an Inquiry to be handled by Quality Management Adjusters. Adjustments are made quickly and efficiently, so your members don't have to wait.

Utilization Management

Utilization management and claims review ensures customers are receiving cost-effective quality of care through the process of analyzing data patterns and trends of network dentists in accordance with guidelines established by the National Association of Dental Plans and by appropriate oversight standards.

We conduct utilization management through a computer-based system called TRACERÂ® (Treatment, Review, Audit, Compensation, Evaluation and Reporting). This system produces reports that evaluate dentist practice patterns and identify dentists who have patterns that deviate from the norm. By identifying and correcting negative practice patterns, we can reduce the overall impact of such behavior on the cost of care, and also improve the quality of care delivered. Utilization management provides us with the opportunity and means to recover monies paid for abusive or fraudulent claims, and to develop methods for preventing future treatment and/or claim fraud or abuse.

Superior Customer Service

MWG Dental uses a three-tiered service model to deliver superior dental customer service. Our "one and done" service philosophy leads to higher levels of service for your customers.

Multi-Lingual Representatives
We have extensive experience working with diverse ethnic groups. We maintain a core of bilingual Customer Service Representatives who can assist Spanish-speaking plan customers with questions. A third of our representatives are bilingual in Spanish. All representatives have the use of a translator. In addition, we contract with AT&T's language service, which acts as a liaison to translate between our staff and customers who speak languages other than Spanish.
Interactive Voice Response
We provide an Interactive Voice Response (IVR) system available 24 hours a day, seven days a week through the customer service toll-free number. This system enables both covered individuals and dentists to access information such as verification of eligibility and benefits, ID card requests, search for a network dentist, verify and check the status of a claim, and request claim forms.
Automatic Call Distribution
Our Automated Call Distribution (ACD) environment provides a flexible method for distributing calls efficiently, intelligently and equitably among the Customer Service Representatives (CSRs). In addition to call distribution, the system allows for real-time display of call data and capturing of data for report statistics used to assist management in maximizing the productivity of the customer service department.

Dentist Credentialing

Before acceptance into our PPO network, dentists undergo a rigorous credentialing verification process, which includes confirmation of education and professional training. It also involves an analysis of information provided on the dentist's official application for network participation. This process ensures that only the highest quality dentists participate in the MWG Dental PPO network.

Once a dentist has become part of the network, we continue to monitor his/her treatment patterns through auditing programs built into our claims processing system. The system will pay only those claims for services a dentist is authorized to provide. For example, if an oral surgeon submits a claim for a periodontal procedure, the claims system will deny the claim.

Our products and services are tailored to the needs of each of our customers based on your plan of benefits, member population, location, and specific concerns and goals. We pride ourselves on an unwavering commitment to customer satisfaction and welcome the opportunity to develop a strong service relationship with you.

How to determine the number of dentists in your area?

Go to www.mwgdental.com.
Click on "members".
Go to "I would like to find a dentist closest to _________".
Type in "city, state, zip".
Type "within radius _________ (number of miles)".
Click on "Submit".
Click on "dentist name for directions to a specific dentist".

COMPANY_NAME
PPO and Indemnity Options

Underwritten by United HealthCare Insurance Company • Rated "A+" Superior by A.M. Best Rating Company

Benefit Description

Marketing Name	The Immediate Coverage Plan
Plan Year	1st Benefit Year	2nd Benefit Year	Thereafter
Reimbursement Method In/Out	*DPO/UCR*
Diagnostic & Preventive	100%
Minor Restorative	80%
Oral Surgery	10%	PPOORAL	PPOORAL
Endodontics	10%	PPOENDO	PPOENDO
Periodontics	10%	PPOPERIO	PPOPERIO
Major Services	10%	Discount Card	Discount Card
Deductible	PPODEDUCT	PPODEDUCT	PPODEDUCT
Deductible waived for D&P	Yes	Yes	Yes
Annual Maximum	PPOANNMAX

DPO reimbursement is based on the negotiated provider fee schedule
UCR reimbursement is based on Usual, Customary & Reasonable (UCR) charges

Diagnostic & Preventitive

Procedures to assist the dentist in determining required dental treatment (oral examinations, x-rays, emergency office visits); prophylaxis (cleaning); topical application of fluoride solutions and space maintainers.

Restorations & Sealants
Amalgam, synthetic porcelain, plastic restoration (fillings) and prefabricated stainless steel restorations (primary teeth only) for treatment of carious lesion (visible destruction of hard tooth surface resulting from the process of decay).
Sealants (to seal developmental grooves and pits in teeth for the purpose of preventing decay).
Sealants are limited to children under the age of 15 and to application on permanent molar teeth with no caries, without restoration and with the occlusal surface intact.

Basic Services

ORAL_WAIVE_WAITING Oral surgery (extractions and certain other surgical procedures, including pre and post-operative care)
PERIO_WAIVE_WAITING Periodontics (treatment of gums supporting the teeth)
ENDO_WAIVE_WAITING Endodontics (treatment of the tooth pulp/root canal therapy.

Crowns & Prosthodontics

WAIVE_WAITING Crowns and cast restoration of carious lesions when teeth cannot be restored with amalgam, synthetic porcelain or plastic restorations; and procedures for construction of fixed bridges, partial or complete dentures and repair of fixed bridges. Initial replacement of teeth extracted prior to coverage is not a benefit.

Orthodontics (if selected / deductible applies)

WAIVE_WAITING Procedures involving the use of active orthodontic appliances and post-treatment retentive appliances are performed by a licensed dentist for treatment of malalignment of teeth and/or jaws which significantly interferes with their function, and is limited to coverage for dependent children to age 19 only.

Monthly Rates (12 Mo Rate Guarantee)

Immediate Coverage Plan
Employee	$38.76
Employee & Family	$105.89

* The proposed monthly rates are contingent upon _CONTINGENT_

THIS IS A DESCRIPTIVE DENTAL PROPOSAL, NOT A CONTRACT

This proposal is designed to highlight features of the dental program. A more complete description of benefits and exclusions is found in the group policy. All benefits are subject to the provisions of the Group Employer Contract

Consumer MaxMultiplier New Value Added Benefit

Consumer MaxMultiplier is a consumer-driven feature included with all of MWG Dental plan designs that puts dental care decisions directly in the hands of the consumer. You have the ability to increase your annual maximum each year at no additional cost.

Consumer MaxMultiplier is administered at the member level. This means each covered family member is eligible to earn his or her own awards.
You must use your dental benefit at least once during the covered benefit year.
If the total of all submitted claims paid does not exceed the established threshold amount, an award balance is established. (See table below) An award balance is the amount accumulated throughout the benefit period.
You qualify for an additional $100 bonus award, if all claims submitted during the benefit period are paid to network providers.
If the plan has a different network versus out-of-network maximums, awards are based on the out-of-network maximum.

If no claims are submitted during the benefit period, no awards are earned and there is no penalty or loss of any previously accumulated award balance. Should your group enroll in an MWG Dental plan or if you are a new hire in the last three months of the benefit year your participation in the Consumer MaxMultiplier will be deferred until the first month of the next full benefit period.

See Example. Different original annual maximums have different accumulations.

Consumer MaxMultiplier Design — Specific Plan Options
Original Annual Max	Annual Claim Threshold	Annual Account Award	Annual Network Bonus	Annual Award + Bonus Max	Increased Annual Max
$1,000	$500	$250	$100	$350	2nd year: $1,350
$1,000	$500	$250	$100	$350	3rd year: $1,700

If you keep your claims below $500 per year, you will carryover $250 dollars toward your next year’s annual maximum. Earn an additional $100 carryover by making all your dental visits to one of our PPO providers. Maximum reward accumulation is $1,000.

Standard Benefits, Limitations, and Exclusions

The dental program covers the following benefits when a licensed dentist provides them and when necessary and customary by the standards of generally accepted dental practice. The following are MWG Dental's benefits:

General Limitations

Oral Examinations Covered as a separate benefit only if no other service was done during the visit other than X-rays. Limited to 2 times per calendar year; limited to one time every 6 months.
Complete Series or Panorex Radiographs Limited to one time per 36 months.
Bitewing RadiographsLimited to 2 series of films per calendar year for enrollees under the age of 18 and 1 series for enrollees age 18 and over.
Extraoral Radiographs Limited to 2 films per calendar year.
Dental Prophylaxis Limited to 2 times per calendar year/ Limited to once every 6 months.
Diagnostic Casts Limited to one time per 24 months.
Flouride Treatments Limited to Covered Persons under the age of 19 years, and limited to [2] times per calendar year. Treatment should be done in conjunction with dental prophylaxis.
Sealants Limited to Covered Persons under the age of 15 years and once per first or second permanent molar every 5 years.
Space Maintainers Limited to Covered Persons under the age of 16 years, once per lifetime. Benefit includes all adjustment within 6 months of installation.
Amalgam Restorations Multiple restorations on one surface will be treated as a single filling.
Pin Retention Limited to 2 pins per tooth; not covered in addition to Cast Restoration.
Gold Inlays and Onlays Limited to one time per 5 calendar years. Covered only when silver fillings cannot restore the tooth.
Crowns Limited to one time per 5 calendar years. Covered only when a filling cannot restore the tooth.
Post and Cores Covered only for teeth that have had root canal therapy.
Sedative Fillings Covered as a separate benefit only if no other service, other than X-Rays and exam, were done during the visit.
Scaling and Root Planning Limited to 1 time per quadrant per 24 months.
Periodontal Maintenance Limited to 2 times within the first 12 months following active and adjunctive periodontal therapy, exclusive of gross debridement.
Full Dentures No additional allowances for over-dentures or customized dentures.
Partial Dentures No additional allowances for precision or semi precision attachments.
Relining Dentures Limited to relining done more than 6 months after the initial insertions. Limited to 1 time per calendar year.
Repairs to Full Dentures, Partial Dentures, Bridges Limited to repairs or adjustments done within 12 months after the initial insertion.
Palliative Treatment Covered as a separate benefit only if no other service, other than exam and radiographs, were done during the visit.
Occlusal GuardsLimited to one guard every 5 years.

General Exclusions

The following are not covered:

Dental Services that are not necessary.
Hospitalization or other facility charges.
Any dental procedure performed solely for cosmetic / aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.)
Reconstructive Surgery regardless of whether or not the surgery which is incidental to a dental disease, injury, or Congenital Anomaly when the primary purpose is to improve physiological functioning of the involved part of the body.
Any dental procedure not directly associated with dental disease.
Any procedure not performed in a dental setting.
Procedures that are considered to be Experimental, Investigational or Unproven. This includes pharmacological regimens not accepted by the American Dental Association (ADA) Council on Dental Therapeutics. The fact that an Experimental, Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Coverage if the procedure is considered to be Experimental, Investigational or Unproven in the treatment of that particular condition.
Services for injuries or conditions covered by Worker's Compensation or employer liability laws, and services that are provided without cost to the Covered Person by any municipality, county, or other political subdivision. This exclusion does not apply to any services covered by Medicaid or Medicare.
Expenses for dental procedures begun prior to the Covered Person's eligibility with the Plan.
Dental Services otherwise Covered under the Policy, but rendered after the date individual Coverage under the Policy terminates, including Dental Services for dental conditions arising prior to the date individual Coverage under the Policy terminates.
Services rendered by a provider with the same legal residence as a Covered Person or who is a member of a Covered Person's family, including spouse, brother, sister, parent or child.
Dental Services provided in a foreign country, unless required as an Emergency.
Replacement of crowns, bridges, and fixed or removable prosthetic appliances inserted prior to plan coverage unless the patient has been eligible under the plan for 12 continuous months. If loss of a tooth requires the addition of a clasp, pontic, and/or abutment(s) within this 12 month period, the plan is responsible only for the procedures associated with the addition.
Replacement of missing natural teeth lost prior to the onset of plan coverage until the patient has been eligible for 12 continuous months. If teeth were extracted while under a previous Carrier's plan, the missing teeth clause is waived.
Full mouth radiograph series in excess of once every 36 months. Panoramic radiographs in excess of once every 36 months, except when taken for diagnosis of third molars, cysts, or neoplasms.
Hard tissue periodontal surgery and soft tissue periodontal surgery per surgical area in excess of once in any 36 month period. This includes gingivectomy, gingivoplasty, gingival curettage (with or without a flap procedure), osseous surgery, pedicle grafts, and free soft tissue grafts.
Osseous grafts, with or without resorbable or non-resorbable GTR membrane placement in excess of once every 36 months per quadrant or surgical site.

Root planing and scaling (ADA Code 4341) in excess of once every 24 months per quadrant.
Full mouth debridement (ADA Code 4355) in excess of once every 36 months.
Replacement of complete or partial dentures, fixed bridgework, or crowns previously submitted for payment under the Plan within sixty (60) months of initial or supplemental placement. This includes retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances.
Replacement of complete or partial dentures, crowns, or fixed bridgework if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is necessary because of patient non-compliance, the patient is liable for the cost of replacement.
Denture relines for complete or partial conventional dentures for the 6 month period following the insertion of a prosthesis. Tissue conditioning and soft and hard relines for immediate full and partial dentures for the first six 6 months. After the six month waiting period, relines are covered not more than once every 12 months.
Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.
Attachments to conventional removable prostheses or fixed bridgework. This includes semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature.
Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO).
Placement of dental implants, implant-supported abutments and prostheses. This includes pharmacological regimens and restorative materials not accepted by the American Dental Association (ADA) Council on Dental Therapeutics.
Placement of fixed bridgework solely for the purpose of achieving periodontal stability.
Billing for incision and drainage (ADA Code 7510) if the involved abscessed tooth is removed on the same date of service.
Treatment of malignant or benign neoplasms, cysts, or other pathology, except excisional removal. Treatment of congenital malformations of hard or soft tissue, including excision.
Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.
Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and lower jawbone surgery (including that related to the temporomandibular joint). No Coverage is provided for orthognathic surgery, jaw alignment, or treatment for the temporomandibular joint.
Acupuncture; acupressure and other forms of alternative treatment.
General Anesthesia, except if required for patients under 6 years of age or patients with behavioral problems or physical disabilities.
Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.
Occlusal guards except if prescribed to control of habitual grinding, including those specifically used as safety items or to affect performance primarily in sports-related activities.
Charges for failure to keep a scheduled appointment without giving the dental office 24 hours notice.