Dental Insurance

Features Of The Regular And PPO Dental Options

SOME IMPORTANT FEATURES OF THE REGULAR AND PPO DENTAL OPTIONS  |   PRE-DETERMINATION OF BENEFITS  |   SOME EXCLUSIONS FOR REGULAR AND PPO DENTAL OPTIONS  |   EXAMPLE OF REGULAR AND PPO BENEFIT PAYMENTS

SOME IMPORTANT FEATURES OF THE REGULAR AND PPO DENTAL OPTIONS

There are some features to keep in mind when you use the dental options, Regular or PPO.

• The options of the State Health Benefit Plan (PPO, Indemnity, and HMO) provide limited, if any, coverage for dental treatment. See your SPD, UPDATERs and Health Plan Decision Guide for more information. For more detailed HMO information, contact the HMO directly.
  
  
• The PPO dentists have agreed to provide quality services at reduced rates. This means you save money if you use a PPO dentist. If you enroll in the dental PPO, receiving dental care from a non PPO dentist can result in an increased out-of pocket expense for you, as shown in the example on the chart below.
  
  
• United Concordia uses the American Dental Association (ADA) procedure codes in effect at the time a claim is handled to determine benefits.

PRE-DETERMINATION OF BENEFITS
Under the Regular and PPO Dental Options, for any service of more than $300, it is recommended it is reviewed by United Concordia before receiving treatment. This is called a "pre-determination of benefits." You can call United Concordia toll free at 1-866-215-2356 with any claim questions you may have.

SOME EXCLUSIONS FOR REGULAR AND PPO DENTAL OPTIONS

Items and services that are not covered by the Regular and PPO Options are set forth in the Summary Plan Description for those options. Some examples include:

• charges for oral hygiene, plaque control programs, and dietary instruction;
• the initial placement of full or partial dentures or bridges, if the prosthesis includes teeth that were missing before you were covered by the dental option.

EXAMPLE OF REGULAR AND PPO BENEFIT PAYMENTS

The chart below shows the differences in benefits paid by the Regular and PPO Options for the same expense. In addition, it illustrates the advantages of using PPO dentists, if you choose the PPO option. For the same $500 charge, this employee would pay:

• $100 if covered under the Regular Option;
• $35 if covered under the PPO Option and using a PPO dentist;
• $185 if covered under the PPO Option but using a non-PPO dentist.

DENTAL OPTIONS COMPARISON CHART

REGULAR DENTAL Non-Network Dentist

PPO OPTION

PPO Dentist

Non-PPO Dentist

Dentist's Normal Charge

$500

$500

$500

Discount PPO Fee For PPO Dentist

Does Not Apply

$350

Does Not Apply

Covered Expense

$500

$350

$350

Plan Pays

x 80%

x 90%

x 90%

Basic Expense/Type II

$400

$315

$315

Maximum Amount the Dentist Can Bill You

$500

$350

$500

Your Out-of-Pocket Expense

$100

$35

$185

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