Delta Dental PPO 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 dentist.

The AARP Dental Insurance Plan does not provide benefits for:

  1. Treatment of injuries or illness covered by workers' compensation or employers' liability laws; services received without cost from any federal, state or local agency, unless the exclusion is prohibited by law.
  2. Treatment or materials that are benefits to an Enrollee under Medicare unless this exclusion is prohibited by law.
  3. Treatment or materials to correct congenital or developmental malformations (including treatment of enamel hypoplasia) except for newborn children eligible at birth, children placed for adoption and 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.
  4. 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.
  5. Cosmetic procedures and treatments performed soley to enhance appearance and which is not treatment provided for the patient's dental health under generally accepted dental practice standards (e.g. teeth whitening, veneers and implants.)
  6. Treatment or materials for which no charge is made, for which the Enrollee is not legally obligated to pay, or for which no charge would be made in the absence of Dentegra coverage.
  7. Services provided or materials furnished prior to the effective eligibility date of an Enrollee under this plan.
  8. Periodontal splinting, equilibration, gnathological recordings and associated treatment and extra-oral grafts.
  9. Preventive plaque control programs, including oral hygiene instruction programs.
  10. Myofunctional therapy, unless covered by the exception in Item 2, above.
  11. Temporomandibular joint dysfunction, which is medical in nature, unless covered by the exception in Item 2, above.
  12. Prescription drugs including topically applied medication for treatment of periodontal disease, pre-medication, analgesics, antimicrobial agents, separate charges for local anesthetics, general anesthesia except as a covered benefit in conjunction with a covered Oral Surgery procedure. Prescription drugs are medications provided after treatment (e.g. pain relief medication).
  13. Experimental procedures that have not been accepted under generally accepted dental practice standards.
  14. 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.
  15. Charges for hospitalization or any other surgical treatment facility, including hospital visits.
  16. 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.
  17. Replacement of existing restorations for any purpose other than restoring active carious lesions or demonstrable breakdown of the restoration.
  18. Materials and procedures for construction of bridges, partial and complete dentures, unless a covered benefit.
  19. Orthodontic services, including tooth guidance appliances.

Delta Dental PPO 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 dentist 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 this plan.
  3. Limitation on Major Restorative Benefits. If a tooth can be restored with amalgam, synthetic porcelain or plastic, but the Enrollee and the dentist 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 this 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 does not meet Generally Accepted Dental Practice Standards. The five-year period shall be measured from the date on which the restoration was last supplied, whether paid for under the provisions of this 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 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 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 does not meet Generally Accepted Dental Practice Standards. 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 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 Exclusions

  1. Any procedure that is not specifically listed under Schedule A, Description of Benefits and Copayments.
  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 Services as described 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. Dental expenses incurred in connection with any dental or orthodontic procedure started before the Enrollee's eligibility with the DeltaCare USA program. Examples include: teeth prepared for crowns, root canals in progress, full or partial dentures for which an impression has been taken, and orthodontics unless qualified for the orthodontic treatment in progress provision.
  14. Lost, stolen, or broken orthodontic appliances.
  15. Changes in orthodontic treatment necessitated by accident of any kind.
  16. Myofunctional and parafunctional appliances and/or therapies.
  17. Composite or ceramic brackets, lingual adaptation of orthodontic bands and other specialized or cosmetic alternatives to standard fixed and removable orthodontic appliances.
  18. Treatment or appliances that are provided by a Dentist whose practice specializes in prosthodontic services.

DeltaCare USA 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 the Administrator, 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. 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.
90-A-EB-WWGT 05/13

290-US3-WEB-006 06/15