How does the Aetna DMO® plan* work?
Choose a primary care dentist who participates in our network. Each covered family member can select his or her own.
- Depending on your plan, you may pay for dental care in one of two ways:
- Copay — You pay a set dollar amount
- Coinsurance — You pay a percentage of covered expenses
- There are no deductibles or annual dollar maximums.
- Your dentist usually will submit your claims for you.
I did not get an ID card. How will my dentist know I have coverage through Aetna Dental?
Aetna Dental members do not need a member ID card to get dental care. When you go to the dentist, tell the office staff that you have Aetna Dental and they will verify your coverage.
You can print out an ID card on your secure member website. Signing up is simple and free. With our free mobile app, you can access your account from your phone.
I'm enrolled in more than one dental plan. How does coverage work with two plans?
If your plan has a coordination of benefits provision, we confirm which plan has primary responsibility for claim payment. If we have primary responsibility, we pay as the primary payor. If not, we pay as the secondary payor.
The primary payor pays claims as it normally would, as if there were no secondary payor. The secondary plan acts like a supplement to the primary plan.
If you are enrolled in two dental plans, benefits are not additive. For example, if each plan covers two cleanings per year, you are not entitled to four cleanings per year.
Please note that there are several types of coordination of benefits provisions. They may differ by plan. If you need more information, please contact Member Services using the number on your ID card.
Do I have to select a Primary Care Dentist (PCD)?
Yes. The PCD has primary responsibility for managing your dental care. Each DMO member must select a PCD. You can switch your selection as frequently as once per month.
To change your PCD, log in to your secure member website, or call Member Services using the number on your ID card.
If you choose a new PCD on or before the 15th of the month, the change will go into effect on the first day of the following month. (For example, if you change your PCD on April 15, the change will take effect May 1.)
If you choose a new PCD on the 16th day of the month or later, the change will go into effect two months afterward. (For example, a change made on April 16 will take effect June 1.)
How do I find a dentist?
You can find a network dentist with our online directory. For personalized results, first log in to your secure member website. Search for a dentist by name, specialty, zip code or the number of miles you are willing to travel.
Can a pediatric dentist be a PCD?
Unless required by state law, a pediatric dentist is considered a specialist, not a PCD. So members cannot choose a pediatric dentist as their PCD.
Most PCDs treat children, and can refer members to a pediatric dentist if necessary.
Do I need a referral to see a specialist?
Referrals are not required for orthodontic treatment from a participating provider. For other specialists, the PCD will arrange a referral if it is necessary.
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.
How are the co-payments or coinsurance determined for each service?
Aetna has an arrangement with our DMO providers that sets what they can charge for covered services. What you pay will be based on either a percentage of those charges (coinsurance) or it will be a flat dollar amount (copay).
The DMO plan does not have any deductibles or annual maximums.
What can I do if I feel I am being overcharged by my dentist?
Please contact Member Services at the number on your ID card.
What if my PCD is not available and I need emergency care?
Your must contact us before treatment so we can authorize the use of a different provider.
Which dental services are covered?
Your Aetna Summary of Benefits describes the services that are covered under your plan. You can get a Summary of Benefits from the employer that is providing your insurance.
Are composite fillings (white fillings) covered?
Yes, but some plans may limit the benefit to certain teeth. Contact Member Services if you have questions.
Are there any restrictions in replacing my missing teeth?
If the teeth were lost or extracted before your coverage began, then services to replace them may not be covered by your plan. This applies to first-time dentures, fixed or removable bridges, and implants. For more details, contact Member Services or review your plan documents.
How often will my plan replace crowns, bridges, and other devices?
Please see your plan documents or contact Member Services for coverage details.
Are there any restrictions on how often a service can be performed?
Yes. Some services have this type of restriction. Please see your plan documents or contact Member Services for details.
Which orthodontia treatments are covered?
What will my Aetna plan cover if a service started before my effective date, but finishes after my Aetna coverage began?
If you were covered under a previous insurance carrier, certain services will be covered by that plan even after your Aetna coverage begins. This is called an extension of benefits provision. These services include:
- Crowns and fixed bridgework, when the teeth were prepared before your Aetna coverage began
- Appliances (such as dentures), when the impression was taken before your Aetna coverage began
- Root canal therapy, when the tooth's pulp chamber was opened before your Aetna coverage began
If you had no coverage and started treatment for a service, that service may not be covered under your Aetna plan. Contact Member Services to see if your plan has a work-in-progress exclusion.
If more than one service is needed to fix a problem, most services are considered separately.
How will I know if the treatment I need will be covered?
Have your dentist send a pretreatment estimate (predetermination) to us. This will let you and the dentist know what the benefit would be if the service were done. You or your dentist may also call Member Services at the number on your member ID card.
How will oral surgery be covered by my dental plan?
When is periodontal maintenance covered?
Periodontal maintenance is for patients who have previously been treated for periodontal disease. DMO plans require a surgical periodontal history.
Page last reviewed January 5, 2016
*Illinois Members: State laws vary with regard to out-of-network benefits. In Illinois, DMO plans provide limited out-of-network benefits. However, in order to receive maximum benefits, members must select and have care coordinated by a participating primary care dentist. Illinois DMO is not an HMO.
Virginia Members: In Virginia, DMO is called DNO (Dental Network Only). DNO (Dental Network Only) in Virginia is not an HMO. To receive maximum benefits, members must choose a participating primary care dentist to coordinate their care with in-network providers.