How the Dental Plan works
The Dental Plan, administered by Aetna, includes preventive and diagnostic care, basic services, major services, and orthodontic treatment for eligible children.
How the plan works
The Dental Plan covers preventive and diagnostic care, basic services, and major services. Comprehensive orthodontic* treatment is covered for eligible children if they are under age 22 when treatment begins.
Depending on where you live, you have at least one of the following dental coverage options:
- PPO (preferred provider organization)
- DMO (dental maintenance organization)
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.
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.
*Limitations may apply for orthodontic work already in progress when you first become eligible for coverage. Call Aetna Member Services at 877-238-6200 for more information.
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. Even 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 are enrolled in the Passive PPO, the plan pays for services based on the higher level of network benefits.
DMO
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).
Summary of dental benefits
Below is an overview of dental deductibles, maximums, and benefits.
| Plan Feature | DMO | PPO: Network (including Passive PPO | 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 |
| Deductible | None | $50 | $100 |
| Family deductible | None | $100 | $200 |
|
Orthodontia | |||
| Orthodontia (children under age 22) | Yes | Yes | Yes |
| Orthodontia benefit** | 50% | 50% (after deductible) | 50% (after deductible) |
| Deductible | None | $50 | $100 |
| Lifetime maximum** | None | $2,000 | $1,000 |
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.
**Benefits are reduced when reimbursement has occurred for orthodontic work already in progress prior to coverage in these dental benefits.
Additional covered dental expenses
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.
- one additional prophylaxis (cleaning) per year
- scaling and root planing — per quadrant (four or more teeth)
- scaling and root planing — per quadrant
- full mouth debridement (limited to one to three teeth)
- periodontal maintenance (one additional treatment per year)
- localized delivery of antimicrobial agents (not covered for pregnancy)
Contact Aetna Member Services at 877-238-6200 for more information.
Network providers
Depending on where you're located, you may have access to one or both of these dental provider networks:
- preferred provider organization (PPO)/passive PPO
- dental maintenance organization (DMO)
The PPO offers the flexibility to visit out-of-network providers while the DMO costs less. (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).
If you have questions on how to view or calculate rates, contact the Board of Pensions at 800-773-7752 (800-PRESPLAN) (TTY: 711).
To locate network dentists, visit the Aetna website or call Aetna at 877-238-6200.