1. ©UFS Dental Benefits – U.S. Market June 2010 Dr. Alan Vogel MetLife, VP Dental Products

2. 2 Today’s Topics US Dental Market – Statistics Dental Plan Evolution – Design & Administration – Initial approach - Cost Drivers Plan Design and Contract Provisions Plan Administration Provider Networks – Current approach – Cost & Value Drivers Research based / Evidenced Based Dentistry Consumer Directed Plans Tools – Employee – Future Wellness / Disease Management Data management

3. 3 Number of Covered Lives: Approx. 176 million (57% of U.S. population) 1 Total Dental Dollars: $46.5B in premium 2, $101.2B spent on dental in 2008 3 DPPO Lives 1 :101,504,708 / 101.5 million DHMO Lives 1 :12,644,357 / 12.6 million Indemnity Lives 1 :22,116,711 / 22.1 million Access Lives 1 :15,222,239 / 15.2 million Size of U.S. Dental Market (1) NAD/DPPA 2009 Dental Benefits Joint Report: Enrollment, June 2009 pg. 7, Dallas, Texas. Ordering information at www.nadp.org. (2) NADP 2009 State of the Dental Benefits Market, February 2009, pg. 6. Dallas, Texas. (3) Centers for Medicare & Medicaid Services, Office of the Actuary. National Health Expenditures Amounts by Type of Expense an Source of Funds: Calendar Years 1965-2019, January 2010.

4. 4 Dental Plan Trends (1) NAD/DPPA 2009 Dental Benefits Joint Report: Enrollment, June 2009 pg. 7, Dallas, Texas. Ordering information at www.nadp.org. Numbers in millions of covered lives.www.nadp.org DPPOs are the only segment with significant growth from 2000 - 2008 1

5. 5 Types of Plans DHMO – Dentist paid on a per capita basis at a fixed rate for each individual or family enrolled regardless of number of services performed. Co-payment may be required for certain procedures – Referral required for specialist care Indemnity – Fee-for-service reimbursement generally based either on a schedule of allowances or UCR – No network provider assigned or available DPPO – Fee-for-service reimbursement with in and out-of-network options – Network of dentists agreeing to a discounted level of payment for covered services – Patient may choose to go out-of-network and plan design/carrier will determine out-of-network reimbursement level. Access Plan – Network Plan – no out of network access – No Benefits Covered

6. 6 Plan Financials Insured – Plan and Administration Defined by Carrier – Regulated by State ASC (Administrative Services Contract) – Plan and Administration Defined by Employer – Exempt from State Regulation Employer Sponsored – Majority of Costs picked up by Employer (50%+) – Cost sharing with Employee and / or Dependent Voluntary – Employee picks up majority of Costs or all the Costs (50-100%) – Usually Insured

7. 7 ©UFS Evolution of Dental Plans Examining the Present and Future

8. 8 Initial Plans Focused on Costs Cost Drivers – Plan Design Allocation of Services Age, Frequency & Dollar Limits Contract Provisions – Alternate Benefit – Pre-existing Space – Plan Administration Bundling Software Tooth Map History – Provider Networks Discounts Patterns of Care

9. 9 Costs -Plan Design Components - DPPO / Indemnity Allocation of Services & Coinsurance percentages – Preventive: Cleanings, Routine X-rays (100%) – Basic Restorative: Fillings, Periodontics, Surgery, Endodontics (80%) – Major Restorative: Crowns, Bridges/Dentures (50%) Plan maximums ($) – Annual Max and Orthodontia Lifetime Max Deductibles (individual & Family) Reimbursement Design Age & Frequency Limitations Exclusions

10. 10  Fillings  Repairs  Periapicals  Pulp capping/ pulpal therapy  Endodontics/root canal  Periodontal maintenance  Periodontics  Rebases/relines  Simple extractions  Surgical extractions  Oral surgery  General anesthesia  Consultations Potential Allocation of Services  Orthodontic diagnostics  Orthodontic treatment Type C Prosthodontics  Inlays/onlays  Crowns  Dentures  Bridges Type D Orthodontics Type B Restorative Type A Preventive & Diagnostic  Oral exams  Full mouth X-rays  Bitewing X-rays, periapicals & other X-rays  Lab and other tests  Prophylaxis (cleaning)  Fluoride treatments  Space maintainers  Palliative care  Sealants — Type A, B, C & D covered services

11. 11 Fluoride age Once per 12 months Space maintainer age Once per lifetime Periodontal maintenance Combined with cleaning Prosthodontic services Sealant age One per 60 months R&C Percentile Implants Standard Up to age 19 2 per year 1 in 5 years Up to age 16 Molars only 90 th Not covered Limitations and Exclusions

12. 12 Costs - Plan Administration - PPO / Indemnity Unbundling software Claim Review Reimbursement amounts Alternate benefits Pre existing conditions Prior History (Tooth Map History)

13. 13 Costs - Networks - PPO Provider Selection & Credentialing – Practice Patterns Contract – Defines Relationship to Carrier – Defines Relationship to Plans Fee Schedule – Creates maximum reimbursement amounts – Defines many plan requirements Access to Providers – Geo-Access reports – Generalist & Specialist

14. 14 Current Plans Focus on Value & Costs Value Drivers (Evidence Based Benefits) – Researched Based Plan Design Build Research into Age, Frequency Limits Build Research into Guidelines & Covered Services – Consumer Based Plan Ideas Cover Services That Treat Disease at Higher Levels Patient makes “Bad Choice” = Higher Costs – Employee Tools Oral Health Library Decision Support

15. 15 Value- Covered Services – Researched based Implants White Fillings on Molars Bruxing Appliances Add These Services Without Increasing Costs, How? Evidenced Based Dentistry - Modify – Age & frequency limits – Allocation of Services – Replacement Limits

16. 16  Fillings – resin on molars  Repairs  Periapicals  Pulp capping/ pulpal therapy  Full mouth X-rays  Space maintainers  Palliative care  Periodontal maintenance  Periodontics – non surgical  Rebases/relines  Simple extractions  Surgical extractions  General anesthesia  Consultations Adjusted Allocation of Services  Orthodontic diagnostics  Orthodontic treatment Type C Prosthodontics  Inlays/onlays  Crowns  Dentures  Bridges  Implants  Endodontics/ root canal  Periodontics–surgery  Oral surgery  Bruxing Appliance Type D Orthodontics Type B Restorative Type A Preventive & Diagnostic  Oral exams  Bitewing X-rays, periapicals & other X-rays  Lab and other tests  Prophylaxis (cleaning)  Fluoride treatments  Sealants — Type A, B, C & D covered services

17. 17 Fluoride age Once per 12 months Space maintainer age Once per lifetime Periodontal maintenance Combined with cleaning Prosthodontic services Sealant age One per 60 months R&C Percentile Implants Up to age 14 4 per year 1 in 10 years Up to age 19 Molars only 70 th or 80 th Covered Standard Research based Alternatives Up to age 19 2 per year 1 in 5 years Up to age 16 Molars only 90 th Not covered Adjusted- Limitations and Exclusions

18. 18 Value- Employee Tools Self Service – Claim information – Plan information – Network Providers Oral Health Library – Educational on Services – Educational on Risks Fee Estimator

19. 19 What’s Driving Dental Plan Design Evolution? Do the dental plans you recommend recognize and incorporate these trends? Dental Standards & Market Practice Dental Benefits Environment Research & Risk Changing Benefits Objectives & Demands Dental Plan Design

20. 20 More Employees Seek Advice and Guidance at the Workplace Source: 7th Annual MetLife Study of Employee Benefits Trends Benefits Objectives and Demands Employers Creating a Culture of Health and Responsibility 2005 Programs 2008 Programs WELLNESS PROGRAMS Employers offer wellness programs 27% 33% 2005 2008  While companies remain concerned with the rising cost of healthcare coverage, at a broader, more holistic level, they are also focusing on how to encourage employees to behave in ways that help them lead healthier lives.  43% of employees want access to benefits advisors at the workplace, and are interested in professional advice regarding critical decisions about their benefits (up from 33% of employees in 2006). Changing Benefits Objectives & Demands

21. 21 Risk Is Playing a More Important Role in Dental Plan Design (1) Khader YS, Ta’ani Q. Periodontal diseases and the risk of preterm birth and low birth weight: a meta-analysis. Evid Based Dent 2005 Feb; 76(2):161-5. (2) Mealey B.L. Oates T.V. Diabetes Mellitus and Periodontal Diseases. AAP-Commissioned Review. J Periodontal 2006;77:1289-1303.. (3) Humphrey LL, Fu R Buckley DI, Freeman M, Helfand M. J Gen Intern Med. 2008;23(12):2079-86; (4) Keene, Joseph J. Jr., et al. “Antidepressant use in psychiatry and medicine — Importance for dental practice,” Journal of the American Dental Association, Vol. 134, January 2003; (5) Dirix, Piet, et al. “Radiation- Induced Xerostomia in Patients with Head and Neck Cancer,” Cancer, Vol. 107, number 11, December 2006; (6) Migliorati et al. “Managing the care of patients with bisphosphonate-associated osteonecrosis: An American Academy of Oral Medicine Position Paper.” Journal of the American Dental Association. Vol. 136, December 2005; (7) Ioannidou et al. Elevated Serum Interleukin-6 (IL-6) in Solid-Organ Transplant Recipients Is Positively Associated With Tissue Destruction and IL-6 Gene Expression in the Periodontium.” Journal of Periodontology, 2006, Vol. 77, No. 1, pg 1871-1878. 21 People taking Antidepressants or Cancer Patients undergoing radiation — In some cases antidepressants and radiation may cause Xerostomia (dry mouth), which can compromise oral health. 4,5 Women taking Bisphosphonates for Osteoporosis (Injectable) — Bisphosphonates may contribute to osteonecrosis of the jaw in some cases 6 People in need of organ transplants — One study suggests they may have a better chance for success of the transplant if their oral health is good 7 (a link between chronic periodontitis and the risk for rejection)  Research has suggested a relationship between oral and overall health, and has associated periodontal disease with conditions such as preterm births 1, diabetes 2, and coronary heart disease 3.  However, studies have suggested additional relationships between oral and overall health for which further research is underway: Research & Risk

22. 22 Do you know? It’s estimated 35% of adults have periodontal disease 1, and up to 13% have moderate or severe periodontal disease 2. Q:and what percent is attributed to smoking? A:Half 2,3 (1) Quality Resource Guide, “Assessing Risk for Chronic Periodontitis in Adults, Dr. Ray Williams, DMD, Chair Department of Periodontology, University of North Carolina School of Dentistry. (2) Center for Disease Control, Oral Health at a Glance, 2010 (3) Journal of the American Dental Association, “Risk assessment and management of periodontal disease”, Douglass, 2006 (4) Tobacco and healthy teeth don’t mix. Canadian Dental Association website. www.healthyteeth.org/tobacco. Accessed October 2, 2009.

23. 23 Do you know? So what? Research suggests there is a two-way connection between diabetes and periodontal disease – not only are diabetics more susceptible (to periodontal disease), but the presence (of perio disease) may also make glycemic control more difficult. 2 (1) Center for Disease Control, National Diabetes Fact Sheet, 2007 (2) Department of Health and Human Services, “Working Together to Manage Diabetes”, 2007

24. 24 Do you know? Q:Among the 50 most prescribed medications, this percent had the capacity to cause xerostomia 1, or dry mouth, as a side effect? A:Half (1) Quality Resource Guide, “Recognition and Management of Patients with Xerostomia”, James Guggenheimer, DDS, University of Pittsburgh School of Dental Medicine

25. 25 Future Plan Focus Disease Management / Wellness – Medical / Dental Integration – Patient Information – Education – To Risks for Disease – Variable Benefits – Based on Individual Risk Data Mining – Outcome Measures – Network Selection Process – Provider (Dentist) Profiles – Focused Claim Review – Utilization Statistics – Show Value of Program to: Patients Dentists Payor

26. 26 WHY??? So A Carrier Can:  Analyze and challenge plan designs –Look deeper than 100/80/50 and question where services are allocated –Understand limitations, exclusions, contract language — and ask questions!  Understand what adds value to a plan and what is questionable  Educate your clients on “why change plans”  Present the best plans and alternatives to meet your customers’ unique needs

27. 27 Questions?