As California Pours Money into Denti-Cal Reform, State Sees Modest Improvements

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Source: California Health Report

California has given dentists nearly $130 million in incentive payments in the last two years in return for treating more low-income children.

While only 45.3 percent of children with Denti-Cal, the state’s low-income dental program, received preventative care at a dentist’s office in 2017, that’s 20 percent more than did before the state improvements began. In 2014, two years before the Dental Transformation Initiative launch, less than 38 percent of children in Denti-Cal received any sort of preventative care.

The number of dentists providing preventative care services to Denti-Cal enrollees also increased more than 7 percent, and the number of individual services provided has climbed by 14.8 percent.

“We think it’s a great improvement,” said Eileen Espejo, senior managing director for media and health policy for Children Now, an Oakland-based advocacy group. “Any way to increase utilization is critical.”

About half of California’s children are enrolled in Denti-Cal, the Medi-Cal dental insurance program.

In addition to increasing preventative dental care, the state’s Dental Transformation Initiative is focused on continuity of care, assessing and managing tooth decay, and local pilot projects. Preventative treatments that fall under the continuity of care category have increased 27.7 percent between 2014 and 2017. A total of $2 million in incentive payments for assessing and reducing the risk of tooth decay began in 2017, according to the state Department of Health Care Services, which oversees Denti-Cal.

“The Department of Health Care Services is satisfied with what has been accomplished under the Dental Transformation Initiative,” Tony Cava, an agency spokesperson, said in an email.

Paul Glassman, a dentist, professor at the University of the Pacific in San Francisco and principal investigator for all the Dental Transformation Initiative subcontractors, noted that the program got off to a slow start in terms of handing out contracts.

“It’s turning out to be less than a four-year initiative,” Glassman said. “Things are going better now.” The initiative ends in 2020.

Espejo noted that the dozen local pilot projects, which the state has spent $16.3 million on to date, have shown some success. One of the pilots, known as a virtual dental home, is being deployed in five counties. Dental hygienists use portable equipment to x-ray children in schools, and the x-rays are electronically transmitted to dentists for further examination. The hygienists can also perform what are known as an interim therapeutic restoration—essentially a filling that can be inserted without drilling.

Glassman, who oversaw a six-year proof-of-concept project for virtual dental homes before they were operated under the initiative, noted there are about 40 hygienists working in conjunction with about 30 dentists and federally qualified health clinics to provide the virtual home care. The project is working as well in cities as it is in rural areas.

“About two-thirds of very low-income kids could be kept healthy without seeing a dentist,” Glassman said.

According to Espejo, there are also promising pilots in place to train primary-care physicians to check on the oral health of their pediatric patients, and one at UCLA that analyzes electronic medical records for patients in need of potential dental care. Specific data about the efficacy of the pilots was not immediately available. Glassman noted that the gathering and transmission of data to the state for the pilot projects is an issue that has yet to be fully resolved.

The Health Care department acknowledges that more challenges for the initiative lie ahead. Cava noted that one of the biggest challenges is changing perceptions toward preventative dental care.

“The general public doesn’t normally prioritize the mouth and dental care for preventive maintenance like they do for medical care,” he said. “People tend to go to the dentist when they are in pain versus routine care. DHCS is trying to change that dynamic.”

For 2019, the agency has expanded exams for dental decay into 18 additional counties, for a total of 29, and increased focus on continuity of care in 19 new counties, for a total of 36.

However, whether the initiative will be a long-term success remains to be seen. While Cava noted that the agency will issue a comprehensive report in 2021, there is some skepticism about whether or not any progress will be sustainable.

Both Espejo and Glassman agree that many dentists in California remain reluctant to treat Denti-Cal enrollees, primarily because the extra reimbursement from government programs tends to be transient. Should the hundreds of millions being spent under the initiative disappear, it is quite possible the recently recruited providers will retreat.

“There are still a lot of lessons to be learned about what is working and not working,” Espejo said.

Fewer Older Americans Have Dental Insurance

Only 12% of older Americans have dental insurance and fewer than half visited a dentist in the previous year, according to a study of Medicare beneficiaries by the Johns Hopkins Bloomberg School of Public Health. Insurance status appeared to be the biggest predictor of whether a person got oral health care: For those with incomes just over the federal poverty level, 27% of those without dental insurance had a dental visit in the previous year, compared to 65% with dental insurance, according to an analysis of 2012 Medicare data.

Income also played a role: High-income beneficiaries were almost three times as likely to have gotten dental care in the previous 12 months compared to low-income beneficiaries, 74% of whom got no dental care. Many high-income beneficiaries paid a sizable portion of their bills out of pocket – even those with dental insurance. “Medicare is focused specifically on physical health needs and not oral health needs and, as a result, a staggering 49 million Medicare beneficiaries in this country don’t have dental insurance. With fewer and fewer retiree health plans covering dental benefits, we are ushering in a population of people with less coverage and who are less likely to routinely see a dentist. We need to think about cost-effective solutions to this problem,” says study author Amber Willink, Ph.D., an assistant scientist in the Department of Health Policy and Management at the Bloomberg School.

Eighty percent of Americans under 65 are covered by employer-sponsored programs that offer dental insurance, which covers routine cleanings and cost-sharing on fillings and other dental work. Many of them lose that coverage when they retire or go on Medicare. The vast majority of Medicare beneficiaries who have dental insurance are those who are still covered by employer-sponsored insurance, either because they are still working or because they are part of an ever-dwindling group of people with very generous retiree medical and dental benefits.

On average, Medicare beneficiaries reported spending $427 on dental care over the previous year, 77% of which was out-of-pocket spending. Seven percent spent more than $1,500. Dental expenses accounted for 14% of Medicare beneficiaries’ out-of-pocket health spending.

Poor dental hygiene not only contributes to gum disease, but also the same bacteria has been linked to pneumonia. It can also contribute to difficulty eating, swallowing, or speaking, all of which bring their own health challenges. Nearly one in five Medicare beneficiaries doesn’t have any of his or her original teeth left, according to the Centers for Disease Control and Prevention.

The researchers analyzed two separate proposals for adding dental benefits to Medicare, estimating how much each would cost. One was similar to the premium-financed, voluntary Medicare Part D benefit that was added to Medicare a decade ago to help cover prescription drugs for seniors.

It would cost an average premium of $29-a-month and would come with a subsidy for low-income seniors who couldn’t afford that, would run an estimated $4.4 to $5.9 billion annually depending on the number of low-income beneficiaries who participate.

A proposal that has been introduced in Congress would embed dental care into Medicare as a core benefit for all of the program’s 56 million beneficiaries. It is not expected to pass before Congress recesses. With a $7 monthly premium and subsidies for low-income people, it would cost $12.8 billion to $16.2 billion annually. The packages would cover the full cost of one preventive care visit a year and 50% of allowable costs for necessary care up to a $1,500 limit per year to cover additional preventive care and treatment of acute gum disease or tooth decay. “It’s hard to tell in this current political climate whether this is something that will be addressed by lawmakers, but regardless this is affecting the lives of many older adults,” Willink says. She cautions that if the costs become too high for Medicare beneficiaries, they could lose whatever wealth they have and end up on Medicaid, the insurance for the very poor which the government pays for fully.

Covered California Launches Open Enrollment

Covered Californians kicked off its fourth annual open enrollment last week for 2017. More than 92% of consumers will have three or more health plans to choose from, and none will have fewer than two. For 2017, most consumers will see a lower copay for their primary care visits. Urgent care costs in every plan will be the same as the primary care visit, helping consumers save up to $55 per visit. Consumers in Silver, Gold, and Platinum plans will pay a flat copay for emergency room visits in 2017 without having to satisfy a deductible. Most outpatient services in Silver, Gold and Platinum plans are not subject to a deductible, including primary care visits, specialist visits, lab tests, X-rays and imaging.

Even consumers in Covered California’s most affordable Bronze plans can see their doctor or a specialist three times before the visits are subject to the deductible.

Three of Covered California’s 11 health plans are expanding their coverage areas. Molina Healthcare is moving into Orange County, Kaiser Permanente will be available in Santa Cruz County, and Oscar Health Plan of California will be offering coverage in San Francisco County. The other plans continuing to offer coverage for 2017 are Anthem Blue Cross of California, Blue Shield of California, Chinese Community Health Plan, Health Net, L.A. Care Health Plan, Sharp Health Plan, Valley Health Plan and Western Health Advantage. Covered California is also adding two new family dental plans, Liberty Dental Plan and California Dental Network. They will join Access Dental Plan, Anthem Blue Cross, Delta Dental of California, Dental Health Services and Premier Access. Liberty Dental Plan will offer coverage in all ZIP codes in 2017, and California Dental Network will offer very competitive rates in the Bay Area, Los Angeles and Orange counties, and in parts of Sacramento, the north Bay Area, the Central Valley, the Inland Empire and San Diego.

An upgraded online shopping tool enables consumers to see 12 plan options on a page and filter their choices by plan, plan type, price, out-of-pocket costs, quality rating and metal tier, among other features. Consumers can also select their preferred plan and the information will be transferred to the application automatically. Another feature is the ability to shop for health or dental insurance and switch between the two offerings. Consumers who want assistance by phone can leave their number for a call back from the Covered California Service Center.

Starting in 2017, Covered California enrollees who don’t have a doctor will be matched to a primary care physician. They can designate a different physician at any time.

The ACA Spurs Growth of Dental Plans

Dental benefit offerings have seen an uptick as the Affordable Care Act (ACA) has become more ingrained in the U.S. health care system, according to an A.M. Best report. Companies that filed an annual health statement with the National Association of Insurance Commissioners increased their dental net premiums written by 77% over the past decade. The largest annual rate of growth came in 2014, when net premiums written increased 14% year-over-year. Similarly, enrollment grew 53% for the same period, with a 19% year-over-year increase in 2014. Despite geographic and provider network challenges, dental business has given health insurers steady net operating gain profitability over the past decade, with a fairly substantial improvement in results since 2009. The consistent operating profitability has been supported by a loss ratio from 60% in 2008 to 64% in 2013. Dental writers benefit from the mostly consistent utilization of policyholders. They usually don’t experience large one-time shock claims that may be associated with more typical health lines of business, which keeps the loss ratio fairly manageable and predictable. As companies expand into individual dental markets where adverse selection is a potential risk, the products are modified to include longer waiting periods for major dental services and lower annual maximums.

The top 10 dental writers account for 62% of the market, with MetLife holding the dominant share at 17%. The individual dental market also is highly concentrated as the top 10 players account for 67% of the market, led by MCNA Insurance Company’s 30%. Individual dental benefits are relatively new, with interest emerging and premium growing rapidly over the past 10 years. Regardless of some provider network challenges and certain under-served geographic areas, the dental insurance industry is poised for growth as employees continue to value the benefit offering and more dental insurers participate in the ACA exchanges. Increasing competition, including numerous small carriers expanding their exchange offerings, may pressure operating results. But underwriting gains in each of the past five years are substantially higher than levels recorded in 2005-2009, according to A.M. Best. To get a copy of the report, visit

Making the Most Out of Open Enrollment


Nearly half of employees are stressed by the open enrollment process and only half are confident about the benefit decisions they made last year, according to a study by MetLife. Millennials are the most stressed and confused. When asked about the most effective benefit resources, respondents ranked one-on-consultations well above other resources. In fact, Millennials led their generational counterparts in valuing one-on-one consultations. However, only half of employers offer one-on-one consultations. Sixty percent of Millenials consult with their families and friends on benefits. MetLife says that employers need to help their employees connect the value of non-medical benefits to their day-to-day lives. Employers should also do the following:

  • Make sure that employees fully understand key terms such as “deductible,” “premium,” “PPO,” and “HMO.”
  • Have employees ask themselves, “Do I have a big life event coming up, such as marriage or retirement?” It’s critical to choose benefits based on present and future needs.
  • Make sure that employees review their benefits and fully understand them. Only half of employees said they thoroughly reviewed their benefits choices last year.

The survey also reveals how employees feel about their benefits:

  • Financial uncertainty: In contrast to decreasing unemployment numbers, American workers remain pessimistic about their financial future. Less than half feel in control of their finances. Even fewer expect their situations to improve in the next year (46% in 2015, compared to 52% in 2014). More than half are concerned about having enough money to cover out-of-pocket medical costs as well as meeting monthly living expenses and financial obligations. These worries that have increased every year since 2012.
  • Job Satisfaction: More than half of employees are satisfied with their jobs and are committed to the organizations’ goals. An increasing number plan to be with their companies a year from now.
  • Financial Benefits: 71% of employees consider work to be the foundation of their financial safety net. Sixty-two percent of employees want more financial security benefits. Millennials are more financially vulnerable compared to their counterparts. Gen Xrs say they are less secure than other generations.
  • Appreciation of benefits: Half of employees agree strongly that their benefits help them worry less about unexpected health and financial issues. Seventy percent of employees say that having customizable benefits would increase their loyalty to their employer.
  • Supplemental benefits: Employees continue to ask for a range of solutions, especially for more common benefits, such as medical, prescription, 401(k), dental, life, and vision care. Employers are keeping pace with many of their employees’ top benefit requests. However, there are large gaps in accident insurance, critical illness, and hospital indemnity. Most employers understand how non-medical benefits can provide financial protection, such as offsetting out-of-pocket medical expenses. Yet, only 47% of employees believe that supplemental health benefits can help close these gaps.
  • A streamlined plan design: Plan design, claims management, and implementation rank highly as advantages of streamlining the number of carriers that employers use.
  • Use of enrollment firms: Three-quarters of employers have positive attitudes towards enrollment firms. Seventy-one percent of employers say that working with an enrollment firm helped them improve benefit communications.
  • Wellness plans: More than two thirds of employees are interested in physical well-being programs that reward healthy behavior. This is especially true among Millennials (75%) and female employees (72%).
  • Retirement Benefits: Forty percent of employees say that having retiree benefits is a key reason to stay with their employer. Millennials feel the most strongly about this, probably due to their lack of financial confidence. About a third of employees plan to postpone retirement, an increase of 5% over 2015. Almost 6 in 10 employees plan to work or consult once retired. Of this 60%, 44% plan to work part-time.
  • Older workers: With today’s workers redefining what it means to be a retiree, employers must also redefine what retiree benefits look like in order to appeal to this rich reservoir of talent. For example, 63% of employees say that dental is a must-have retiree benefit while only 42% of employers offer it. Similar gaps can be found across other critical non-medical benefits, such as vision and life insurance. More than half of employees say that their employer does not offer any employer-paid non-medical benefits. With retiree benefits being such an important loyalty factor for many employees, employers have an opportunity to keep pace in 2016 and beyond.

Dental Coverage Legislation

Senators Pat Roberts (R-KS) and Michael Bennet (D-CO) introduced bipartisan legislation to clarify that people outside the public exchanges can have the same choices for dental coverage as people inside the public exchanges. The Aligning Children’s Dental Coverage Act (S. 3244) is a companion to HR 3463, sponsored by Representatives Morgan Griffith (R-VA) and Diana DeGette (D-CO).

Inside the exchanges, parents can pick stand-alone dental benefits for their children as an option. About 99% of Americans select dental coverage separately from their medical coverage. But, outside the public exchanges, the Affordable Care Act isn’t clear on whether families can purchase stand-alone dental plans as part of the required pediatric dental care benefit. As a result, individuals, employers, and carriers are confused about what coverage options are available.

Jason Daughn, vice president of government relations for Delta Dental Plans Assn. said, “The Senate and House legislation offers a simple, but crucial solution to ensure that families across the nation continue to have the access they need and the choices they deserve in obtaining dental benefits. This is a common sense solution to an issue that could pose big problems to families and children across the nation.”

Study Reveals Leading Healthcare Benefit Trends


The Healthcare Treds Institute issued a massive survey of employee benefit trends. The good news is that employers are looking to insurance brokers and benefit consultants to help them evaluate health benefit designs and distribution models. Forty percent of employers say they will depend on insurance brokers to learn about new health benefit models, such as defined contribution plans and private exchanges, and 31% will depend on benefit consultants. Nearly 40% rely on insurance brokers to learn about health benefit designs and platforms.

“The ACA has created a dynamic marketplace in which brokers have a front row seat navigating in this new era,” according to the study. Human resource professionals have new responsibilities due to the ACA. Thirty percent are looking for help from benefit consultants. However, 30% are researching independently compared to 26% in the previous year. Employers gave the following answers to this question, “What partners would you depend on to help you learn about new health benefit designs and distribution models?”

  • Insurance broker 39.7%
  • Will research independently 30.8%
  • Benefit consultant 30.8%
  • Insurance carrier 24.4%
  • TPA 19.2%
  • None 15.4%
  • Trade Association 11.5%
  • Payroll company 10.3%
  • Other 5.1%

What Benefits Employers Are Offering

About 40% of employers offer three or more health plan options, which are usually a PPO, an HDHP, and an HMO. Employees are choosing HDHPs (39%) over HMOs (35%). The following is a breakdown of benefits that employers offer:

  • PPO 59.5%
  • Flexible spending account (FSA)59.5%
  • Health savings account (HSA) 52.1%
  • High deductible health plan (HDHP) 38.8%
  • HMO 34.7%
  • Self-insured plan 22.3%
  • Health-reimbursement arrangement (HRA) 15.7%
  • Catastrophic insurance 8.3%
  • Dental plan 73.6%
  • Vision plan 67.8%
  • Prescription drug coverage 67.8%
  • Mental health coverage 52.1%

How Healthcare Reform Has Affected Employee Benefit Packages

Forty-nine percent say that healthcare reform will increase employee cost-sharing; 39.6% say it will increase premium contributions, and 3.6% say it will shift their company towards a defined contribution plan. Employee cost-sharing has risen every year for 10 years. Employers and the medical industry have had to deal with other ACA implications, such as the employer mandate and new compliance, which has caused an increase in capital and human resources. Employers have done the following in response to health reform:

  • Increased employee cost sharing 49%
  • Has had no effect 30%
  • Enhanced wellness/preventive health programs 23%
  • Increased employee engagement in their health 19%
  • Increased employee engagement in reducing healthcare costs 18%
  • Adopted new wellness/preventive health programs 17%
  • Reduced covered benefits 15%
  • Added HDHPs/CDHPs 14%
  • Stopped offering healthcare benefits 9%
  • Shifted to a defined-contribution plan

The Cadillac Tax

The impending 2018 Cadillac Tax is a prevalent challenge for employers. The ACA 40% excise tax will be imposed on the portion of group health plan premiums that exceed specified thresholds. The concern may be more regional since it could be triggered in parts of the country where healthcare costs are high and less likely to be triggered in parts of the U.S. with below average healthcare costs. Thirty-five percent of employers are very concerned about the 2018 Cadillac Tax; 25% are somewhat concerned; and 30% are not concerned. Sixty-one percent are making no changes to their benefits in light of the impending Cadillac tax while 18% have changed plans to avoid the Cadillac Tax. Recent news reports along with lobbying efforts may be influencing the 61% of companies who have a wait and see approach about the Cadillac Tax.

Defined Contribution Plans

Employers continue to learn more about defined contribution plans and private exchanges with about 35% saying they are familiar with them. This is an increase of about 5% over last year. Twenty-eight percent say that exchanges help employees understand the value of their benefits. Twenty-five percent say that a defined-contribution plan would help employees understand the value of their benefits and make more cost-conscious benefit decisions.

Five percent of employers offer defined-contribution plans (not on a private exchange) while same offer defined-contribution plans on a private exchange. Also, 7% are considering offering a defined contribution plans on a private exchange while 53% have not explored defined contribution plans.

Fifty-five percent of employers who are considering a defined-contribution plan, say they would explore the option for 2017 or 2018. This suggests that near-term adoption will be gradual. But the adoption curve may steepen as the benefits of defined-contribution plans become better known.

Private Exchanges

Employers want private exchanges to provide many solutions including health spending accounts (62%), carrier integration (58%), COBRA compliance (56%), automation of premium payments (51%), and payroll integration (50%). Employers choose private exchanges to control costs and increase employee choices, which is why employers say, most often, that they are looking for health spending accounts. Incorporating consumer directed healthcare coverage, such as HDHPs, HSAs and HRAs, helps private exchanges create a competitive marketplace that promotes cost-savings for employees and employers.

To succeed a private exchange needs to provide broad choices and help participants in the selection process. Sixty-two percent of employers say that it is somewhat important to very important to have health-spending accounts in an insurance exchange. Also considered somewhat important to very important are carrier integration (59%), COBRA compliance (56.4%), and premium payment automation (53%). Employers say they would choose the following offerings in an exchange:

  • Plan and cost comparison tools 80%
  • Online capabilities 69%
  • Combined benefit enrollment 47%
  • A help line 47%
  • Transparency solutions for treatment cost comparisons 45%
  • Mobile applications 45%
  • Progressive cost tracking tools 35%
  • Consolidated employer billing 35%
  • Integrated consumer healthcare accounts 30%
  • Financial account options 28%

Employers rank several exchange features as important, such as being a private exchange instead of a public exchange (83%), having a large selection of plan choices at targeted benefit levels (58%), and being provided by their broker or benefit consultant (55%). These findings indicate that broad choice is more important than who runs the exchange (broker versus carrier).


Wellness programs continue to gain interest as 35% of employers have initiatives in place compared to 30% last year. Another 22% are considering implementing a program. Sixty-five percent are considering adopting a wellness program in 2017, and 16% are considering adopting one by the end of 2016.

Fifty-five percent of those offering wellness programs, offer an employee-assistance program (EAP); 53% offer flu shots or vaccinations; and 37% offer a smoking cessation program. The disease management tools that most employers offer are for diabetes (30%) and depression or other mental health (30%). Fifty-four percent of employees are not offering disease management tools. But 30% are providing services for diabetes and mental health conditions. To promote positive health outcomes, 44% of employers offer at least one wellness program; 31% offer biometric screening; and 20% offer a disease management program.

Forty-four percent have at least one wellness initiative in their workplace. Employers that are interested in offering wellness plans should consider how it would affect productivity, absenteeism, turnover, retention, and recruitment, according to the survey authors. Including these factors in the ROI discussion can help demonstrate additional savings a company could achieve.

When it comes to wellness incentives, HSA and HRA contributions (18%) and premium reductions (16%) are most popular. Companies are split on whether to offer wellness incentives with 58% not providing rewards to employees and 42% offering some type of incentive in varying monetary amounts to participate. The value of the incentives remains relatively modest. Companies interested in wellness incentives can use the ACA as a guide. Eighteen percent offer $250 or more of incentives to employees for health-related tasks. Common values of incentives are $101 to 250 and $1 to $50. For more information, visit www.HealthcareTrendsInstitute.

One in Five Consumers Never Visit or Only Go to the Dentist for Urgent Situations

Twenty percent of consumers never visit the dentist or only go when they need urgent treatment, according to a survey by FAIR Health. This statistic increases to 30% for households with annual incomes of less than $35,000 and falls to less than 10% for households with incomes of $100,000 or more.

African-Americans, Latinos, and people living in lower-income households, as well as adults with a high school diploma or less visit the dentist less frequently than other racial, ethnic or socio-economic groups. African-Americans and Latinos are more likely to say that someone in their household visited a hospital emergency room for oral healthcare in the past five years.

Eleven percent of consumers have used daily deal sites for discounted dental services or would consider using them. Millennials (ages 18-34), African-Americans, Latinos, and men express the strongest interest in using these sites. Latinos are the most likely to say that a member of their household got dental care at a community clinic in the past five years. Consumers with a high school education or less are most likely to say they would be willing to receive treatment from a dental school or community health clinic to save money.

Major Health Insurance Changes for the New Year

Covered CA 2016 ChangesCovered California is reminding consumers and small businesses about important changes in 2016. Starting January 1, Covered California increased access to plans and providers and offered more health plans, and increased the number of benefits that are not subject to a deductible. Here is a run-down of the changes:

Most California Consumers Get New Forms for the 2015 Tax Year
This year, consumers who are insured through their employer or a government program, like Medi-Cal, will get Form 1095-B or Form 1095-C. The forms show who maintained minimum essential coverage and is not liable for the tax penalty. Consumers under Covered California will continue to get a Form 1095-A. For more information, visit

The Penalty for Not Buying Affordable Insurance Is Going Up — A Lot
The IRS penalty applies to people who go without insurance when they can afford to buy it. It will increase for 2016 to at least $695 per adult and $347.50 per child under 18 or 2.5% of household income, whichever is greater. A recent study by the Henry J. Kaiser Family Foundation estimates that the average household penalty in 2016 will be $969, which is a 47% increase from 2015. For more information, visit

New Requirements and New Options for Many of California’s Small Businesses
Employers with more than 50 full-time-equivalent (FTE) employees must offer health insurance to employees or pay a penalty. Through 2015, this requirement applied only to businesses with more than 100 employees. Any of these employers with an employee who does not take their offer of coverage will have to pay a penalty if the employee goes on to get financial assistance to purchase coverage through Covered California. For more information, visit

Covered California for Small Business will expand beyond the ceiling of 50 employees to serve companies employing 100 or fewer FTE employees. For more information, visit

Major Improvements in Choice, Access and Benefits
Covered California used its power as an active purchaser to hold down rate changes for a second year. Before the Affordable Care Act, consumers regularly experienced double-digit premium increases. For 2016, Covered California negotiated a weighted average change of 4%, which is lower than last year’s change of 4.2%. In addition, nearly 90% of Covered California enrollees get some financial assistance to help pay premiums. On average, those subsidies resulted in more than $5,200 for each household in 2014.

Benefit Changes for the 2016 coverage year:

  • The majority of Bronze plan consumers now get three office visits a year to a primary care provider or specialist with no deductible. Other needed services, such as lab tests and rehabilitation, will not be subject to a deductible.
  • Covered California’s Silver plan will combine copay and coinsurance into a single product. Every doctor visit, lab test, and prescription will not be subject to a deductible in this single product. Consumers with chronic conditions will be protected by a cap on specialty drugs. The vast majority of consumers will see their specialty drugs capped at $250 per month, per prescription. Plus, because of Covered California’s standard benefit design, the caps must be offered by every health insurance plan in the individual market and by all plans offered by the exchange. For more information, visit
  • Adult dental coverage is now offered as an add-on.
  • 6% of Covered California consumers will be able to choose from at least three health insurance companies thanks to the addition of two new health insurance companies — UnitedHealthcare Benefits Plan of California and Oscar Health Plan of California as well as the expansion of Blue Shield of California and Health Net.
  • More than 90% of hospitals (general acute centers as designated by the California Office of Statewide Health Planning and Development) in California will be available through at least one health insurance company, and 74% will be available through three or more companies.

 Medi-Cal Coverage for Undocumented Children

  • Medi-Cal will be expanded to all children regardless of their immigration status. The new law goes into effect in May 2016.

Health Care Improvements for All Californians
Starting July 1, health plans must publish and maintain printed and online provider directories. Health plans must maintain accurate provider directories, including routine updates. For more information, visit

A new state law will require health plans and insurers to implement formula-tier requirements and cost-sharing caps similar to products offered through Covered California. Assembly Bill 339 requires plans and insurers to have formularies that do not discourage the enrollment of people with certain health conditions. It also sets requirements regarding access to in-network retail pharmacies, standardized formularies, and coverage for certain single-tablet HIV and AIDS treatments. For more information, visit

United Gets High Ratings for Dental Plan

UnitedHealthcare ranks highest in customer satisfaction with dental plan insurers for a second consecutive year. The plan performed particularly well in the coverage, cost, and communications factors, according to the J.D. Power 2015 Dental Plan Satisfaction Report. Satisfaction is calculated on a 1,000-point scale.

Across all dental plan carriers, 42% of members have not gotten any information about their plan from their insurer. Satisfaction among these members is 662, compared to 758 among those who did get some type of information from their carriers. Among dental plan members who rate their experience 10 (outstanding), 87% say they definitely will choose their carrier in the future, compared to the report average of 43%. Among dental plan members who rate their experience outstanding, the average number of positive recommendations is four, compared to 1.6 for the report average.

The following are dental plan rankings:

  • UnitedHealthcare Dental 754
  • DentaQuest 736
  • HumanaDental 727
  • United Concordia Dental 720
  • Aetna Dental 714
  • MetLife Dental 709
  • Guardian Access Dental/Premier Access 706
  • myCigna Dental 701

Last Updated 02/24/2021

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