Dental Maintenance Organization (DMO) FAQs

General/administration questions                                                                                  

How does the Aetna Dental Maintenance Organization (DMO) work?
Choose a primary care dentist who participates in our network. Each covered family member can select his or her own.

• Show your member ID card when you visit your dentist for covered services.
• Depending on your plan, you may pay for dental care in one of two ways:
  • Copay — You pay a set dollar amount at the time of service, or
  • Coinsurance — You pay a percentage of covered expenses at the time of service
• There are no deductibles or annual dollar maximums.
• Typically your dentist will submit your claims for you.

Eligibility – How will my primary care dentist (PCD) know I am an eligible dental plan member? 
A Primary Care Dentist has many ways to verify member eligibility: paper rosters; visiting our secure dentist website or by calling our self-service line (Aetna Voice Advantage).

Eligibility – How do you receive my eligibility information?
Aetna receives your secure eligibility information from your employer. It is sent in through paper enrollment forms or by an electronic file. Your employer determines your coverage effective date or termination date of coverage based on their benefit eligibility guidelines.

ID cards – Do I get a DMO® member ID card? If so, when will I receive it?
You should receive an ID card approximately 7-10 days after you have enrolled. DMO® members must select a primary dentist in order to receive an ID card.

Enrolled in more than one dental plan – How does Aetna coordinate benefits?
Coordination of Benefits applies when you have more than one dental plan. Aetna will coordinate benefits with other dental plans. There is a verification process to confirm who has primary responsibility for claim payment. Once this is confirmed, Aetna will consider claims accordingly and either pays as the primary payor or the secondary payor.

For example: Your spouse is offered coverage through his/her employer and is covered by both your Aetna plan and his/her employer plan. According to most plans’ Coordination of Benefits rules, your spouse's employer’s coverage would be considered primary for him/her. As a result, your Aetna plan would be considered the secondary payor for your spouse.

Please note that there are several types of coordination of benefits provisions that may differ by plan. Please contact customer service for more information regarding your plan. 
 
Network questions 

Primary Care Dentist requirement – Does a DMO® member have to select a Primary Care Dentist (PCD)? 
Yes. The PCD has primary responsibility for managing the patient’s dental care. Each member must select a PCD and can change their PCD at anytime. Members can switch their PCD on the Aetna Navigator website at www.aetna.com, or by calling customer service on the back of your ID card.

Finding participating dentists – How do I find a dentist? 
You can find a network dentist on our DocFind® online directory, in Aetna Navigator (if enrolled) or by calling customer service. Search for a dentist by name, specialty, zip code or miles you are willing to travel. You can search by city and state, or county and state. You’ll even find maps and directions to your dentist’s office.

Changing Primary Care Dentists – Can a member switch their Primary Care Dentist (PCD), and when will the switch take effect?
Members can switch their PCD on the Aetna Navigator website, or by calling customer service. In order for the switch to be effective on the first day of the next month, the switch must be requested by the 15th day of the current month. Members can switch their PCD every month.

Pediatric dentists – Can a pediatric dentist be a Primary Care Dentist (PCD)?
Unless required by state law, a pediatric dentist is considered a specialist and not a PCD. Members cannot sign-up with a pediatric dentist as their PCD.  Most PCD’s treat children.  Aetna has protocols for referrals to a pediatric dentist by a PCD.

Referrals – Do I need a referral to see a specialist?
The Primary Care Dentist (PCD) is responsible for determining the appropriate course of treatment. If necessary, they will arrange the referral to a specialist. Referrals are not required for orthodontic treatment provided by a participating provider.

Dentist reimbursement – How do dentists get reimbursed under the DMO®? 
Dentist's reimbursement is a combination of what Aetna pays the dentist and the member’s copay/coinsurance amount.

Co-payment – How are the co-payments determined for each service?
Aetna does have an agreed arrangement with all Aetna DMO providers on the amount they can
charge for covered services. Your co-payment will be based on either a percentage or a flat dollar amount.

The Aetna DMO plan does not have any deductibles or annual maximums.

Dentist Fee – What can I do if I feel I am being overcharged by my dentist?
Please contact Aetna customer service to go over your treatment plan and discuss your options.

Emergency Care – What if the Primary Care Dentist (PCD)  is not available and can’t treat me or I need emergency care?
In the event of an emergency and the PCD is unable to see or treat a patient, the member must contact Aetna prior to being seen by another provider for authorization of palliative/emergency treatment.

Plan design

Covered Services – Are all dental services covered by the Aetna DMO plan?
The plan allows coverage for covered dental expenses and services. Your Aetna Summary of Benefits will describe the services that are covered under your plan and this Summary of Benefits is available through your Benefits Department. The plan allows coverage according to your summary of benefits.

Composite filling (white filling) – Are they covered? 
Aetna’s plans do cover composite fillings. However, some plans may restrict this benefit depending on the location of tooth. For more detailed information contact customer service.

Missing-tooth exclusion – Are there any restrictions in replacing my missing teeth? 
The "Tooth Missing But Not Replaced” rule applies to initial dentures, fixed/removable bridgework and implants that replace teeth missing, lost, or extracted before the effective date of coverage. Services subject to the "Tooth Missing But Not Replaced" rule may not be covered by your plan. Please see your plan booklet for specifics.

Orthodontia – Which orthodontia treatments are covered?
Aetna DMO® plans may cover comprehensive orthodontic treatment of adolescent and adult teeth. Please see your plan booklet for information on orthodontic coverage under your plan or contact customer service for details.

Prosthetic replacement rule – How often will my plan replace prosthetics?
The Aetna dental plans do cover replacement prosthetics, once every 5 years, subject to plan limitations or exclusions. Please see your plan document or contact customer service for details.

Services started before your effective date – What will the Aetna plan cover if a service started before my effective date?

• If you were covered under a previous carrier and started treatment for the following services while you were still eligible under that plan, the extension of benefits provision under your earlier plan should consider the service:
  • crowns and fixed bridgework when the teeth were prepared before the effective date of this plan
  • appliances, when the impression was taken before the effective date of this plan
  • root canal therapy, when the pulp chamber was opened before the effective date of this plan
• If you were not covered under a previous carrier and started treatment for a service, it may not be considered eligible under this plan if your plan has a work-in-progress exclusion.

If more than one service is needed to fix a problem, most services would be considered separately. Although services started before the start date of coverage may be denied, any services started after the effective date would be considered for benefits.

Frequency limitations – Are there restrictions to how often a service can be performed?
Yes, there are certain services under your plan that will have a frequency limitation. As an example, standard plans include frequency limitations for the following procedures:

• Cleanings – 2 per calendar year
• Exams – 4 exams total (any type) per calendar year
• Fluoride treatment – 1 application per calendar year for children under age 16
• Bitewing X-rays – 1 set per calendar year
• Full mouth X-rays – 1 set every 3 rolling years
• Sealants – 1 per tooth every 3 rolling years under age 16; permanent molars only
• Scaling and root planning – 4 separate quadrants every 3 rolling years
• Periodontal maintenance – 2 per calendar year following surgical therapy
• Gingivectomy – 1 per quadrant or per site every 3 rolling years
• Osseous surgery – 1 per quadrant every 3 rolling years
• Space maintainers – no age limit (covered for premature loss of primary teeth only)
• Denture, crown, inlays & onlays replacement – must be at least 5 years old

Please see your plan document or contact customer service for details.

Predetermination – How will I know if the treatment I need will be covered?
The easiest way is to have your dentist send a pretreatment estimate (predetermination).
This will let both you and the dentist know what the benefit would be if the service were done.
You and your dentist may also call customer service at the number on your ID card for general information about your dental coverage.

Oral surgery – How will oral surgery services be covered by my dental plan? 
Oral surgery maybe consider under your Aetna medical or Aetna dental plan. Please send Aetna a predetermination or contact customer service for benefit information.

For more information on oral surgery, please visit www.aetnadental.com – Understanding Aetna Oral Surgery Benefits.
 
Periodontal maintenance – When is periodontal maintenance covered?
This procedure is for patients who have previously been treated for periodontal disease.  DMO® plans require surgical periodontal history.

Orthodontic/takeover and work-in-progress questions

Continuing or starting orthodontic treatment – What do I need to know? 
If you or an eligible family member is enrolled in active orthodontic treatment or considering treatment, we want you and your orthodontist to have a positive experience when you transition or begin your orthodontic treatment with Aetna.

Please include all of the following information with your first paper or electronic claims submission. This will help us make a benefit determination quickly and should eliminate the need for additional claims submissions.

• Banding date
• Number of months of treatment
• Assignment information
• ADA code
• Total case fee
• Primary insurance provider explanation of benefits (if coordination of benefits is necessary)
• Previous insurance provider information, including deductible, coinsurance/copay, maximum and amount paid to date (if patient is continuing active treatment). This will help us determine your available orthodontic benefit.

Please note that you do not have to change your orthodontist if you began treatment before your Aetna effective date. For member eligibility questions, call the customer service number on the member’s ID card.

Takeover and work in progress – What is this and how will it impact my orthodontic benefits?
Work in progress: This is a situation in which an individual member who was not previously active with the plan sponsor begins coverage with an Aetna plan.

Example: Plan sponsor ABC has Aetna dental coverage effective 01/01/2008. A new ABC employee enrolls for dental coverage on 06/01/2010.

If your plan includes the work-in-progress exclusion, orthodontic treatment will not be eligible for coverage. Please see your plan document or contact customer service for details.

Takeover: This means a situation in which a plan sponsor previously had dental coverage through another carrier and provided coverage for the service. The plan sponsor terminates coverage with the previous carrier and begins coverage with Aetna. This only includes individuals who were covered under the prior plan at the time of the takeover.

Example: Plan sponsor ABC has XYZ dental coverage effective 01/01/2008. The entire ABC Company terminates with XYZ dental on 12/31/2008 and begins coverage with Aetna dental on 01/01/2009.

In orthodontic takeover situations, the treatment is only eligible for consideration under Aetna if the previous dental carrier covered and considered the member’s orthodontic treatment plan.

Self-service tools questions 

What can I do once I am enrolled in an Aetna plan? 
Find a dentist. Track a claim. Replace your ID card and more. It’s easy with our Aetna Navigator® secure member website that is available 24 hours a day, 7 days a week. You can:

• Find a network dentist on our DocFind® online directory. Search for a dentist by name, specialty, zip code or miles. You can do it by city and state, or county and state. You’ll even find maps and directions to your dentist’s office.
• Get estimated average costs for cleanings, fillings, X-rays, dentures and more.
• See who’s covered by your plan.
• Check claims and statements.
• Send customer service an e-mail.

Aetna Navigator is located right on the Aetna home page. No computer? No problem! After you enroll, you can call customer service toll free for answers. Our experienced staff is ready to help!
Visit our dental website Simple Steps To Better Dental Health for articles and facts on over 50 dental conditions and treatments.

Do I have access to other discount programs at no extra charge with Aetna Dental®? 
Yes! As an Aetna Dental member, you get access to discount programs* and services at no additional charge. They’ll help support your healthy lifestyle — and provide on-the-spot savings. These savings are part of a discount program, not insurance. For more information and a complete listing of discounts available, visit Aetna.com.

• Aetna Vision^SM discounts
• GlobalFit^TM 
• HearPO® provided by Aetna Hearing^SM discounts
• Aetna Natural Products and Services^SM 
• Waterpik discounts
• EPIC discounts

*In Illinois, the following discount arrangements may not be available: Aetna Vision^SM discounts, Aetna Hearing^SM discounts and/or Aetna Natural Products and Services program.