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." If
treatment occurs without a predetermination of benefits and the service is
denied, you may experience unexpected out-of-pocket costs.
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.
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DENTAL OPTIONS COMPARISON CHART
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REGULAR
DENTAL
Non-Network Dentist |
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PPO
OPTION |
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PPO
Dentist |
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Non-PPO
Dentist |
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Dentist's
Normal Charge
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$500 |
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$500 |
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$500 |
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Discount PPO Fee
For PPO Dentist
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Does
Not Apply |
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$350 |
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Does
Not Apply |
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Covered Expense
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$500 |
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$350 |
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$350 |
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Plan Pays
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x
80% |
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x
90% |
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x
90% |
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Basic Expense/Type II
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$400 |
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$315 |
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$315 |
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Maximum Amount the Dentist Can Bill You
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$500 |
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$350 |
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$500 |
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Your Out-of-Pocket Expense
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$100 |
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$35 |
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$185 |
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