Delta Dental DPO Excluded Benefits

The AARP® Dental Insurance Plan covers a wide variety of dental care expenses, but there are some services for which we do not provide benefits. It is important for you to know what these services are before you visit your provider.

The AARP Dental Insurance Plan does not provide benefits for:

  1. Treatment or materials that are benefits to an Enrollee under Medicare unless this exclusion is prohibited by Texas Insurance Code §1204.201. Delta Dental will reimburse the Texas Department of Human Resources for the cost of services paid by the Department under Chapters 31 and 31 of the Human Resources Code to the extent such costs are for services which are Benefits under this Contract.

    If the Texas Department of Human Resources is paying benefits pursuant to Chapter 31 and 32 of the Human Resources Code (financial and medical assistance programs administered pursuant to the Human Services Code) and a parent who is covered by the group policy has possession or access to a child pursuant to a court order, or is entitled to access or possession of a child and is required by the court to pay child support, then all benefits paid on behalf of the child or children must be paid to the Texas Department of Human Resources.
  2. Treatment or materials to correct congenital or developmental malformations (including treatment of enamel hypoplasia) except for newborn children eligible at birth, children for whom the Enrollee has become party to a suit in which he/she seeks to adopt the child and/or adopted children so long as such eligible children continue to be enrolled. When services are not excluded under this provision congenital defects or anomalies specifically includes individuals born with cleft lip or cleft palate, and other limitations and exclusions of this section shall specifically apply.
  3. Treatment that increases the vertical dimension of an occlusion, replaces tooth structure lost by attrition or erosion, or otherwise unless it is part of a treatment dentally necessary due to accident or injury.
  4. Treatment or materials primarily for cosmetic purposes including but not limited to treatment of fluorosis (a type of discoloration of the teeth) and porcelain or other veneers not for restorative purposes, except as part of a treatment dentally necessary due to accident or injury. If services are not excluded as to particular teeth under this provision, cosmetic treatment of teeth adjacent or near the affected teeth are excluded.
  5. Treatment or materials for which the Enrollee would have no legal obligation to pay.
  6. Services provided or materials furnished prior to the effective eligibility date of an Enrollee under the plan.
  7. Periodontal splinting, equilibration, gnathological recordings and associated treatment and extra-oral grafts.
  8. Preventive plaque control programs, including oral hygiene instruction programs.
  9. Myofunctional therapy, unless covered by the exception in Item 2, above.
  10. Temporomandibular joint dysfunction treatment, which is medical in nature, unless covered by the exception in Item 2, above.
  11. Prescription drugs including topically applied medication for treatment of periodontal disease, pre-medication, analgesias, separate charges for local anesthetics, general anesthesia except as a covered benefit in conjunction with a covered Oral Surgery procedure.
  12. Experimental procedures that have not been accepted under generally accepted dental practice standards.
  13. Services provided or material furnished after the termination date of coverage for which premium has been paid, as applicable to individual Enrollees, except this shall not apply to services commenced while the plan was in effect or the Enrollee was eligible.
  14. Charges for hospitalization or any other surgical treatment facility, including hospital visits.
  15. Dental practice administrative services including but not limited to, preparation of claims, any non-treatment phase of dentistry such as provision of an antiseptic environment, sterilization of equipment or infection control, or any ancillary materials used during the routine course of providing treatment such as cotton swabs, gauze, bibs, masks, or relaxation techniques such as music.
  16. Replacement of existing restorations for any purpose other than restoring active carious lesions or demonstrable breakdown of the restoration.
  17. Materials and procedures for construction of bridges, partial and complete dentures, unless a covered benefit.
  18. Orthodontic services, including tooth guidance appliances.
  19. Services for injuries or conditions which are compensable under Workers' Compensation or similar law.

Delta Dental DPO Limitations

Benefits to Enrollees under the Plan are limited based on various factors including the frequency of services whether paid for under the provisions of this plan, under any prior dental contract and/or policy or by the Enrollee. We recommend you obtain a pre-treatment estimate prior to receiving more complicated or expensive procedures. Also, you should have your Provider verify benefit eligibility prior to receiving any treatment. Limitations are as follows:

  1. Limitation on Optional Treatment Plan. In all cases in which there are optional plans of treatment carrying different treatment costs, payment will be made only for the applicable percentage of the least costly course of treatment, so long as such treatment will restore the oral condition in a professionally accepted manner, with the balance of the treatment cost remaining the responsibility of the Enrollee. Such optional treatment includes, but is not limited to, specialized techniques involving gold, precision partial attachments, overlays, bridge attachments, precision dentures, personalization or characterization such as jewels or lettering, shoulders on crowns or other means of unbundling procedures into individual components not customarily performed alone in generally accepted dental practice.
  2. Limitation on Basic Restorative Benefits. If a tooth can be restored with amalgam, synthetic porcelain or plastic, but the Enrollee and the Provider select another type of restoration, the obligation of Delta Dental shall be only to pay the applicable percentage of the fee appropriate to the least costly restorative procedure. The balance of the treatment shall be considered a dental treatment excluded from coverage under the plan.
  3. Limitation on Major Restorative Benefits. If a tooth can be restored with amalgam, synthetic porcelain or plastic, but the Enrollee and the Provider select another type of restoration, the obligation of Delta Dental shall be only to pay the applicable percentage of the fee appropriate to the least costly restorative procedure. The balance of the treatment shall be considered a dental treatment excluded from coverage under the plan. Replacement of crowns, jackets, inlays and onlays shall be provided no more often than once in any five-year period and then only in the event that the existing crown, jacket, inlay or onlay is not satisfactory and cannot be made satisfactory. The five-year period shall be measured from the date on which the restoration was last supplied, whether paid for under the provisions of the plan, under any prior dental care contract, or by the Primary Enrollee.
  4. Limitation on Diagnostic Aids. Full mouth X-rays (including panoramic X-rays accompanied by supplemental films, which are considered equivalent to a full mouth X-ray) are limited to once in any five-year period. Bitewing X-rays are limited to twice in any Calendar Year period for Enrollees to age 19, and once in a Calendar Year for all other Enrollees. Periodic examinations of the full mouth are limited to three in any Calendar Year period.
  5. Limitation on Prophylaxis, Periodontal Maintenance Cleanings and Fluoride. Prophylaxes, periodontal maintenance cleanings and fluoride application may be performed either together or separately. You may have any combination of prophylaxes and/or periodontal maintenance cleanings (if Enrollee has a previous history of periodontal therapy) for a total of three in any Calendar Year. Fluoride applications as a benefit are limited to twice in any Calendar Year period up to age 19. Note: Periodontal maintenance cleanings are covered at a different percentage.
  6. Limitation on Sealants. Application of sealants as a benefit is limited to Enrollees up to age 14 through the completion of the procedure or the date eligibility terminates, whichever occurs first. Treatment with sealants as a covered service is limited to applications to eight posterior teeth. Applications to deciduous teeth or teeth with caries are not covered services. Sealants will be replaced only after three (3) years have elapsed following any prior provision of such materials. Single-surface occlusal restorations of a tooth to which a sealant has been applied within 12 months, and two or three surface restorations within six (6) months, which include occlusal surfaces on which sealants have been placed are not covered services. If a single-surface occlusal restoration is performed on a tooth from twelve to 36 months after a sealant has been applied to that tooth, the obligation of Delta Dental shall be only to pay the fee appropriate to the restoration in excess of the fee paid for the application of the sealant.
  7. Limitation on Prosthodontic Benefits. Replacement of an existing denture and/or implant will be made only if it is unsatisfactory and cannot be made satisfactory. Services, including denture repair and relining, which are necessary to make such appliances fit will be provided as outlined in the section "Covered Benefits." Prosthodontic appliances, implants and/or abutment crowns will be replaced only after five years have elapsed following any prior provision of such appliance, implant and abutment crown under any plan procedure.

    Diagnostic and treatment facilitating aids for implants are considered a part of, and included in, the fees for the definitive treatment. Delta Dental's payment for implant removal is limited to one (1) for each implant during the Enrollee's lifetime whether provided under Delta Dental or any other dental care plan.

    The initial installation of a prosthodontic appliance and/or implant is not a Benefit unless the prosthodontic appliance, implant, bridge or denture is made necessary by natural, permanent teeth extraction.
  8. Limitation on Periodontal Surgery. Benefits for periodontal surgery in the same quadrant are limited to once in any five-year period. The five-year period shall be measured from the date on which the last periodontal surgery was performed in that quadrant, whether paid for under the provisions of this plan, under any prior dental contract, or by the Primary Enrollee.

    Periodontal services, including bone replacement grafts, guided tissue regeneration, graft procedures and biological materials to aid in soft and osseous tissue regeneration are only covered for the treatment of natural teeth and are not covered when submitted in conjunction with extractions, periradicular surgery, ridge augmentation or implants.
  9. Limitation on Temporomandibular Joint Dysfunction (TMJD). Benefits for Temporomandibular Joint Dysfunction are limited to services relating to the hinging joints of the jaw including diagnostic tests, splinting and other treatments as have demonstrably satisfactory prognosis. Benefits for TMJD include temporomandibular joint arthrograms (including injection), occlusal guards (by report), occlusal analysis (mounted case) and occlusal adjustments (complete). Other procedures are considered medical in nature, and are excluded benefits.

DeltaCare USA DHMO Exclusions

  1. Any procedure that is not specifically listed under Schedule A, Description of Benefits and Copayments as described in the Evidence of Coverage.
  2. Any procedure that in the professional opinion of the Contract Dentist:
    a. has poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/or surrounding structures; or
    b. is inconsistent with generally accepted standards for dentistry.
  3. Services solely for cosmetic purposes, with the exception of procedure D9975 (external bleaching for home application, per arch), or for conditions that are a result of hereditary or developmental defects, such as cleft palate, upper and lower jaw malformations, congenitally missing teeth and teeth that are discolored or lacking enamel, except for the treatment of newborn children with congenital defects or birth abnormalities.
  4. Porcelain crowns, porcelain fused to metal, cast metal or resin with metal-type crowns and fixed partial dentures (bridges) for children under 16 years of age.
  5. Lost or stolen appliances including, but not limited to, full or partial dentures, space maintainers, crowns and fixed partial dentures (bridges).
  6. Procedures, appliances or restoration if the purpose is to change vertical dimension or to diagnose or treat abnormal conditions of the temporomandibular joint (TMJ).
  7. Precious metal for removable appliances, metallic, or permanent soft bases for complete dentures, porcelain denture teeth, precision abutments for removable partials or fixed partial dentures (overlays, implants, and appliances associated therewith) and personalization and characterization of complete and partial dentures.
  8. Implant-supported dental appliances and attachments, implant placement, maintenance, removal and all other services associated with a dental implant.
  9. Consultations for non-covered benefits.
  10. Dental services received from any dental facility other than the assigned Contract Dentist, a preauthorized dental specialist, or a Contract Orthodontist except for Emergency Dental Services as described in Schedule A in the Contract and/or Evidence of Coverage.
  11. All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similar care facility.
  12. Prescription drugs.
  13. Lost, stolen, or broken orthodontic appliances.
  14. Changes in orthodontic treatment necessitated by accident of any kind.
  15. Myofunctional and parafunctional appliances and/or therapies.
  16. Composite or ceramic brackets, lingual adaptation of orthodontic bands and other specialized or cosmetic alternatives to standard fixed and removable orthodontic appliances.
  17. Treatment or appliances that are provided by a Dentist whose practice specializes in prosthodontic services.

DeltaCare USA DHMO Limitations

  1. The frequency of certain Benefits is limited. All frequency limitations are listed in Schedule A, Description of Benefits and Copayments (see your Evidence of Coverage/Member Handbook).
  2. If the Enrollee accepts a treatment plan from the Contract Dentist that includes any combination of more than six crowns, bridge pontics, and/or bridge retainers, the Enrollee may be charged an additional $100.00 above the listed Copayment for each of these services after the sixth unit has been provided.
  3. General anesthesia and/or intravenous sedation/analgesia is limited to treatment by a contracted oral surgeon and in conjunction with an approved referral for the removal of one or more partial or full bony impactions, (Procedures D7230, D7240, and D7241).
  4. Benefits provided by a pediatric Dentist are limited to children through age seven following an attempt by the assigned Contract Dentist to treat the child and upon prior authorization by Delta Dental, less applicable Copayments. Exceptions for medical conditions, regardless of age limitation, will be considered on an individual basis.
  5. The cost to an Enrollee receiving orthodontic treatment whose coverage is cancelled or terminated for any reason will be based on the Contract Orthodontist's usual fee for the treatment plan. The Contract Orthodontist will prorate the amount for the number of months remaining to complete treatment. The Enrollee makes payment directly to the Contract Orthodontist as arranged.
  6. Benefits for dental expenses incurred in connection with any dental or orthodontic procedure started before the Enrolleeā€™s eligibility with this Program are limited as follows:

    Upon request of a newly covered Enrollee, Alpha will provide Benefits for the completion of covered services begun prior to the time his or her coverage became effective. Alpha will not provide coverage for incomplete services that are not otherwise Benefits under the terms and conditions of the Contract. Enrollees may request completion of treatment in progress by calling the Customer Service department at [800-422-4234] during normal business hours, or by sending a written request to Alpha.

    Whenever possible, an Enrollee should complete treatment in progress with the Dentist who initiated the service. If such Dentist is an out-of-network Dentist, that Dentist must agree to the same terms and conditions that apply to an in-network Dentist in order for Alpha to provide Benefits. Copayments and other cost sharing components will apply. Benefits may be adjusted so that the total paid by the Enrollee and/or coverage provided by all plans is not more that 100% of total Allowable Expenses (as defined in the Coordination of Benefits section of the Contract).

    Should the Enrollee be unable to complete treatment with the Dentist who initiated the service, Alpha will make reasonable and appropriate arrangements for completion of such treatment by a Contract Dentist.
  7. Orthodontic treatment in progress is limited to new DeltaCare USA Enrollees who, at the time of their original effective date, are in active treatment started under their previous employer-sponsored dental plan, as long as they continue to be eligible under the DeltaCare USA program. Active treatment means tooth movement has begun. Enrollees are responsible for all Copayments and fees subject to the provisions of their prior dental plan. Delta Dental is financially responsible only for amounts unpaid by the prior dental plan for qualifying orthodontic cases.
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AARP Dental Insurance Plan

Delta Dental DPO plan is insured and administered by Delta Dental Insurance Company.

DeltaCare USA dental HMO plan is underwritten by Alpha Dental Programs, Inc., and administered by Delta Dental Insurance Company.

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