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OFFICERS & DIRECTORSAugust 6, 2014Mr. Rodolfo Ramos, DDSChair and Presiding OfficerMs. Julie HildebrandExecutive DirectorTexas State Board of Dental Examiners333 Guadalupe Street, Tower 3, Suite 800Austin, TX 78701Sent via emailRe: Draft Amendments to TAC 108.70 and 108.74Dear Chair Ramos, Ms. Hildebrand and Members of the Board:The National Association of Dental Plans (NADP) would like to comment on draftregulations amending Texas Administrative Code (TAC) 108.70 and adding 108.74 to beconsidered by the Board of Dental Examiners impacting the management of dentalpractices.As drafted, the regulations are overly stringent and would threaten consumer choiceand access to existing care. NADP understands and appreciates the importance ofprotecting dentists’ independent performance, clinical judgment and relationships withpatients. These proposed standards however have a much greater scope, especiallywhen compared to methods employed within other states.Dental Support Organizations (DSO) provide assistance to dental offices with nonclinical business and administrative services, and they are becoming a more popularoption for dentists who do not want to be burdened with the administrative functionsof owning a small business, but prefer to focus on providing the best patient care. Thistrend is similar to that experienced in the medical field more than a decade ago. Thestructure of these draft regulations seems to invalidate this business model, with thepurpose of making DSOs less competitive to non-existent.ChairCHRIS SWANKER, FSA, MAAAGuardian Life InsuranceCompany of AmericaBethlehem, PAVice ChairTHERESA McCONEGHEYPrincipal Financial GroupDes Moines, IASecretaryDR. GENE SHERMANStarmount LifeBaton Rouge, LATreasurerKIRK E. ANDREWSUnited Healthcare DentalSanta Ana, CACHARLES BRODYDominion Dental Services, Inc.Alexandria, VADR. DAN CROLEYDelta Dental ofCA, NY, PA & AffiliatesSan Francisco, CAMARK COYNEPPO USA, a Division of GEHALee's Summit, MOROBIN MUCKPremier Access Dentaland VisionSacramento, CAFRED SHARPE, DDSAvesis Third Party Admin.Owings Mills, MDImmediate Past ChairFORREST FLINTHealthPartners, Inc.Minneapolis, MNExecutive DirectorEVELYN F. IRELAND, CAENational Associationof Dental PlansDallas, TXNADP would appreciate further dialog to better understand the repercussions of thesestandards as it seems they will completely disrupt current patient (and our enrollees)care. We look forward to discussions and working with the Board of Dental Examinersto develop a structure which provides safeguards for dentists while allowing flexibility for managing theadministration of a dental office.12700 Park Central Drive Suite 400 Dallas, Texas 75251972.458.6998 972.458.2258 [fax]

NADP greatly appreciates the opportunity to share our views, and please contact me with any questionsregarding these comments at khathaway@nadp.org or 972.458.6998x111. Attached you will find aTexas Dental State Fact Sheet and NADP member list for your review. Again, thank you for yourconsideration.Sincerely,Kris HathawayDirector of Government RelationsNADP DESCRIPTIONNADP is the largest non-profit trade association focused exclusively on the dental benefits industry, i.e.dental PPOs, dental HMOs, discount dental plans and dental indemnity products. NADP’s membersprovide dental benefits to approximately 90 percent of the 187 million Americans with dental benefits.Our members include the entire spectrum of dental carriers; companies that provide both medical anddental coverage, companies that provide only dental coverage, major national carriers, regional, andsingle state companies, as well as companies organized as non-profit plans.12700 Park Central Drive Suite 400 Dallas, Texas 75251972.458.6998 972.458.2258 [fax]

TexasDental Benefits Fact SheetNational Enrollment TrendsState EnrollmentEnrollmentPrivate Plan EnrollmentSource: 2013 NADP/DDPA Joint Dental Benefits Report on EnrollmentSource: 2013 NADP/DDPA Joint Dental Benefits Report on EnrollmentGroup Policy FundingDistribution of Commercial Benefits: State vs NationalTexasNational23.8%EmployeePays 8Public Plan EnrollmentMedicaid/CHIP12,034,0692Other Public2,129,6752003 2004 2005 2006 2007 2008 2009 2010 2011 2012Employee &EmployerShare CostEnrollmentDHMODPPOIndemnityOther 00,534Plan Type155,939,275Population with Dental BenefitsAn estimated 11,069,236 people are enrolled ina private dental plan from Texas.EmployerPays %7.8%5.4%Sources of Private Dental Coverage9.1%Group – 94%Individual – 5%Integrated w/ medical – 1%Other – 0%Source: 2013 NADP/DDPA Joint Dental Benefits Report on EnrollmentSource: 2013 NADP/DDPA Joint Dental Benefits Report on EnrollmentPremium FactsNationally, premium increases ranged forexisting group coverage from 0.2% for DHMOproducts to 1.5% for DPPO products12Average monthly dental premium permember per month in Texas:DPPO: 32.17Data from the Center for Medicare and Medicaid Services. If 0, then CMS data is not available.“Other Public”: Includes enrollment in federal and state programs not part of MedicaidSource: NADP 2013 Dental Benefits Report: Premium and Benefit Utilization Trends, Dec 2013 2014 National Association of Dental Plans, Inc.12700 Park Central Drive, Suite 400 Dallas, Texas 75251-1529 p 972.458.6998 f 972.458.2258 www.nadp.org

Texas Dental Benefits Fact SheetWorkforceNADP MembersPlan Types Offered by NADP MembersThe federal standard for an adequate supply of dentists is 3.332practicing dentists per 10,000 population.According to the American Dental Association 11,467 dentists areactively practicing in Texas or 4.4003648154550232 dentists per310,000 OSource: 2013 NADP/DDPA Joint Dental Benefits Report on Network Statistics15173014DiscountIndemnitySource: 2013 NADP Membership DirectoryWhere do Consumers Get Dental BenefitsWho Has Dental BenefitsEmployers Offering Dental Benefitsby Employer SizeConsumers with Dental Benefitsby Household Income compared toGeneral Population56%45%6 to 24 EEs25 to 50 EEs48%74%36%29%89%51 to 100 EEs93%101 to 499 EEs11% 10%97%500 to 999 EEs5%8%96%1,000 EEs 50K 50- 99K 100K- 149KPopulation with Dental BenefitsSource: 2013 NADP Purchaser Behavior Survey 150K U.S. PopulationSource: 2013 NADP Survey of ConsumersAboutThe National Association of Dental Plans (NADP), a nonprofit corporation with headquarters inDallas, Texas, is the “representative and recognized resource of the dental benefitsindustry.” NADP is the only national trade organization that includes the full spectrum of dentalbenefits companies operating in the United States. NADP’s members provide dental benefits toapproximately 90 percent of the 187 million Americans with dental benefits.23U.S. Department of Health and Human ServicesAmerican Dental Association 2014 National Association of Dental Plans, Inc.12700 Park Central Drive, Suite 400 Dallas, Texas 75251-1529 p 972.458.6998 f 972.458.2258 www.nadp.org

NADP MEMBERS & SUBSIDIARIESLast Updated: June 2014Advantage Dental PlanAetna DentalGroup Dental ServiceAltus Dental Ins CoDelta Dental of RIAmerican Dental Professional SvcsAmerican Dental PartnersAmerican Enterprise GroupMedco BenefitsAmeriPlan CorporationAmeritas Life Ins Corp.First Ameritas Life Ins Corp.Argus Dental Plan, Inc.Assurant Employee BenefitsDental Health Alliance, LLCDentCare, Inc. a Kentucky corporationDentiCare of Alabama, Inc.DentiCare of Oklahoma, Inc.DentiCare, Inc. a Florida corporationFirst Fortis Life Ins CoFortis Benefits DentalCare of New Jersey InFortis Benefits DentalCare of WI, Inc.Fortis Benefits Ins CoFortis Dental BenefitsGeorgia Dental Plan, Inc.UDC Life and Health Ins CoUnion Security Life Ins Co of NYUnited Dental Care Ins CoUnited Dental Care of Arizona, Inc.United Dental Care of Colorado, Inc.United Dental Care of Michigan, Inc.United Dental Care of Missouri, Inc.United Dental Care of NebraskaUnited Dental Care of New Mexico, Inc.United Dental Care of Ohio, Inc.United Dental Care of Pennsylvannia, Inc.United Dental Care of Texas, Inc.United Dental Care of Utah, Inc.United Dental Ins. CompanyAvesis Third Party Admin. Inc.Best Life and Health Ins CoBlue Cross Blue Shield of AZBlue Cross Blue Shield of MABlue Shield of ArkansasBlue Shield of HawaiiBlue Cross of FloridaFlorida Combined Life Ins CoUSAble LifeLife & Specialty VenturesBlue Cross Blue Shield of MIBlue Care NetworkBlue Care Network of East MIBlue Cross Blue Shield of NCBlue Cross Blue Shield of NEBlue Cross Blue Shield of SCBlue Shield of CACareFirst BlueCross BlueShieldThe Dental Network, Inc.CAREINGTON INTERNATIONALCBA, Inc.Blue Cross of VermontThe CDI GroupCigna Dental & Vision CareGreat West HealthcareCitizens Security Life Ins CoCompanion Life Ins CoDedicated Dental / InterdentDelta Dental of AZDelta Dental of CAAlpha Delta of ALAlpha Delta of AZAlpha Delta of NVDelta Dental Ins. Co.Delta Dental of DEDelta Dental of DCDelta Dental of MDDelta Dental of NYDelta Dental of PADelta Dental of PR & VIDelta Dental of WVDelta Dental of IADelta Dental of MI, OH, INDelta CareDelta Dental of ARDelta Dental of TNRenaissance Dental NetworkRenaissance Health Inc. Company of NYRenaissance Life & Health Ins. CompanyDelta Dental of MOAdvantica BenefitsDelta Dental of WADENCAP Dental PlansDental Care Plus Group Inc.Dental Health Svcs of AmericaCustom Benefit AdvisorsDBA‐Preferred AdministratorsDental Health Svcs (an Oregon corp)Dental Health Svcs, Inc.Dental Health Svcs, Inc. (Arizona corp)Dental Management SvcsDental Network SvcsDHS Ins Svcs IncNational Association of Dental Plans