Dental PPO benefit summary FAQs

General/administration questions

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.

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 payer or the secondary payer.

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 payer 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.

ID cards – How/when will I receive my ID card for my PPO* plan?
You do not need a member ID card to get care with Aetna Dental. However, if you want one just print out a card by going to the secure member website at www.aetna.com.

Network Questions

Finding participating dentists – How do I find a dentist? 
Find a network dentist with our online directory. 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.

No computer? No problem! After you enroll, you can call customer service toll free for answers. Our experienced staff is ready to help!

Claim reimbursement – How will my claims be reimbursed?
If you visit a PPO participating dentist:
Participating dentists have agreed to offer certain services at a negotiated rate — so you generally pay less out of pocket for your care. 

• If your plan has a deductible (a dollar amount you must pay for covered expenses in a plan year), you must meet the deductible before your plan covers your eligible dental expenses. 
• After you meet your deductible, you will pay a coinsurance amount (a percentage of covered expenses) at the time of service. Read your Dental Benefits Summary to learn this amount. 
• Your dentist may submit your claims for you.

If you visit a nonparticipating dentist:
Nonparticipating dentists may bill you their normal fee for procedures. Your plan provides benefits for covered expenses at the established charge Aetna determines to be usual and prevailing for the service in that geographical area. When we determine the amount of a charge that is covered we may consider other factors, including the established charge in other areas. Aetna’s determination of the established charge does not suggest your dentist’s fee is not reasonable and proper. Your dentist may bill you for the difference between their normal fee and Aetna’s usual and prevailing fee. 

• Your plan may have a deductible. The deductible is the dollar amount you must pay before your plan covers your eligible dental expenses. 
• You may pay a coinsurance percentage or flat dollar amount. That means you’ll pay a percentage of covered expenses at the time of service. See your plan documents for specific amounts. 
• You or your dentist can submit a claim form for reimbursement.

Please note if you are enrolled in a PPO Max plan, your out-of-network benefits will be based on the in-network negotiated rate in the applicable geographic area. Please see your plan document or contact customer service for details on your specific plan.

Plan Design 

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 PPO plans may cover comprehensive orthodontic treatment of transitional, adolescent and adult teeth. Please contact Customer Service for details.

Prosthetic replacement rule – How often will my plan replace prosthetics? 
The Aetna dental plans do cover replacement prosthetics, 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 – Routine: 2 per year/Problem focused: 2 per year
• Fluoride treatment – 1 per year for children under age 16
• Bitewing X-rays – one set per calendar year
• Full mouth X-rays – one set every 3 rolling years
• Sealants – 1 per tooth every 3 rolling years under age 16; permanent molars only
• Scaling and root planing – 4 separate quadrants every 2 rolling years
• Periodontal maintenance – 2 per calendar year following active therapy
• Gingivectomy – 1 per quadrant or 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 8 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.

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. PPO plans require surgical and/or non surgical periodontal history.

Orthodontic/takeover and work-in-progress

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.

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 01/01/2012. A new ABC employee enrolls for dental coverage on 06/01/2014.

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 01/01/2013. The entire ABC Company terminates with XYZ dental on 12/31/2013 and begins coverage with Aetna dental on 01/01/2014.

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 

What can I do once I am enrolled in an Aetna plan? 
Find a dentist. Track a claim 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 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 can be accessed from Aetna.com.
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 discounts at no extra charge with Aetna Dental®?
Yes! As an Aetna Dental member, you get access to discounts on a variety of products 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.  

You can save on gym memberships, weight loss programs, eyeglasses, massage therapy, hearing aids and more. For more information and a complete listing of discounts available, visit Aetna.com.