Dental Coverage
Healthy teeth and gums are essential to your overall health. Often, your oral health can be an indicator for other issues you may be facing. Our dental plan, administered by Delta Dental® of Massachusetts, is designed to help you maintain good dental hygiene. There are two dental plans to choose from:
Each option includes a $50 individual/$150 family deductible. Once you pay the deductible, the plan begins sharing in the cost of eligible expenses. The deductible is waived for diagnostic and preventive services.
|
Core Plan |
Consumer Choice Plan |
|||||
|---|---|---|---|---|---|---|
|
Category / |
Qualifications |
In-Network |
Out-of-Network1 |
In-Network |
Out-of-Network1 |
|
|
Annual Deductible The amount you must pay each year before the plan begins paying benefits. |
||||||
|
Individual |
$50 |
$50 |
||||
|
Family |
$150 |
$150 |
||||
|
Calendar Year Maximum The maximum amount the plan will pay each year. |
$2,000 |
$1,000 |
||||
|
Diagnostic |
Comprehensive evaluation |
Once every 60 months |
Covered in full |
Covered in full |
||
|
Periodic oral exam |
Twice per calendar year |
Covered in full |
Covered in full |
|||
|
Panoramic or full-mouth X-rays |
Once every 60 months |
Covered in full |
Covered in full |
|||
|
Bitewing X-rays |
Two bitewing X-rays to age 10 and 4 bitewing X-rays age 10 and above per calendar year |
Covered in full |
Covered in full |
|||
|
Single tooth X-rays |
As needed |
Covered in full |
Covered in full |
|||
|
Preventive |
Teeth cleaning |
Twice per calendar year |
Covered in full |
Covered in full |
||
|
Fluoride treatments |
Twice per calendar year for members under age 19 |
Covered in full |
Covered in full |
|||
|
Space maintainers |
Required due to the premature loss of teeth; for members under age 14 and not for the replacement of primary or permanent anterior teeth |
Covered in full |
Covered in full |
|||
|
Sealants |
Unrestored permanent molars, every four years per tooth for members through age 15; sealants also covered for members age 16 up to age 19 with a recent cavity and are at risk for decay |
Covered in full |
Covered in full |
|||
|
Periodontal cleaning |
Four times per calendar year following active periodontal therapy (scaling and root planing or osseus surgery); not to be combined with preventive cleanings |
Covered in full |
Covered in full |
|||
|
Restorative |
Silver fillings |
Once every 24 months per surface per tooth |
20% |
50% |
||
|
White fillings |
Once every 24 months per surface per tooth |
20% |
50% |
|||
|
Protective restorations |
Once per tooth |
20% |
50% |
|||
|
Stainless steel crowns |
Once every 24 months per tooth (on primary teeth only) |
20% |
50% |
|||
|
Oral Surgery |
Extractions |
Once per tooth |
20% |
50% |
||
|
General anesthesia |
General anesthesia and IV sedation allowed with covered surgical impacted teeth only (up to one hour) |
20% |
50% |
|||
|
Periodontics (on natural teeth only) |
Periodontal surgery |
One surgical procedure per quadrant in 36 months |
20% |
50% |
||
|
Scaling and root planing |
Once in 24 months, per quadrant; no more than two quadrants per date of service |
20% |
50% |
|||
|
Bone grafts/GTR |
No more than two teeth per quadrant per 36 months on natural teeth |
20% |
50% |
|||
|
Endodontics |
Root canal treatment |
Once per tooth |
20% |
50% |
||
|
Root canal retreatment |
Once per tooth after 24 months have elapsed from initial treatment |
20% |
50% |
|||
|
Vital pulpotomy |
Limited to deciduous teeth |
20% |
50% |
|||
|
Prosthetic Maintenance |
Bridge or denture repair |
Once per bridge/denture per 12 months, after 24 months of initial insertion |
20% |
50% |
||
|
Crown or onlay repair |
Once per tooth per 12 months, after 24 months of initial placement |
20% |
50% |
|||
|
Rebase or reline dentures |
Once per denture within 36 months |
20% |
50% |
|||
|
Replacement of crowns, onlays, bridges |
Once per crown, onlay or bridge |
20% |
50% |
|||
|
Emergency Dental Care |
Palliative treatment |
Three occurrences in 12 months |
20% |
50% |
||
|
Prosthodontics |
Dentures |
Once within 60 months (age 16 and older) |
50% |
50% |
||
|
Fixed bridges |
Once within 60 months (age 16 and older) |
50% |
50% |
|||
|
Implants |
Once per 60 months per implant (pre-estimate recommended) |
50% |
50% |
|||
|
Implant abutments |
Once per implant only when surgical implant is benefitted |
50% |
50% |
|||
|
Major Restorative |
Crowns, jackets labial veneers, inlays, onlays |
When teeth cannot be restored with regular fillings; once within 60 months per tooth (age 12 and older) |
50% |
50% |
||
|
Cast posts/buildups |
Once per tooth per 60 months only benefitted to retain a crown |
50% |
50% |
|||
|
Orthodontics |
Covered at 50% of maximum plan allowance charges, up to any age. Orthodontic treatment must be administered/supervised by a licensed dentist. |
Plan pays 50% up to $2,000 per person/lifetime maximum |
Plan pays 50% up to $1,000 per person/lifetime maximum |
|||
1 Non-participating dentists may balance bill. Subscribers are responsible for the difference between the non-participating maximum plan allowance and the full fee charged by the dentist.
Note
Rollover Max rewards good dental habits by allowing you to roll over unused dental benefits from the previous year. Rollover Max is available with both dental plans:
To qualify for Rollover Max, you must have had at least one cleaning or oral exam within the past year. Also, you must be enrolled in dental coverage before the fourth quarter of the calendar year. Rollover Max dollars do not apply to orthodontic services. The accumulated Rollover Max is capped at $1,500 (total calendar-year maximum benefit is capped at $3,500 for the Core Plan and $2,500 for the Consumer Choice Plan). Refer to the Rollover Max Brochure for more information.
As a Delta Dental PPO Plus Premier subscriber, you have access to two of Dental Dental’s extensive national networks:
Three out of four dentists, nationwide, participate in one or both networks.
Why Receive Care from a Network Dentist?
You’ll receive discounted fees and a no balance billing policy, and you’ll take advantage of even more savings when you visit a Delta Dental PPO network dentist. Visit www.deltadentalma.com to find a network dentist.
If you choose to receive services from a non-participating dentist, you will have higher out-of-pocket costs. The Delta Dental contract rates and the no-balance billing policy do not apply. In some cases, the provider may submit a claim directly on your behalf, and then send you a bill for the balance (“balance billing”) that may not be fully reimbursed by the plan.
You and the Company share the cost for dental coverage, with the Company paying the majority.
The rates below show the cost you will pay for dental coverage per bi-weekly pay period.
|
Coverage Level |
Dental Core Plan |
Dental Consumer Choice Plan |
|---|---|---|
|
Employee Only |
$8.70 |
$1.29 |
|
Employee + Spouse/Domestic Partner |
$19.14 |
$2.84 |
|
Employee + Child(ren) |
$15.66 |
$2.33 |
|
Employee + Family |
$26.10 |
$3.87 |
When you enroll in a Delta Dental plan, you have access to additional benefits:
Electric Toothbrush Discount
Keeping your teeth clean is easier—and less expensive—than ever.
As a member of Delta Dental, you can take advantage of significant discounts on two kinds of Z Sonic toothbrushes, as well as replacement heads.
How to Order
Online
By Phone
Discounts:
You also can receive discounts on Amplifon hearing aids. Contact Delta Dental for details.
Delta Dental of Massachusetts is an Independent Licensee of the Delta Dental Plans Association. ®Registered Marks of the Delta Dental Plans Association. Delta Dental of Massachusetts and Z Sonic are independent, unaffiliated companies.
The plan is not insurance coverage and does not meet the minimum creditable coverage requirements under the Affordable Care Act or Massachusetts M.G.L. c. 111M and 956 CMR 5.00.
If you enroll in the dental plan, virtual visits are available 24/7 using your smartphone, tablet, or computer. Virtual visits let you receive convenient dental care when your dentist isn’t available. For example, if you have an urgent dental concern or emergency and it’s after hours, or you need to consult with a dentist while traveling.
Delta Dental has partnered with TeleDentistry.com to provide virtual visits. Here’s how it works:
TeleDentistry.com dentists diagnose the problem and provide treatment options. You will be referred to a Delta Dental dentist for follow-up care.
This service supplements Delta Dental’s regular plan coverage and should be used after business hours, on holidays, over weekends, or when your regular dentist is otherwise unavailable.