Dental & Vision Plans 
for individuals & Families

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

1. 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?

   Reply

   • 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 pages on dual coverage….

     https://medi-cal.healthreformquotes.com/full-scope/dual-coverage/

     https://individuals.healthreformquotes.com/definitions-glossary/dual-coverage/

     https://medicare.healthreformquotes.com/seminar/part-b/parts-a-b/medicare-dual-coverage/

     Reply

     • 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

       Reply

       • §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.

         Reply

   • 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
     

     Reply

     • 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.

       Reply

       • Hi Steve

         I don’t follow your reply on crown

         Shall I call you

         Reply

         • This stuff is WAY to complex to discuss on the phone. What part do you not follow?

           It appears that what Walmart told you was correct. You can’t collect more than way they pay. I never heard of Non Duplication of Benefits before. So, how am I going to explain it over the phone. I cut and pasted what they said and verified it with the law.

           If we were to discuss it, I would only do it on Zoom or Skype, so that you can see where I’m reading the material from.

           Reply

2. 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

   Reply

   • 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 https://steveshorr.com/steveshorr/individual_and_family/blue_cross/2014/eoc.platinum.bc.ppo.2014.pdf#page=72

     If we don’t have access to your EOC Evidence of Coverage, https://individuals.healthreformquotes.com/appeal-grievances/plain-meaning-rule/eoc-platinum/ then you’ll need to send them to us.

     Reply

3. 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. https://individuals.healthreformquotes.com/aca/10-essential-benefits/ 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 http://healthreformquotes.com/individual/companies/covered-ca/snafu-pay-bill-get-id-cards/ 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.

   Reply

4. What dental plan provides the most comprehensive coverage for “deep cleaning?”

   Reply

   • 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. https://www.deltadentalwa.com/blog/entry/2019/10/dental-deep-cleaning-teeth

     The Difference: Deep Dental Cleaning vs Regular Cleaning

     

     You Tube VIDEO https://youtu.be/LSJto5PVCoY

     Better VIDEO https://youtu.be/OkZLYwA_qdE
     “Scaling and Root Planing” is just one of many Spear Patient Education videos. These resources help dentists explain conditions and procedures to their patients. To learn more, visit http://www.speareducation.com/cta?ref….

     Reply

     • What can I do, so that I can avoid the pain, cost and expense of a deep cleaning?

       Reply

       • 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. https://www.myidealdental.com/blog/do-i-really-need-a-deep-cleaning/

         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.

         https://www.considerable.com/health/dental-care/deep-dental-cleaning/

         Reply

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

   Reply

   • 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.

     Reply

6. I don’t recall that you’ve ever contacted my office or website before. I need to know which plans you have and then I can direct you to the provider finder for that carrier. Our main provider finder is here.

   Are you with Medi-Cal, Covered CA or directly with an Insurance Company?

   Are you willing to appoint us as your agent so that we can get compensated to help you?

   Reply