Routine oral exams—limited to 2 per calendar year
Prophylaxis (the cleaning and scaling of teeth) — limited to 2 per calendar year
Topical application of fluoride—for dependent children under age 19; limited to 1 per calendar year (not applicable in all states)
Intra-Oral Occlusal Film
Bitewing X-rays (up to a set of 4)—limited to 1 per calendar year
Full mouth X-rays (Panoramic film or Full series)— no less than 36 months apart
Pin retention—per tooth, in addition to restorations
Composite restorations—limited to anterior teeth and bicuspids
Antibiotic injections administered by a Dentist
Denture Rebase—no less than 24 months apart
Denture Reline—no less than 24 months apart
Inlays, onlays and crowns
Prosthetic services—dentures or bridges
*Applies only to ClassicOne and PremierOne options
What is Maximum Allowable Charge (MAC)?
The BasicOne plan is a PPO plan using the Dentemax PPO network and fee schedule for in and out of network benefits. The MAC benefit is payable as a percentage of the network fee schedule regardless of whether the treatment is provided by a network provider. Out-of-network charges in excess of the net work fee schedule are the responsibility of the covered person.
What is a Covered Charge?
Expenses must be incurred while the coverage is in force and the person is covered by the Policy. To be a covered charge, the dental services must be performed by: • A licensed Dentist acting within the scope of his license; • A licensed Physician performing dental services within the scope of his license; or • A licensed dental hygienist acting under the supervision and direction of a Dentist.
When is a Covered Charge considered incurred?
A covered charge is considered incurred on the following dates: • For full and partial dentures—on the date the first impression is taken. • For fixed bridges, crowns, inlays and onlays—on the date the teeth are first prepared. • For root canal therapy—on the date the pulp chamber is opened. • For periodontal surgery—on the day surgery is performed. • For all other services—on the date the service is performed.
Predetermination of Benefits
Except in an Emergency, if You need treatment which will cost more than the Predetermination Amount shown on the Schedule of Benefits page, Your Dentist must submit a claim to Us before beginning treatment which describes the treatment necessary and its cost.
We have the right to request any additional information We deem necessary to evaluate this claim. This includes, but is not limited to, dental records and X-rays. We will prepare and return to You and Your Dentist an estimate of the treatment and the amount for which benefits are payable. This estimate is not a guarantee of payment by Us. We will still consider a claim for which You have not obtained prior approval. These claims will be subject to reduced benefits based on Our determination of Reasonable and Customary Charges and Medically Necessary treatment.
Coordination of Benefits:
This coverage will be coordinated with any other group, blanket or franchise plan under which a covered person will receive benefits. This helps keep the cost of the plan reasonable.
What is a Reasonable and Customary Fee?
The most common charge for similar professional services, drugs, procedures, devices, supplies or treatment within the Geographic Area in which the charge is incurred. The most common charge means the lesser of:
|The actual amount charged by the provider|
|The negotiated rate|
|The usual charge which would have been made by a provider (Dentist, Hospital, etc) for the same or comparable professional services, drugs, procedures, devices, supplies or treatment within the same Geographic Area as determined by Us. “Geographic Area” means the three digit zip code in which the service, treatment, procedure, drugs or supplies are provided; or a greater area if necessary to obtain a representative cross-section of charge for a like treatment, service, procedure, device drug or supply.|
What is an Alternate Benefit?
An alternate benefit will apply: (1) If we determine that a less expensive alternative procedure, service or Course of Treatment can be performed in place of the proposed treatment to correct a dental condition; and (2) the alternative treatment will produce a professionally satisfactory result; then the maximum we will allow will be the Reasonable and Customary charge for the less expensive treatment.
What is the OrthoCare Program?
The OrthoCare Orthodontic Discount Program* is an optional program for orthodontic care. When using a contracted OrthoCare Orthodontist, you will save 15% - 20% on the services performed. The OrthoCare program has been designed to offer orthodontic benefits to both individuals and families, providing benefits for the routine orthodontic treatment for children and adults.
*The optional OrthoCare Program is not an insurance benefit, nor is it affiliated with Standard Security Life Insurance Company of New York or a part of the Secure DentalOne insurance plan.
Who is the Association?
Communicating for America, Inc.** (CA) provides many benefits and discounts to its members. Your enrollment as a member of CA is completed upon receipt of the association annual dues. Your membership information will be mailed shortly thereafter.
**CA is not affiliated with Standard Security Life Insurance Company of New York, nor is it a part of the insurance coverage. CA is a 501c5 non-profit association headquartered in Fergus Falls, Minn., providing members valued benefits and savings since 1972.
This website provides a brief description of the benefits, exclusions and other provisions of the Master Policy# SSL ADEN-POL 0606 issued to Communicating for America. For a complete listing, the Group Policy is available for inspection at the Policyholder’s offices. Benefits may vary in different states. Secure DentalOne may not be available in all states. All rights reserved. SSL Secure DentalOne Bro. 1-19-07