Dental & Vision Plans  Covered California
 individuals & Families 
Employer Groups

Introduction To Dental Insurance

Dental & Vision covers things like Root Canals, crowns, Dentures, Braces, routine cleaning, “deep cleaning” eye exams & glasses.

Adult Dental & Vision for adults, as opposed to coverage for children  is pretty much, but not totally  excluded from Health Plans, as it’s not an essential benefit.  Specimen Policy Page 118      

Please note the maximum payouts/year are generally $1,000 or $1,500 and sometimes 6 months to one year waiting periods to get major services,  There are also rules so that insurance companies can stay financially solvent like the 80% Medical Loss Ratio, rule and underwriting to avoid adverse selection so IMHO he more important issue is:

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Dental For #Everyone,
has an excellent  website with full brochures, Instant online quoting and enrollment

Dental for everyone free quote

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#Importance of Dental Coverage 
Dental & General Health

Insurance 101?

We suggest that you check out Life Insurance, Disability, Long Term Care and Retirement as these risks may cause much more financial devastating to your budget than dental bills.

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Why you need Group Dental Coverage

 

Steve on buying, shopping and best use of premium dollars
Dental Insurance VIDEO

steve's video on dental coverage

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#Pediatric Dental and Vision

Pediatric Dental and Vision are Mandatory essential benefits under Section “J” 42  USC  18022  SB 951, even if there are no children on the policy.  If there are no children, you are not getting charged see FAQ below for more detail.

Our other pages on Dental Coverage

We don't put a lot of effort into selling dental coverage.  Generally it's a wash on paying premiums vs getting back claims payments.  Unless it's employer group.  Then the premiums are tax deductible under IRS  Section 106.

Here's more information on how we feel about dental.  Here's our page on implants, where we get lots of inquires, but few sales.  Most people only seem to want dental coverage, after they've been told they need a lot of dental work.  Not profitable for Insurance Companies.  See our other pages for details & explanations.   See our page on Medical Loss Ratio.  Insurance Companies need to take in $1 to pay 80c in claims.

 

Medicare Plans

Individual & Family Plans

Dental For Everyone,
has an excellent  website with full brochures, Instant online quoting and enrollment

Dental for everyone free quote

One of our colleagues on how Dental for Everyone Works..

 

Employer Group Plans

Dental, Vision, Supplemental

 

 

 

Dental - Glossary – #Dictionary

Technical & Research Resources

webb dental.com/

TMJ society.org/

tmj.org/

AB 2994, TMJ mandated if medically-necessary

Dental FAQ’s

 

Coordination of benefits – two or more policies in force?

 

Is it worth it and safe to have dental coverage, during the pandemic as people are postponing routine cleaning, etc, during the pandemic?

Blue Cross has already announced lower rates and that they are paying extra to the dentists for COVID 19 extra costs to prevent transmission.

If no one goes to the dentist, under the Medical Loss Ratio rule, Insurance Companies will have to give rebates, so that they pay out 85 cents on every dollar they take in .

Anthem issues premium credits to employer groups

We continue to look for ways to provide support and financial relief to our employers and members during the COVID-19 emergency.

Shelter-in-place orders across the country have caused significant disruption to traditional patterns of care. As a response to these challenges, we are supporting our customers by issuing premium credits to our Fully Insured employer groups based on their April 2020 invoices.
The credits will appear on employers’ August 2020 invoices (issued in July 2020):
• 15% of the April premium for Anthem Small Group medical plans
• 50% of the April premium for Anthem Dental plans – Source – Broker Email 6.5.2020PPE reimbursement protects members and supports dentistsCOVID-19 requires that dentists take extra precautions to protect both themselves and their patients. These added steps can add to the cost of a dental visit.

To protect the health of our members while minimizing unexpected fees, we are paying dentists an extra reimbursement from June 15 through August 31, 2020.

Anthem will pay $10 per dental patient, per visit, on dental PPO network claims for personal protective equipment (PPE).

Supporting the dentists in our networks can help preserve employee access to providers in their plans. Broker email dates 6.22.2020

is it safe to go to the dentist?

COVID-19 spreads primarily through respiratory droplets that often make their way into your mouth, nose, or even eyes, you may be putting yourself in danger while sitting in the dentist chair (remember: dental hygienists and dentists are all up in your mouth during cleanings and procedures—and you wearing a mask is basically impossible).

Viral transmission can happen if someone isn’t showing symptoms yet, so even if a dental office is making staff who are showing symptoms stay home, that won’t be helpful if a staffer is asymptomatic. That said, “as long as the dentist and assistants wear masks and get tested,” a dental procedure can be perfectly safe if you’re experiencing any type of dental emergency—swelling, uncontrolled bleeding, pain, trauma from an accident, or if you have a dental concern related to an underlying condition (chemotherapy, uncontrolled diabetes, etc.)—it’s important to see your dentist as soon as possible since, again, many offices are still open for emergency procedures and visits.
In the meantime, and again, as long as you’re not currently facing a dental emergency, remember to keep your teeth and mouth healthy by brushing your teeth and flossing twice a day (yes, even in quarantine).  Learn more NPR.org 6.3.2020 Is it safe?

questions to ask medical and dental staff when scheduling an appointment:

Do the staff and patients wear masks at all times?
Do the staff have enough masks and protective equipment?
Will there be a limit on how many people can be in a waiting room?
Are the staff being tested for COVID-19?
How often are staff cleaning the waiting rooms and offices?
If you don’t drive, can you take public transit while keeping your distance from other people and washing your hands before and afterward?Evidence of Coverage for Delta Dental PPOTimely Access to CarePPO and Premier Providers have agreed waiting times to Enrollees for appointments for care which will
never be greater than the following timeframes:
ƒ for emergency care, 24 hours a day, 7 day days a week;
ƒ for any urgent care, 72 hours for appointments consistent with the Enrollee’s individual needs;
ƒ for any non-urgent care, 36 business days; and
ƒ for any preventative services, 40 business days.
During non-business hours, the Enrollee will have access to his or her Provider’s answering machine,
answering service, cell phone or pager for guidance on what to do and whom to contact if he or she is
experiencing an Emergency Dental Condition.
If the Enrollee calls our Customer Service Center, a representative will answer their call within 10 minutes
during normal business hours.
Should the Enrollee need interpretation services when scheduling an appointment with any of our PPO or
Premier Providers, he or she may call our Customer Service Center at 800-471-0287 for assistance.

Waiting Period

Major Services

limited to enrollees who have been enrolled in the Contract for 6 consecutive months
Periodontics (other than maintenance)
Endodontics
Crowns and Casts
Prosthodontics
Oral Surgery

11 comments on “Dental & Vision for Adults and Mandatory Pediatic as an essential benefit

  1. give Medicare the power to negotiate for lower drug prices, add new benefits to Medicare

    Adding dental, hearing and vision benefits to Medicare.

    Making new investments in home and community-based services to “help seniors, persons with disabilities and home care workers,”

    Extending a boost to ACA income-based subsidies that were included in the American Rescue Plan Act. The boosted subsidies are set to expire after the 2022 coverage year.

    https://www.fiercehealthcare.com/payer/framework-for-3-5t-senate-package-seeks-to-close-medicaid-gap-add-new-medicare-benefits-and

  2. I have an employer group dental plan with Walmart that only coordinates with other group plans.

    I’m interested in a Individual Delta Dental PPO.

    What does their co-ordination of benefits say?

    • I don’t see a co-ordination of benefits clause in the INDIVIDUAL Delta Dental disclosure

      The disclosure you sent me, says your Walmart Group Plan only coordinates with other GROUP plans.

      See also Delta’s webpage on coordination of benefits

      The definition of a “Plan” within the COB provision of group contracts enumerates the types of coverage which the Plan may consider in determining whether other coverage exists with respect to a specific claim. The definition:
      1. May not include individual or family policies, or individual or family subscriber contracts, except… § 1300.67.13. Coordination of Benefits (“COB”)

      This all is rather complex. Let me email Delta to double check.

      See our webpage on dual coverage….

      Non-duplication of Benefits

      Some Delta Dental groups that are not subject to the provisions of California Health and Safety Code §1374.19 have a non-duplication of benefits clause in their contract.

      Such clauses means that the secondary plan will not pay any benefits if the primary plan paid the same or more than what the secondary plan allows for that dentist.

      For example, if both the primary and secondary carrier pay for the service at 80 percent level but the primary allows $100 and the secondary carrier normally allows $80 for the same treatment, the secondary carrier would not make any additional payment. However, if the primary carrier only pays 50 percent of the dentist’s allowed fee, then the secondary carrier would reduce its payment by the amount paid by the primary plan and pay the difference. In this case, the secondary carrier would pay $14 ($80 x 80 percent – $50 = $14).

      Dual coverage saves money for you and your group by sharing the total cost of dental benefits between two carriers. Containing costs is an important part of Delta Dental’s plan to keep you smiling.

      understanding non duplication

      Nonduplication COB – In the case of nonduplication COB, if the primary carrier paid the same or
      more than what the secondary carrier would have paid if it had been primary, then the secondary
      carrier is not responsible for any payment at all. ADA.org

      Columbus.Gov

      How does dual coverage and COB work?

      With non-duplication of benefits, the primary carrier pays its portion first and the secondary carrier, instead of paying the remainder, calculates what it would have paid if it were the primary carrier and subtracts what the other plan paid.

      For example, if the primary carrier paid 80 percent, and the secondary carrier normally covers 80 percent as well, the secondary carrier would not make any additional payment. However, in the same scenario, if the primary carrier paid 50 percent, the secondary carrier would pay up to 30 percent. Dental Dental

      §1374.19.   

      (a)  This section shall only apply to a health care service plan covering dental services or a specialized health care service plan contract covering dental service pursuant to this chapter.

      (b) For purposes of this section, the following terms have the following meanings:

      (1) “Coordination of benefits” means the method by which a health care service plan covering dental services or a specialized health care service plan contract, covering dental services, and one or more other health care service plans, specialized health care service plans, or disability insurers, covering dental services, pay their respective reimbursements for dental benefits when an enrollee is covered by multiple health care service plans or specialized health care services plan contracts, or a combination thereof, or a combination of health care service plans or specialized health care service plan contracts and disability insurers.

      (2) “Primary dental benefit plan” means a health care service plan or specialized health care service plan contract regulated pursuant to this chapter or a dental insurance policy issued by a disability insurer regulated pursuant to Part 2 (commencing with Section 10110) of Division 2 of the Insurance Code that provides an enrollee or insured with primary dental coverage.

      (3) “Secondary dental benefit plan” means a health care service plan or specialized health care service plan contract regulated pursuant to this chapter or a dental insurance policy issued by a disability insurer regulated pursuant to Part 2 (commencing with Section 10110) of Division 2 of the Insurance Code that provides an enrollee or insured with secondary dental coverage.

      (c) A health care service plan covering dental services or a specialized health care service plan issuing a specialized health care service plan contract covering dental services shall declare its coordination of benefits policy prominently in its evidence of coverage or contract with both enrollee and subscriber.

      (d) When a primary dental benefit plan is coordinating its benefits with one or more secondary dental benefits plans, it shall pay the maximum amount required by its contract with the enrollee or subscriber.

      (e) A health care service plan covering dental services or a specialized health care service plan contract covering dental services, when acting as a secondary dental benefit plan, shall pay the lesser of either the amount that it would have paid in the absence of any other dental benefit coverage, or the enrollee’s total out-of-pocket cost payable under the primary dental benefit plan for benefits covered under the secondary plan.

      (f) Nothing in this section is intended to conflict with or modify the way in which a health care service plan covering dental services or a specialized health care service plan covering dental services determines which dental benefit plan is primary and which is secondary in coordinating benefits with another plan or insurer pursuant to existing state law or regulation.

      Since you said that when you called Walmart’s HR department and you state they told you something different, I googled and found more recent information on their website!

      IF YOU HAVE COVERAGE UNDER MORE THAN ONE DENTAL PLAN

      If you or a family member have coverage under the dental plan and are also covered under another dental plan (for example, your spouse/partner’s company plan), coordination of benefits may apply. The dental plan has the right to coordinate with other plans you are covered under so the total dental benefits payable will not exceed the level of benefits otherwise payable under the dental plan.

      Coordination of benefits procedures and plans referred to as “other plans” are described in

      If you have coverage under more than one medical plan in The medical plan chapter page 89

      If you have coverage under more than one medical plan

      The AMP [associates medical plan] has the right to coordinate with other plans under which you are covered so the total medical benefits payable do not exceed the level of benefits otherwise payable under the AMP. “Other plans” refers to the following types of medical and health care coverage:

      • Coverage under a governmental program provided or required by statute, including no-fault coverage to the extent required in policies or contracts by a motor vehicle insurance statute or similar legislation

      • Group insurance or other coverage for a group of individuals, including coverage under another employer plan or student coverage obtained through an educational institution

      • Any coverage under labor-management trusteed plans, union welfare plans, employer organization plans, or employee benefit organization plans

      • Any coverage under governmental plans, such as Medicare or TRICARE, but not including a state plan under Medicaid or any governmental plan when, by law, its benefits are secondary to those of any private insurance, nongovernmental program, and

      • Any private or association policy or plan of medical expense reimbursement that is group or individual rated.

      Graph – from Walmart Benefit Book

      So, how would coverage for Crowns work?

      Walmart Plan

      MAJOR CARE

      After you meet the annual deductible, the Plan pays 50% of the maximum plan allowance for major care.

      Crowns, cast restorations, inlays, onlays, and veneers:

      Covered only when the tooth cannot be restored by amalgam or composite resin filling

      • Replacement is not covered unless the existing crown, cast restoration, inlay, onlay, or veneer is more than five years old and cannot be repaired.

      MAXIMUM PLAN ALLOWANCE (MPA)

      The MPA is the maximum amount the dental plan pays for covered dental services. The MPA applies to network and out-of-network dental services.

      For covered network services, the MPA is that portion of a provider’s charges covered by the dental plan as determined by the provider’s contract with Delta Dental of Arkansas.

      Network providers agree to accept an amount negotiated by Delta Dental for covered services as payment in full, subject to applicable deductible and coinsurance amounts.

      Delta Individual

      So, at best – the Individual Plan pays 50%. Group Plan pays 50%, so in this case, near as I can tell, you wouldn’t get anything extra as your Walmart Plan has Non Duplication of Benefits and not the “normal” Coordination of Benefits which would have allowed you to collect up to 100% of what the dentist charged you.

      Please note, I’m not an attorney nor an authorized claims representative for Walmart nor Delta Dental.

  3. Dr Brent Matza called in this prescription for me last week because I have a tooth that was growing under another and couldn’t be removed at that time .

    I have a terrible infection or abscess in my jaw where tooth is infected under the gums.

    I really need to get another presc of amoxicillin to finish clearing up the swelling and infection.

    I can’t lay on that side of my cheek, right side jaw bone hurts bad.

    I’ll be trying to find a dentist next week.

    My prescriptions go in to Walgreens on Ming Ave in bakersfield CA 93309

    • Thanks for the compliment, asking us complex claims problems….

      However, we are not the official claims site for Health Net or any dental insurer.

      Please try the number on the back of your ID card.

      If you have questions like, what gets covered by Health Insurance or what gets covered by dental, we can probably look that up, if you let us know exactly what policies you have. Here’s an example EOC Evidence of Coverage

      If we don’t have access to your EOC Evidence of Coverage, then you’ll need to send them to us.

  4. I am a 60 yr. old mother of adult children, no minors are covered under my individual policy, so how on earth can Pediatric Dental be “mandatory”,

    Reply

    That’s the law. Everyone has to have it. It’s an essential benefit. You are also required to have maternity.  There is no charge for the dental though.  

    Next Question

    It is a question of principle, not $6.89 additional monthly fee!

    How come this fee is being padded after the contract was signed last year?

    There is not a single thing, in my opinion, that has gone right with the roll out of Health Care Reform.

    Our Reply

    See my SNAFU page  I’m doing twice or more work with less than ½ the pay. I especially resent that Covered CA (CC) advertising does not mention that one can buy from an agent. Worse, so many people think they can only buy from CC and only CC provides guaranteed issue. So, I’m certainly not making it up on volume. The policy is effective Jan 1, 2014.

    Next Question

    No one mentioned this earlier. It was the law though. For some reason, CC policies do not currently include pediatric dental, nor do I believe it’s available! After months of repeated requests and no resolution to auto payment, now someone decides to add mandatory fee retroactively and initiate auto payment. This is not right!   It is unfair and a dishonest act. If the fee became mandatory after the policy was issued, wait till the renewal date of the policy at the end of 2014 and then add this fee.

    • Deep dental cleaning is also called periodontal scaling and root planning, or SRP. It’s similar to how a hygienist typically cleans your teeth but focuses on the outer surface of the roots and below your gum line. This special cleaning is needed when tartar buildup has caused infection of the gums. Pockets form, a widening of the gumline that has pulled away from the tooth. Loss of this connective tissue can lead to bone loss and, eventually, tooth loss. Learn More

      The Difference: Deep Dental Cleaning vs Regular Cleaning

      cleaning vs deep cleaning

      You Tube VIDEO on deep cleaning

      Better VIDEO on deep cleaning

      If you’re a dentist check out Spear Education.com

      If you have recently sat in your dentist’s chair for a routine exam, or you plan to in the near future, you are already ahead of the 34% of Americans who skip their checkup.

      Let’s set the record straight: if your dentist has suggested a deep cleaning, it is important that you get one scheduled right away. my ideal dental.com

      Here’s how to avoid the need for a deep dental cleaning

      You can prevent gingivitis and periodontal disease and avoid the need for a deep dental cleaning. “Probably 95 to 98% of dental disease, and periodontal disease in particular, is preventable,” Dr. Crum says.

      Key to prevention is better home care. You’ve had the recommendations drilled into your head since you were a kid—brush twice a day and floss once a day. If traditional brushing and flossing aren’t cutting it for you, there are different home care tools you can try.

      People with manual dexterity issues or arthritis might do better with an electric toothbrush.

      People who don’t like wrapping floss around their fingers can use floss picks or power cleaners like Waterpiks.

      People who have larger spaces between their teeth can try small brushes for cleaning that area.
      Visiting your dentist periodically is also key. Regular cleanings can catch gum disease early and keep the plaque and tartar from spreading below the gumline.

      considerable.com

  5. We have individual family Delta Dental HMO which is due for renewal at just $250/yr total premium

    I need crown work so looking for best plan to move into that will offer the deepest discounts for crown, post, and root canal. My estimate for work is over $5,000

    • Please, when asking us to compare or advise on plans, let us know the exact plan you have, ages and how many people are covered.

      Are you talking about the DeltaCare® USA CAA54 Individual/Family Dental Program Disclosure Contract

      This plan does NOT have waiting periods and no annual maximums!

      Are you happy with the dentists on the provider list?

      How about appointing us as your agent on this plan?

      One problem with dental, is that the premiums and thus the commissions are so low, we don’t really have time to shop and compare for you.

      Thus, we suggest you use the shop & compare tools on our website like:

      Dental for Everyone Which shops maybe 50 plans and allows side by side comparisons.

      Scroll back up and visit our pages and compare benefits for Blue Cross, Blue Shield and Health Net

      It’s also difficult for us as agents, as most people that ask about dental coverage, are in need of MAJOR services and facing huge bills. That’s not really something Insurance Companies are looking to pay immediate claims for.

      Note also, that employer group plans often offer richer benefits, shorter waiting periods and higher maximums as there they are getting people that don’t need MAJOR services right away to make up or help pay for ones with immediate claims.

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