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Ameritas Dental Plan Details
Combined Calendar Year Deductible
$25.00 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 benefit
period)
Cleanings (Two per benefit
period)
Fluoride for Children (Under age
19)
Space Maintainers
Radiographs (X-rays)
Bitewings (Two per benefit
period)
Type II - Basic Procedures
- Type II benefits are payable at 80-90-100% $25.00 deductible applies.80-90-100% INCENTIVE PLAN
If you visit a dentist during each calendar year and have at least one covered dental procedure performed while insured under the Companys policy, your Type I (Basic) procedures will advance to the 90% level on the following January 1 and to 100% on the next January 1. Your Type I (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 Companys policy.
If you do not have at least one covered dental procedure performed during any calendar year while insured under the Companys policy, you will revert back to 80% coinsurance level during the next calendar year and must begin to progressively advance to the next level as described above.
Type III -Major
Procedures - Type III Benefits are payable at 50% U&C*.
$25.00 deductible applies.
Endodontics (Root Canal)
Restorative - Crowns
Periodontics ( Non-Surgical)
Periodontics (Surgical)
Prosthodontics - Fixed Pontics or Abutment
Prosthodontics - Removable
Bridges/Pontics
Dentures, Partials
TMJ- $500 Lifetime Maximum
OrthodontiA
(Children and adults)
Paid at 50% U&C*.
No deductible applies.
$1,000 Lifetime maximum per person.
Annual Maximum benefit
Applies to Type II and Type III
Procedures
$1,500 per calendar year per person
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.
Annual Maximum Carryover
1. Visit a dentist between January 1 and December 31 of each year.
2. Submit a claim for a covered procedure prior to March 1 of the
following year.
3. Total dental benefits paid for the calendar year must be less than $750.
If you meet all 3 requirements then you will be eligible for the Annual
Maximum Carryover benefit. This benefit will provide you with an additional $250
towards your annual dental maximum for the following year. In future years, if
you continue to meet these requirements you will continue to see an increase in
your annual maximum by $250 until you have reached an annual maximum carryover
limit of $1,000. This benefit allows you to accumulate up to a $2,500 annual
dental maximum.
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 24 if wholly dependent upon you for maintenance and
support and if enrolled as a full-time student in an accredited school or
college).
PreDetermination of Benefits
Coordination of Benefits
Certificate of Insurance
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.
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 treatments. The late entrant provision is waived if the employee comes
on the plan as a result of a qualifying event.
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.
This insurance is underwritten by Ameritas Life Insurance Corp.
Monthly Dental Rates
|
Employee Only |
$22.12 |
| Employee & Child(ren) | $61.76 |
| Employee & Spouse | $47.86 |
| Employee & Family | $83.98 |
Usual & Customary
