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Introducing…
Dental (A-81000 Series)
Field Sales Guide
• Provides standard information only
• Available online via AFLAC University
• Review administrative guidelines for
state- specific information
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Section 1
Introduction
AFLAC Dental
• First introduced in 2000
• $60 million in 2001
• 2003 – reduced group size and participation requirements
• 2004 – opened to nonpayroll sales
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People Want Dental Insurance
• The ADA recommends two dental cleanings per year
• Having dental insurance and getting the recommended cleanings
allows policyholders to realize immediate benefits
• Dental insurance consistently ranks high in employee benefit polls
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The Small Employer Market
• Often don’t offer dental insurance because of the cost
• Want a simple product that is not complicated by provider networks,
pre- certification, etc.
• Nonpayroll rates available if needed
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The Large Employer Market
• Provider networks and pre-certification help to reduce costs
• Often employer-paid
• 90% of employers with at least 500 employees already offer dental
benefits
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Focus on Small Businesses
• Only 56% of all employers offer
dental benefits
• Small employers need dental
insurance!
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What’s New with AFLAC Dental?
• Fewer options
• X-Ray Benefit
• 3-month waiting period for fillings
• Increased benefits
• Orthodontic rider covers everyone
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What’s New with AFLAC Dental?
• New Cosmetic Rider
• Provider education tools
• Enhanced brochures
• Streamlined competitive replacement process
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Section 2
The Dental Insurance Market
Medical vs. Dental Insurance
Medical
• Spread of risk; price is based
on an estimate of how many
people will use it
Dental
• High utilization; most everyone
will use it
• Out-of-pocket expenses are
capped for the policyholder
• Yearly benefits are capped to
control expenses
• Focus on preventive benefits
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Types of Dental Insurance
• Indemnity Plans
• PPOs
• HMOs
• Table of Allowances
• Direct Reimbursement
• Discount Plans
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Indemnity Plans
• “Traditional” dental insurance
• Based on usual, customary, and reasonable (UCR) fees
– 100% for preventive care
– 80% for restorative services
– 50% for major services
• Annual maximums
• Usually a deductible
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Preferred Provider Organizations (PPOs)
• Provider network
• Providers agree to pre-set fees and savings are passed to the insured
• Usually no deductible
• Patient can go out of network, but will incur higher costs
• Exclusive Provider Organizations (EPOs) do not cover out-of-network
treatment
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Health Maintenance Organizations (HMOs)
• Capitation plans
• Preventive and basic services usually performed at no charge
• Patient may have a co-payment for major services
• Raises concerns about the quality of treatment
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Table of Allowances
• Similar to AFLAC’s definition of “indemnity”
• Fixed benefit is paid for each procedure, regardless of charges
• Patient chooses dentist
• AFLAC Dental is a table of allowances plan
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Direct Reimbursement
• Self-funded by employer
• Patient pays dentist and files for reimbursement with employer
• Reimbursement based on charges, not type of treatment
• Patient chooses dentist
• The ADA promotes direct reimbursement plans
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Discount Plans
• Not a form of insurance
• Requires a membership fee
• Participating dentists provide discounted services
• No benefit maximums
• Typically quote a savings of 20%-50%
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Categories of Benefits
• Preventive, Diagnostic, and Emergency
– Oral examinations, cleanings, X-rays
– Fluoride applications, sealants
• Routine or Basic Care
– Fillings
– Routine oral surgery, periodontal care
• Complex or Major Care
– Crowns
– Complex oral surgery, extensive care
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Section 3
Plan Structure
Original AFLAC Dental
• 6 levels of coverage
• Too many options
• Higher Wellness Benefit consistently outsold lower benefit
– Level 4 – 38%
– Level 3 – 3%
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New AFLAC Dental Options
Basic
• $25 wellness
• Lowest benefit schedule
Standard
• $50 wellness
• Mid-range benefits
Premier
• $50 wellness
• Higher tier of benefits
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Waiting Period
• Period of time after effective date for which benefits are not payable
• Controls costs by preventing immediate claims
• Reduces the chance that a person will buy dental insurance because
he or she needs a specific procedure
• Compensates for little underwriting
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Waiting Periods:
• Start over on the date of reinstatement
• Begin on the effective date of a dependent’s addition to the policy
• Apply to increased benefit amounts for conversions
• Run from the original effective date for downgrades
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Waiting Periods
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Dental Wellness Benefits
None
X-Ray Benefit
None
Other Preventive Benefits
6 months
Other Diagnostic Benefits
3 months
Fillings and Other Basic Restorative Benefits
3 months
Crowns and Other Major Restorative Benefits
12 months
Root Canals and Other Endodontic Benefits
12 months
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Waiting Periods
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Gum Treatments/Periodontic Benefits
6 months
Dentures and Other Prosthetic Benefits
24 months
Repairs and Adjustments to Prosthetics Benefits
6 months
Extractions and Other Oral Surgery Benefits
6 months
Pain Relief and Other Adjunctive Services Benefits
3 months
Orthodontic Benefit Rider
24 months
Cosmetic Benefit Rider
24 months
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Policy Year Maximums
• Maximum benefits payable per covered
person per policy year
• Does not include Wellness and X-rays
– Basic - $1,200
– Standard - $1,400
– Premier - $1,600
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Section 4
Policy Benefits and
Provisions
Wellness Benefit
• Pays for one listed treatment per visit
• Visits must be separated by 150 days or more
• Payable twice per person, per policy year
Examples:
– Oral evaluations
– Cleanings
– Fluoride applications
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X-Ray Benefit (new!)
• Pays for one listed X-ray procedure per
visit
• Payable once per person per policy year
– Basic - $10
– Standard - $25
– Premier - $25
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Schedule of Dental Procedures
• Benefit amounts are listed by ADA code
• If ADA codes change, we will pay an amount comparable for the
procedure
• Procedures may fall under more than one category
• Only the schedule varies among the different plans – waiting periods,
limitations and exclusions, etc. are the same
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Orthodontic Benefit Rider
• Applies to all covered persons (new!)
• After 24 month waiting period, pays:
– $600 for initial orthodontic treatment
– $200 every third month for continued treatment
– Covered treatments listed by ADA code
• $1,200 lifetime maximum per person
• $2,400 maximum per policy year
• Payroll sales only
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Cosmetic Benefit Rider (new!)
• Applies to all covered persons
• After 24 month waiting period, pays for specific procedures at benefit
amounts listed
• Examples: bleaching teeth, veneers, etc.
• $1,800 lifetime maximum per policy
• $600 maximum per policy year
• Payroll sales only
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Limitations and Exclusions
• Procedures not listed in the schedule
• Services not recommended by a dentist or not required for oral health
• Repairs to dental work within six months of initial work
• Replacement prosthetics within five years of last placement
• Treatment involving crowns within five years of last placement
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Limitations and Exclusions (continued)
• Replacement for inlays or onlays within five years of last placement
• Treatment received while outside the U.S.
• Sealants:
– Secondary molars for children under 16
– Not more often than every five years
• Replacement of teeth missing before the effective date of coverage
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Section 5
Administrative
Guidelines
Eligibility Requirements
• Issue ages:
– 1865 on payroll
– 1864 on nonpayroll
• No minimum group size for payroll
• Dependent ages 19/23
• Optional riders available for payroll sales only
• If supplementing existing dental insurance, only the Basic policy may
be offered
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Administrative Guidelines
• Flex:
– Base policy and Ortho Rider eligible for pre-tax
– Cosmetic Rider is after-tax only
• Advanced Effective Date (new!)
– Up to 90 days from enrollment date
– More than 60 days requires Statement of Understanding
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Additional Forms
• Replacement Notice
– if replacing another carrier’s dental policy
• Outline of Coverage
– if required in your state
• Guide to Health Insurance for People with
Medicare
– if applicant is eligible for Medicare
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Renewable/Portable
• Guaranteed-renewable for the policyholder’s lifetime
• Payroll rate may be retained after one month’s payment through
payroll deduction
• Changes once on direct billing will be subject to direct rates,
underwriting, and eligibility rules
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Missed Payments
• Dental uses a shorter lapse cycle
– Status 13 (no premiums received)
– Will be notified after the second missed invoice and will lapse in
30 days
– Status 22 (active)
– Will be notified after the first missed invoice and will lapse in 30
days
• No claims paid on policies more than 90 days in arrears, regardless
of policy status
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Section 6
Sales Support
Materials
Brochures
• Brochure folder A81075
• Insert for each policy:
– Basic A81175
– Standard A81275
– Premier A81375
• Inserts list every covered
procedure and benefit amount
(new!)
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Additional Pieces
• Rider inserts:
– Orthodontic A81076
– Cosmetic A81077
• Mailer A81090
– Suitable for both payroll and direct prospects
• Employer Flyer MMC-00-236
– Intended for employers - also used with Dental A-80000 Series
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Provider Education Tools (new!)
• Tent card M1078
• www.aflacdental.com
• Both provide tips for completing the ADA claim form and filing claims
electronically
• Web site allows provider to enter policy number and ADA codes to
retrieve benefit information
– Active policies only
– Only when policy record is available
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Section 7
Applications/Underwriting
Applications
• Payroll A81001
• Nonpayroll A81002D
• Applicant’s section includes a space for the dental provider’s name
• Replacement questions:
– Only Basic plan allowed if keeping other dental insurance
– Must convert an existing AFLAC policy
– Replacement Notice may be required
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Dependent Information
• Dependents must be listed on
application
• Complete Supplement Form
A-80005
– if more than eight dependent
children and provide proof of
dependent status
• Use form A81003 to add
newborns and adopted children
within 31 days
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Underwriting
• No underwriting for payroll applications
• Nonpayroll applications have one question:
– Have you or has anyone to be covered been diagnosed with or
treated for any gum disease such as gingivitis within the last 24
months?
• Any such person will not be covered
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Conversions
• Use new business applications
• Check conversion box and provide current policy number
• For increased benefits, new waiting periods apply only to the increase
in coverage
• For reduced benefits, waiting periods run from the original effective
date
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Continuous Coverage
• Spouse’s coverage terminates at divorce; may apply for equal or
lower coverage without evidence of insurability
• If primary dies, spouse becomes primary insured
• Dependent children must apply within 31 days of losing dependent
status to avoid interruption in coverage
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Section 8
Rates and
Commissions
Rate Comparison
New Plan
Original Plan
Basic
Level 2
6%
17%
Standard
Level 4
9%
21%
Premier
Level 6
20%
19%
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Aggregate Premium
Increase
Aggregate Benefit
Increase
Forms
• Rate sheet
– M-RS069-1
• Premium work sheet
– A90137-1
• Field Sales Guide includes standard rates only
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Commissions
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First Year
Renewals
New Associate Basic Plan
25.00%
6.10%
New Associate Other Plans
20.00%
5.10%
Veteran Basic Plan
14.00%
10.90%
Veteran Other Plans
10.50%
9.60%
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Section 9
Competitive
Replacements
Requirements
• Competitive replacements allow reduced waiting periods under the
following conditions:
– Fifty or more eligible employees
– Replacing a group dental plan that has been in place for at least
one year
– At least 70% participation in AFLAC Dental
• Conversions of existing AFLAC Dental policies do not count toward
participation requirements.
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Reduced Waiting Periods
• Available only during the initial enrollment period.
• Anyone applying after this time, including new employees, will receive
standard waiting periods.
• All competitive replacement requirements must be met to receive
reduced waiting periods.
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Request Form
• Competitive Replacement Checksheet Form M0978R
– Submit with paper applications
– Submit at least seven days prior to SmartApp® enrollments, then
download group update to access the applications
• Form M0978R is available on Associate Services
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Application (new process!)
• Form A8101T
• Applicant must indicate whether or not standard waiting periods are
acceptable, in case all requirements are not met.
• This prevents you from having to go back and obtain standard
applications.
• Advise applicants to check their Policy Schedule for waiting periods.
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Commissions
New or Veteran
Associate:
First Year
Renewals
Basic Plan
7.50%
7.50%
All Other Plans
7.00%
7.00%
Riders
2.35%
2.35%
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Section 10
Claims
Filing Instructions
• ADA Claim Form HF004
• Electronic claims preferred
• Typed claim forms should be mailed
• Claim checks will not be mailed to the associate
• Most payments will be made to the provider; if an overpayment, the
provider should reimburse the insured
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Claims Guidelines
• ID cards are contained in the policy and reference the provider
Website
• No claims paid on policies more than 90 days in arrears
• Please do not send X-rays
• ADA code revisions may be requested from the Customer Call Center
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Section 11
Marketing AFLAC
Dental
Key Features
• No:
– Provider network
– Pre-certification
– Deductible
– Coordination of benefits
• Simple plan design
• Individually owned
• Rate stability
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Understanding Group Dental
• UCR charges do not necessarily reflect what an individual provider
will charge
• Percentages cannot easily translate to a benefit amount until charged
• High participation requirements, may also require employer
contribution
• Policy owned by the group
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The AFLAC Advantage
• Table of allowances makes benefit determination easy!
• Freedom to choose any dentist
• Individually owned
• Portable
• Rates not tied to group experience
• Contract is between AFLAC and individual
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How Much Coverage is Needed?
• Highest level not always appropriate
• Dental treatment unlikely to cause catastrophic financial
consequences
• Benefits should reduce out-of-pocket expenses, not necessarily
eliminate them
• Overselling may take premium dollars from other AFLAC products
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“Saving” for Rider Benefits
• Ortho Rider
– 34 months to receive full individual benefits
– Individual benefits = $1,200
– 34 individual monthly premiums = $918
• Cosmetic Rider
– 49 months to receive full benefits
– Full benefits = $1,800
– 49 monthly premiums = $1259.30
• Ortho Rider also has pre-tax advantage
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Section 12
Dental Terminology
(self study)
Section 13
Forms List
(self study)
Thank you and Good Luck!
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