Dental coverage, administered by Aetna, includes preventive and diagnostic care, basic services, major services, and orthodontic treatment for eligible children.
The Dental Plan covers preventive and diagnostic care, basic services, and major services. Comprehensive orthodontic treatment is covered for eligible children if you have been enrolled continuously in the plan for a year and children are under age 20 when treatment begins.
Depending on where you live, you have at least one of the following dental coverage options:
All preventive and diagnostic services, such as routine checkups, cleanings, and bitewing X-rays, are 100 percent covered, regardless of whether coverage is through the DMO, PPO, or Passive PPO.
The PPO gives you the option to receive care from any licensed dentist. After you pay the deductible, the plan pays a percentage of covered expenses up to the annual or benefit maximum. Though you have the option to see any dentist, network dentists have agreed to provide services for lower, negotiated fees, and the plan pays more for covered services when you use network providers. So, your out-of-pocket costs are lower when you use network providers; network dentists will also generally submit claims for you.
If you live in an area without adequate network access, you will be able to enroll in the Passive PPO, which pays for services based on the higher level of network benefits.
The DMO (a dental HMO) offers benefits for services provided by a primary care dentist selected from the network of participating DMO dentists. You do not pay deductibles and there is no annual benefit maximum. However, care must be provided or referred by your primary dentist to be covered (except in the event of a dental emergency). You and each covered family member must choose a primary care dentist and provide the appropriate office number as part of the enrollment process (you and your covered family members do not have to select the same primary care dentist, and you may change those selections at any time).
Below is an overview of dental deductibles, maximums, and benefits.
|Plan Feature||DMO|| PPO:|
(including Passive PPO
Out of Network*
|Preventive and diagnostic services, such as routine checkups, cleanings, and bitewing X-rays||100%||100% (no deductible)||100% (no deductible)|
|Basic services, such as fillings and simple extractions||100%||80% (after deductible)||70% (after deductible)|
|Major services, such as bridges, crowns, and dentures||60%||60% (after deductible)||40% (after deductible)|
|Annual plan maximum (per individual)||None||$2,000||$1,000|
|Orthodontia (children only)||Yes||Yes||Yes|
|Orthodontia benefit||50%||50% (after deductible)||50% (after deductible)|
Frequency limits may apply for some services; see the Dental Benefits summaries on pensions.org.
*For the PPO, out-of-network services are paid subject to reasonable and customary charges; any balance due is your responsibility. In the DMO, out-of-network services are not covered.
The following additional dental expenses will be considered covered expenses for you and your covered family members if you have medical coverage through the Board of Pensions and you (or your covered family member) have at least one of the following conditions: pregnancy; coronary artery disease/cardiovascular disease; cerebrovascular disease; or diabetes.
Contact Aetna Member Services at 877-238-6200 for more information.
Depending on where you're located, you may have access to one or both of these dental provider networks:
The DMO costs less, while the PPO offers the flexibility to visit out-of-network providers. (The Passive PPO is offered to participants in areas without reasonable access to PPO providers; if enrolled in the Passive PPO, your benefits are not reduced if you use an out-of-network provider.)
If you enroll in the DMO, all your dental care must be provided or referred by your primary care dentist to be covered (except in the case of a dental emergency).
Insert your ZIP code into the Dental Benefit Rate Checker to determine dental options available in your area.
To locate network dentists, visit the Aetna website or call Aetna at 877-238-6200.