Benefits > Dental > Aetna Coverage and Eligibility

Frequently Asked Questions

General

General

What is a DMO (Dental Maintenance Organization)?
In a DMO (Dental Maintenance Organization) enrollees select a participating primary care dentist (PCD).  Their primary dental care is provided by their PCD and only at locations that participate in the plan.  Though choice of providers is more limited, a DMO tends to cover a greater range of services at lower co-pays than traditional dental plans.

Will I receive an ID card?
Yes, if you select Aetna, DMO you will receive an ID card.  Your card will list out all eligible members of your family (up to 5) and their Primary Care Dentist.   However, if you do not choose a Primary Care Dentist, you will not receive cards.

Where can I get more information on Aetna, DMO?
You may review information and brochures on the Web site at /HRsite/Benefits/FacStaff/Dental/, Aetna's Web site at www.aetna.com or you may contact Aetna's Member Services at 877-238-6200.

Primary Care Dentist

What is a primary care dentist (PCD)?
This is a dentist you choose to manage your overall dental care.  All Aetna DMO enrollees are required to select a PCD.  Visit Aetna's online provider directory at www.aetna.com or you may contact Aetna's Member Services at 877-238-6200 to select your PCD.

Does every member have to select a Primary Care Dentist, and can that be a specialist?
Each dependent has to select a PCD. They could be assigned to a different DMO general dentist, but no person can elect a specialist, including a pediatric dentist, as their general dentist.

My dentist does not participate with Aetna, DMO.  Can I nominate him/her to participate?
Yes, you can nominate your current dentist for consideration to join the Aetna provider network by completing the nomination form.  However, submitting the form does not guarantee that your dentist will apply to or be accepted as an Aetna provider.

I will be in a different state for several months during the plan year.  Should I switch my primary care dentist (PCD)?
It is recommended that you switch your primary care dentist (PCD); you can switch your PCD as often as every 30 days.  If you do not switch your PCD, all services may not be covered unless considered an emergency.

Specialists

Are there any restrictions for seeing a specialist?
The general dentist is technically responsible for all treatments. If he/she feels that the service is beyond the scope of his/her ability, the office should submit to Aetna a pre-authorization listing the treatments needed and the reasons that he/she cannot perform, attaching all needed diagnostic materials to support the treatment, and to whom they wish to refer the patient. Aetna will review and make a determination of coverage based on this information. However, the Primary Care Dentist can “directly refer” members for certain services to a participating Specialty Dentist. In those situations, a preauthorization request is not required. The Primary Care Dentist should review the list of services and/or conditions to identify if the service is eligible for “direct referral”. If so, the Primary Care Dentist selects a participating Specialty Dentist to whom the patient is to be referred and completes the Specialty Referral Form. Direct referrals may be made only to participating providers. For more information, see the Specialty Referrals section of the Dental Office Guide.

Orthodontics

Aetna must permit the member to receive treatment from a non-participating dentist when there is not a participating dentist available. Aetna cannot limit the total fee charged for the case since there is no contractual agreement with that dentist. Aetna is not obligated to pay more than the covered percentage of the case fee. However, we do not wish to penalize the patient because we are unable to locate a participating orthodontist. Therefore, the member’s out of pocket may not exceed an amount equal to what the copayment would have been, based on the PPO fee schedule for an orthodontist. This would be a specialty fee schedule. The balance will be paid even though it may exceed the normal covered percent of the dentist’s charge.

Are referrals from the general dentist necessary to be seen by an orthodontist?
The patient can see a participating orthodontist without a referral.

Are specialty orthodontia, such as Invisalign and the new colored orthodontia covered?
No. However, the plan would cover up to the contracted fee for conventional orthodontic applicants. The member would be responsible for their normal co-payment for the conventional appliance plus the difference between the contracted fee for the conventional appliance and the dentist’s fee for the ceramic/clear/lingual/Invisalign appliance.

Is the replacement of a broken appliance covered?
No. Replacement or recementation of an appliance due to patient abuse or non-compliance after the third re-treatment is ineligible based on the reasonably necessary provision. The patient is responsible for these charges.

Implants

Are implants covered?
No. However, benefits are available for the related prosthesis (after the implant). If the patient elects the implant and the related prosthetic procedures, then the patient is responsible for the full cost of the implant and a copayment for the prosthetic. For example, if a tooth is extracted and an implant is placed the copayment for the crown over the implants is calculated based on the dentist’s fee for a crown placed on an implant. The patient is responsible for the full cost of any related procedures provided solely in connection with the implants, including follow-up procedures.

Is the replacement of missing teeth covered?
Coverage for the first installation of removable dentures, removable dentures, and fixed bridgework are eligible if needed to replace one or more natural teeth that were removed while this policy was in force for a covered person and are not abutments to a partial denture, removable bridge, or fixed bridge installed during the prior 5 years.

Pediatric Care

What are the requirements for a dependent child to see a Pediatric dentist?
Pediatric dentists are specialists, but the Primary Care Dentist may directly refer to a participating Specialty dentist for consultation or problem focused examination for children under age 6 if (a) the Primary dentist has documented at least one unsuccessful attempt to treat the child, and (b) at least one of the following conditions is present. The child has an existing medical condition or is developmentally disabled; presents a behavioral management problem; has rampant carries; or requires emergency care that is beyond the scope or ability of the primary care dentist. All other conditions or procedures not indicated must be preauthorized by Aetna. This includes referrals for children age 6 or older with a medical condition, significant behavioral management problem and severe caries that may require referral to a Specialty Dentist. Until the referral is authorized, only the consultation will be covered.

Are referrals needed for follow-up visits by a pediatric dentist?
No. Once a child is given an approved referral by the PCD to a contracted pediatric dentist, the child can continue to be treated by the pediatric dentist until the age of 6, without additional referrals from the PCD.

Endodontics

Can the Primary Care Dentist refer a patient for any Root Canal Treatment?
No. The primary care dentist may directly refer a member to a participating specialty dentist for the following conditions or treatment, and the specialty dentist may render treatment without preauthorization for consultation or problem-focused examinations, molar root canal therapy and root canal retreatments.

Emergency Care

What is the definition of emergency care?
Emergency care is treatment that must be rendered in order to alleviate pain and/or prevent worsening of a condition that would be caused by delay. It is the primary care dentist’s responsibility to take all appropriate steps to alleviate the pain or otherwise provide palliative treatment whenever possible. Once the patient’s condition is stabilized to the degree possible, referral to a specialty dentist may be appropriate in certain circumstances.

What if the PCD is not available and can’t treat the patient?
In the event of an emergency and the primary care dentist is unable to see or treat a patient, the member must contact Aetna prior to being seen by another provider for authorization of palliative treatment. Palliative treatment authorization may only be provided if the member indicates pain, swelling and/or bleeding.