Dental / Aetna
The Plan offers two different dental programs, both administered by Aetna Dental.
Dental Maintenance Organization (DMO)
The Aetna DMO provides an unlimited annual benefit for you and each of your eligible dependents; however, you MUST use only DMO network providers. You need to select a dentist from the list of Aetna DMO providers and, if you require treatment from a dental specialist, you must get a referral from your primary dentist. If you seek treatment from a dental provider who is not in the Aetna DMO network, unless approved in advance by Aetna, no benefit will be paid.
Dental Preferred Provider Organization (PPO)
The Aetna PPO provides a $5,500 annual benefit for you and for each of your eligible dependents. Plus, you have the ability to increase your annual benefit maximum by $500/year for up to 3 years, for a total annual benefit maximum of $7,000. Just have a preventive service completed in a given year and earn an additional $500 towards your maximum for the following year. The PPO provides the flexibility of using providers who are in the PPO network and out of the PPO network. But if you use a dentist who is part of the PPO network, you will save money. Participating dentists (dentists who are in the Aetna PPO network) have agreed to a negotiated fee with Aetna and cannot bill you for amounts above this “allowed amount.” Your out of pocket expenses are any differences between what Aetna allows and the percentage that Aetna pays, as summarized on the chart below, and any amounts that exceed the annual maximum. When you use non-participating dentists (dentists who are not in the Aetna network), dental payments are based on Aetna’s allowed amount. If your non-participating dentist charges more than the allowed amount you can be billed the difference between what Aetna paid and what the dentist charged.
You must enroll in one of the dental plans before you and your eligible dependents can be covered for dental benefits. You can change from one dental plan to the other only during the Plan’s annual open enrollment period. To find a participating PPO or DMO dentist, call Aetna at 1-877-238-6200 or visit their website at www.aetna.com
Summary Of Dental Benefits
| In-network | PPO | Out of network* | OMO | ||
|---|---|---|---|---|---|
| Annual Deductible | |||||
| Individual | None | None | None | ||
| Family | None | None | None | ||
| Preventive Services | 100% | 100% | 100% | ||
| Basic Services | 100% | 100% | 100% | ||
| Major Services | 100% | 100% | 100% | ||
| Dental Implants | 100% | 100% | Not Covered | ||
| Annual Benefit Maximum.. | $5,500 | None | |||
| Office Visit Copay | N/A | N/A | $0 | ||
| Orthodontic Services | 100% | 100% | 100% | ||
| Orthodontic Deductible | None | None | None | ||
| Orthodontic Lifetime Maximum.. | $4,000 | $4,000 | None | ||
* out of Network services reimbursed at % of allowed charge. Out of network providers may bill you for the difference between amount charged and amount paid by Aetna.
.. Annual and Lifetime Maximums are total of in-network and out-of-network treatment combined
For more information on your Dental program
- Link – www.aetna.com
- 1-877-238-6200
FAQ – Dental
Do we have more than 1 Dental Plan?
Local 22’s Health Plan offers a Dental PPO and a DMO plan both under AETNA.
Do I have to pick a dentist?
The Aetna DMO provides an unlimited annual benefit for you and each of your eligible dependents; however, you MUST use only DMO network providers. You need to select a dentist from the list of Aetna DMO providers and, if you require treatment from a dental specialist, you must get a referral from your primary dentist. If you seek treatment from a dental provider who is not in the Aetna DMO network, unless approved in advance by Aetna, no benefit will be paid.
The Dental PPO allows you to go to any AETNA in-network dentist or out of network providers. In-network dentist will save you money. Participating dentists (dentists who are in the Aetna PPO network) have agreed to a negotiated fee with Aetna and cannot bill you for amounts above the “allowed network negotiated amount.”
Are there any monetary limits on my dental benefits?
There are no monetary limits on covered benefits for the DMO dental plan.
The Dental PPO has a $5,500 per patient annual monetary limit on covered benefits with a lifetime monetary limit on covered Orthodontic benefits of $4,000 per patient. Plus, you can increase your annual benefit maximum by $500/year for up to 3 years, for a total annual benefit maximum of $7,000. Just have a preventive service completed in each year and earn an additional $500 towards your maximum for the following year.
Is my dentist required to pre-authorize dental work?
No – It is the members responsibility to ensure the dentist gets the pre-authorization for payment from AETNA prior to getting dental work done. The member could be financially responsible for any dental work performed that is not covered and/or pre-authorized.
