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Ameritas Dental Plan Details
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.TYPE III MAJOR PROCEDURES
- Type III Benefits are payable at 50% U&C*. $50.00 deductible applies.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 fi led 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
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
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
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.
Monthly Dental Rates
|
Employee (EE) Only |
$0 (Paid by Employer) |
| 1 Dependent | $33.24 |
| 2 or more Dependents | $49.44 |
*Usual & Customary
