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Ameritas Dental Plan
Calendar Year Deductible
$50.00 per individual for Type II (Basic)
and Type III (Major) Procedures (3 times family limit). After the date that 3
members of a family have each satisfied their individual deductible, the entire
deductible or any remaining portion of the deductible for any family member will
be waived for the rest of that calendar year.
Type I - Preventive and Diagnostic - Type I benefits are
payable at 100% U&C*. No deductible applies.
• Evaluations (Two per calendar year)
• Space Maintainers
• Cleanings (Two per calendar year)
• Radiographs (Xrays)
• Fluoride for Children (Under age 19)
• Bitewings (Two per calendar year)
Type II - Basic Procedures
- Type II benefits are payable at 80-90-100% U&C*.
$50.00 deductible applies.
• Sealants (under 17)
• Oral Surgery - Complex Extractions
• Limited Exams
• Oral Surgery - Simple Extractions
• Restorative Amalgam & Resin (excluding inlays and crowns)
• Denture Repair
• Anesthesia
Type III - Major Procedures
- Type III Benefits are payable at 50% U&C*. $50.00 deductible
applies.
• Endodontics (Root Canal)
• Prosthodontics - Removable Dentures, Partials
• Periodontics (Gum Disease)
• Crowns - Stainless Steel
• Prosthodontics - Fixed Pontics or Abutment
• Restorative
Orthodontia (Includes children & adults)
Benefits are payable at 50% U&C* with a lifetime maximum of $ 1,000.00.
No deductible applies.
Benefits will be payable when a Covered Expense is incurred. The Covered
Expenses for a program are based on the estimated cost of the insured’s program.
They are pro-rated by quarter (three month periods) over the estimated length of
the program, but not for more than eight quarters. The last quarterly payment
for a program may be changed if the estimated and actual cost of the program
differ.
100% Preventive, 80-90-100% Incentive
Everyone insured on the effective date of
the Company’s policy begins with 100% coinsurance for Type 1 (Preventive) and
80% coinsurance level for Type II (Basic) procedures and will remain at that
level until the next January 1.
If you visit a dentist during each Calendar Year and have at
least one covered dental procedure performed while insured under the Company’s
policy, your Type II (Basic) procedures will advance to the 90% level on the
following January 1 and to 100% on the next January 1. Your Type II (Basic)
procedures will remain at 100% each year as long as you visit a dentist during
each subsequent calendar year and have at least one covered dental procedure
performed while insured under the Company’s policy.
If you do not have at least one covered dental procedure
performed during any calendar year while insured under the Company’s policy, you
will revert back to 80% coinsurance level during the next calendar year and must
begin to progressively advance to the next levels as described above.
Annual Maximum Benefit
• Type I, II, and III Procedures - $1,000*
per calendar year per person.
• Orthodontia Procedures - $1,000 Lifetime per person (carry over does not
apply).
*This plan includes a maximum carryover for dental. Each
insured (employee and/or dependent) will qualify for a dental maximum carryover
if they:
1. Visit a dentist between January 1 and
December 31 of the plan year.
2. Submit a claim for payment prior to March 1 of the following year.
3. Total benefits paid for the Calendar Year must be less than $500.
If you meet all 3 requirements you will have an additional $250
available in the Annual Dental Maximum for the next plan year. In future years
if you have benefits paid of less than $500, additional amounts of $250 will be
added to the carryover. However, the most you can accumulate in the maximum
carryover is $1,000. Therefore, the maximum annual benefit may never exceed
$2,000 in any one year.
Eligible Employees
You are eligible for insurance if you are a
full-time active employee working at least 30 hours per week.
Eligible Dependents
Provides Coverage On:
• Your Spouse
• Children up to age 19 and unmarried (Up to age 26 if wholly dependent upon you
for maintenance and support and if enrolled as a full-time student in an
accredited school or college.)
Dental Exclusions
(deferment Period)
During the first 36 months following your or your dependent’s Dental
Coverage Effective Date, the initial placement of dentures, partial dentures, or
bridges, if it includes the replacement of teeth all of which are missing prior
to the effective date. (For currently covered insureds, Ameritas will use the
employees Date of Hire to determine the 36 month period.) This exclusion will
not apply if the prosthesis replaces a sound natural tooth which is extracted
while the patient is insured under this Dental Coverage and which is replaced
within 12 months of the extraction. During the first 36 months of coverage, the
replacement of bridges, partial dentures, dentures, inlays or crowns is
excluded. Exceptions to this exclusion will be made if the replacement is
made necessary by: a) accidental bodily injury to sound natural teeth (chewing
injuries are not considered accidental bodily injuries), or b) the extraction of
a sound natural tooth provided the replacement is completed within 12 months of
the date of the injury or extraction.
PREDETERMINATION OF BENEFITS
A treatment plan MAY be filed if a proposed course of treatment will exceed
$200.00. With this information, Ameritas can determine the benefits payable
under this policy prior to the work actually being done. It will give the
insured the amount payable, along with an idea of the out of pocket expense.
Coordination of Benefits
If you or any of your dependents incur charges which are covered by
any other group plan, the benefits of this plan will be coordinated with the
benefits of the other plan so that the total benefits received are not greater
than the charges incurred.
Certificate of Insurance
The Certificate of Insurance issued to you describes in detail the
benefits and limitations of this plan. This brochure is for general information
only.
Late entrant
If you do not elect to participate in the dental program when first
eligible, you will be considered a Late Entrant and you must wait 12
months for most benefits. If an employee or dependent does not elect to
participate when initially eligible, and elects to participate at the
policyholders next annual election period, they will become a Late Entrant.
For a Late Entrant, benefits will be limited to exams, cleanings and
fluoride applications for the first 12 months. The late entrant provision is
waived if the employee comes on the plan as a result of a qualifying event.
Section 125
This policy is provided as part of the Policyholder’s Section 125
Plan. Each member has the option under the Section 125 Plan of participating or
not participating in this policy.
A member may change their election only during an annual
election period, except for a change in family status. Examples of such events
would be marriage, divorce, birth of a child, death of a spouse or child or
termination of employment. Please see your plan administrator for details.
Orthodontia Limitations
(This is not a complete
list)
No benefit is payable for expenses incurred:
• In connection with a Treatment Program
which was begun before the individual became insured for orthodontic benefits.
• During any quarter of a Treatment Program if the individual was not
continuously insured for orthodontic benefits for the entire quarter.
• After the individual’s insurance for orthodontic benefits terminates.
Limitations/Exclusions
(This is not a complete List)
• For any treatment which is for cosmetic
purposes. Facings on crowns or pontics behind the 2nd bicuspid are considered
cosmetic.
• Charges incurred prior to the date the individual became insured under this
plan, or following the date of termination of coverage.
• Services which are not recommended by a dentist or which are not required for
necessary care and treatment.
• Expenses incurred to replace lost or stolen appliances.
• Expenses incurred by an insured because of a sickness for which he /she is
eligible for benefits under Worker’s Compensation Act or similar laws.
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Ameritas Monthly Rates
| Employee Only |
$26.12 |
| Employee plus 1 |
$52.78 |
| Employee plus 2 or
more |
$82.14 |
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*Usual and Customary
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