David: Welcome to Aetna FAQ Theatre, answering the most frequently asked questions people just like you have about Aetna’s dental insurance plans. I’m David, and this is Aetna’s Dental PPO*. We have a question here from… Bill.
Bill: Hi, David. Sorry if this is something I should know, but what’s a PPO?
David: No need to apologize, Bill, we get that one a lot. PPO stands for Preferred Provider Organization. And your next question is…
Bill: What’s a “preferred provider organization”?
David: Right. What that means is that this plan has a network of dentists- quality dentists, who have agreed to negotiated rates for Aetna’s members. A lot of dentists, actually—Aetna’s Dental PPO network includes over 215,000 available dental practice locations** and continues to grow.
Bill: So, I need to see one of those 215,000 dentists? What if my dentist isn’t in the network?
David: Actually, you don’t have to see one of the network dentists. The PPO works like this: there may be a deductible which you need to pay before your coverage kicks in, and then you pay a percentage of the total charges, called coinsurance- and that applies to any dentist you get care from. If your current dentist isn’t in the network, and you’d like to continue to see that dentist, you can. But, this is where the word “preferred” comes into play—if you go to a dentist in the network, the percentage you pay is based on the Aetna-member rates, meaning your final cost will typically be lower, and that lets you stretch your annual maximum even further.
Ellen: I need to pick the right dental plan for my whole family. Does the PPO cover pediatric dentists? You’d be surprised how effective the promise of stickers and bubblegum-flavored fluoride treatments can be in getting my husband to go to the dentist.
David: Well, yes. With the PPO, every member of the family can go to whichever dentist they prefer. And, if you’d like to find a new dentist, you can go to Aetna.com and use the DocFind tool to see all the network dentists in your area—general dentists, specialists, orthodontists… even pediatric dentists.
Gary: I have a cousin who thinks he’s a dentist. He’s a little strange, but he does give a good cleaning, and his rates are reasonable. Will the PPO cover what he charges me?
David: Umm, probably not. You do need to see a licensed dentist. The good news is that preventative care—like cleanings and x-rays—is almost always covered 100%. So, cancel the appointment with your cousin, and see an actual dentist.
Kevin: I have a few teeth I’ve been meaning to get checked out. Is it a bad sign if one of your teeth is making a fizzing noise?
David: Almost definitely. You’ll be glad to hear that the PPO includes coverage for basic care, like fillings, and major care, like root canals and crowns. And, if you need to see a specialist… and I think you may need to… you can see any one you’d like, without a referral.
Kevin: Ohp! Another one has started to fizz!
David: You need to see a dentist immediately. Now. Just go.
Angela: I’m really too busy to actually go see a dentist. Isn’t there any way we can do this on-line? Maybe I could take some pictures of my teeth with my phone, e-mail them to the dentist to examine?
David: Interesting idea, but the technology isn’t quite there yet. There is a lot you can do at Aetna.com, though, beyond finding a new dentist. You can get cost estimates, check on a claim, request replacement ID cards, email customer service and more. You can even do all of this with Aetna’s Mobile App for your smartphone, or by visiting Aetna.com on your web-enabled phone. These tools are just one way Aetna’s bringing innovation to you. There’s even more great info at simplestepsdental.com.
Ryan: Is there somewhere I can find all the benefits of the PPO in a nice neat list?
David: Why, certainly- I have that right here. The PPO gives you the flexibility to see any dentist you’d like, your costs are typically lower if you see one of our network dentists (and with a network as large as Aetna’s, you shouldn’t have any trouble finding one in most locations), you get 24/7 access to plan info at Aetna.com, and a whole lot more.
I’m David, and that’s the FAQ on Aetna’s Dental PPO. Thanks for watching.
* In Texas, the Preferred Provider Organization (PPO) plan is known as the Participating Dental Network (PDN).
** These facts are as of December 2013 based on Aetna provider data.
Exclusions and Limitations
Some services not covered are:
1. Services or supplies that are covered in whole or in part:
a) under any other part of this Dental Care Plan; or
b) under any other plan of group benefits provided by or through your employer.
2. Services and supplies to diagnose or treat a disease or injury that is not:
a) a non-occupational disease; or
b) a non-occupational injury.
3. Services not listed in the Dental Care Schedule that applies, unless otherwise specified in the Booklet-Certificate.
4. Those for replacement of a lost, missing or stolen appliance, and those for replacement of appliances that have been damaged due to abuse, misuse or neglect.
5. Those for plastic, reconstructive or cosmetic surgery, or other dental services or supplies, that are primarily intended to improve, alter or enhance appearance. This applies whether or not the services and supplies are for psychological or emotional reasons. Facings on molar crowns and pontics will always be considered cosmetic.
6. Those for or in connection with services, procedures, drugs or other supplies that are determined by Aetna to be experimental or still under clinical investigation by health professionals.
7. Those for dentures, crowns, inlays, onlays, bridgework, or other appliances or services used for the purpose of splinting, to alter vertical dimension, to restore occlusion, or to correct attrition, abrasion or erosion.
8. Those for any of the following services:
a) An appliance or modification of one if an impression for it was made before the person became a covered person;
b) A crown, bridge, or cast or processed restoration if a tooth was prepared for it before the person became a covered person;
c) Root canal therapy if the pulp chamber for it was opened before the person became a covered person.
9. Services that Aetna defines as not necessary for the diagnosis, care or treatment of the condition involved. This applies even if they are prescribed, recommended or approved by the attending physician or dentist.
10. Those for services intended for treatment of any jaw joint disorder, unless otherwise specified in the Booklet-Certificate.
11. Those for space maintainers, except when needed to preserve space resulting from the premature loss of deciduous teeth.
12. Those for orthodontic treatment, unless otherwise specified in the Booklet-Certificate.
13. Those for general anesthesia and intravenous sedation, unless specifically covered. For plans that cover these services, they will not be eligible for benefits unless done in conjunction with another necessary covered service.
14. Those for treatment by other than a dentist, except that scaling or cleaning of teeth and topical application of fluoride may be done by a licensed dental hygienist. In this case, the treatment must be given under the supervision and guidance of a dentist.
15. Those in connection with a service given to a dependent age 5 or older if that dependent becomes a covered dependent other than:
a) during the first 31 days the dependent is eligible for this coverage, or
b) as prescribed for any period of open enrollment agreed to by the employer and Aetna. This does not apply to charges incurred:
i. after the end of the 12-month period starting on the date the dependent became a covered dependent; or
ii. as a result of accidental injuries sustained while the dependent was a covered dependent; or
iii. for a primary care service in the Dental Care Schedule that applies as shown under the headings Visits and Exams, and X-rays and Pathology.
16. Services given by a nonparticipating dental provider to the extent that the charges exceed the amount payable for the services shown in the Dental Care Schedule that applies.
17. Those for a crown, cast or processed restoration unless:
a) It is treatment for decay or traumatic injury and teeth cannot be restored with a filling material; or
b) The tooth is an abutment to a covered partial denture or fixed bridge.
18. Those for pontics, crowns, cast or processed restorations made with high-noble metals, unless otherwise specified in the Booklet-Certificate.
19. Those for surgical removal of impacted wisdom teeth only for orthodontic reasons, unless otherwise specified in the Booklet-Certificate.
20. Services needed solely in connection with non-covered services.
21. Services done where there is no evidence of pathology, dysfunction or disease other than covered preventive services.
Dental PPO insurance plans are underwritten and/or administered by Aetna Life Insurance Company (Aetna).
If you require language assistance from an Aetna representative, please call the Member Services number located on your ID card, and you will be connected with the language line if needed; or you may dial direct at 1-888-982-3862. (140 languages are available. You must ask for an interpreter.) TDD 1-800-628-3323 (hearing impaired only).
Si requiere la asistencia de un representante de Aetna que hable su idioma, por favor llame al número de Servicios al Miembro que aparece en su tarjeta de identifi cación y se le comunicará con la línea de idiomas si es necesario; de lo contrario, puede llamar directamente al 1-888-982-3862. (140 idiomas disponibles. Debe pedir un intérprete.)
TDD-1-800-628-3323 (sólo para las personas con impedimentos auditivos).
This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benef ts vary by location. Dental insurance plans contain exclusions and limitations. Dental information programs provide general dental information and are not a substitute for diagnosis or treatment by a dentist or other dental care professional. Dental providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to dental services. Not all dental services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and/or group size and are subject to change. For self-funded accounts, benefits coverage is offered by your employer, with administrative services only provided by Aetna Life Insurance Company. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com.
Policy forms issued in OK include: GR-9/GR-9N. GR-23 and/or GR-29/GR-29N
© 2014 Aetna Inc.
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