Q. How are payments determined?
A. The Plan helps you and your family members with dental expenses. You and the Plan share costs for covered treatment and services. You pay a percentage co-payment for most covered expenses. You must satisfy an annual deductible before the Plan starts paying on covered non-preventive services. The Plan also has an annual maximum and a lifetime orthodontia maximum amount. Once the maximum lifetime benefit maximum has been paid, no other benefits will be paid under any circumstances. Once the Plan has paid charges for covered expenses up to the maximum, you are responsible for all charges above the maximum. See the Adjustments to billed charges section for other factors that may affect reimbursement.
This section explains some of the terms and provisions you need to know to use the Plan to your best advantage.
The annual maximum is $2,000, which is the amount of benefits payable under the Plan for covered dental expenses (other than preventive and orthodontic services) each calendar year for each covered person. This annual maximum benefit is determined after you pay any necessary deductibles and co-payments. Orthodontic expenses have a separate lifetime limit of $2,000.
Once the annual maximum benefit has been paid, no other benefits are available under any circumstances. You are responsible for all charges above the annual maximum benefit.
The negotiated rates do not apply once your yearly dental maximum has been reached. The dental provider may charge you their full billed rates.
You have had several dental procedures totaling $1,800 between January 1st and July 31st. You have $200 remaining until you reach the annual maximum. On September 2nd, you have a dental procedure performed, and the cost to the Plan is $300. Since the annual maximum is $2,000, the Plan will pay only $200 of the charge. You are responsible for $100, and no benefits are available for dental services performed for the remainder of the calendar year.
However, beginning January 1st of the following year, a new annual maximum benefit will be available to pay charges for covered expenses incurred during that calendar year.
The deductible is the amount of covered expenses you must pay each calendar year before the Plan begins sharing the cost. You do not pay a deductible for preventive or orthodontic services. An annual deductible must be met for general and major services. A $50 deductible applies to each covered person. Once deductibles for your family reach $150, your family has satisfied the deductible requirements for the year. The deductible does not include any amounts above the reasonable and customary limits (see Reasonable and Customary Limits under Adjustments to billed charges).
The co-payment is the percentage of the cost of covered dental treatment or services that you pay. You pay a 20% co-payment for general services and a 50% co-payment for major and orthodontic services.
Orthodontia lifetime maximum
The Plan pays up to $2,000 for covered orthodontic expenses for the lifetime of each covered person. This is in addition to the annual maximum benefit for other types of dental care.
Adjustments to billed charges
When providers submit charges for payment, the following factors affect the amount that will be considered eligible for reimbursement. References to these limitations may appear on your explanation of benefits. Contact Aetna Member Services for more information. A pre-determination of benefits is strongly recommended before you incur any major or unusual expenses.
Reasonable and customary limits
Allowable amounts for services are determined by reasonable and customary (R&C) limits. The Plan's claims administrator determines R&C limits. These limits are based on data obtained from the Prevailing Healthcare Charges System owned by FAIR Health. R&C limits for services are set at the 90th percentile of the range of charges for a particular procedure in the same geographic area(s). R&C limits apply only to non-network providers and services.
If any non-network provider charges a fee that exceeds the R&C limit, you are responsible for the excess amount. The amount above the R&C limit does not apply toward your annual deductible or your percentage co-payments. To find out if a proposed charge is within R&C limits, contact Aetna Member Services. PPO provider negotiated rates are always within R&C limits.
Assume that the R&C charge in your area for a tooth filling is $120, your non-network dentist charges $140 to fill your tooth, and the network dentist's negotiated charge is $100.
The Benefit Summary provides an overview of the ExxonMobil Dental Plan. More detailed explanations of the expenses covered under each category (preventive, general, major, and orthodontic) and expenses not covered are provided in the Exclusions section of this SPD.
Alternative course of treatment
In situations where an alternative course of treatment would provide professionally adequate (based on American Dental Association guidelines) results at a lower cost, the lower-cost treatment is considered the covered expense.
The alternative course of treatment is determined either at the time a pre-determination is made or when the claim is processed. Reimbursement and subsequent repairs, replacement, or servicing is based on that alternative course of treatment. Use the Plan's pre-determination of benefits feature to avoid unexpected expenses.
If you incur a service that is eligible for an alternative course of treatment without a pre-determination or you choose not to use the alternative course of treatment identified during a pre-determination, you will be responsible for the following:
- Any reasonable and customary charges that you may incur while using a non-PPO provider.
- The difference in cost between the alternative course of treatment and the treatment performed.
- Your co-payment based on the alternative course of treatment, if your deductible has been met.
Assume that you have one or more missing teeth and you would like them replaced with an initial bridge. Dental bridges bridge the gap created by one or more missing teeth. Your provider is a Dental PPO network provider and the submitted charge is $2000 for an initial bridge. When you submit your treatment plan for a pre-determination of benefits, Aetna determines that a medically necessary, cost-effective alternative course of treatment is available – a partial denture – that costs $1000. The table below shows the cost you would pay if you choose to proceed with an initial dental bridge instead of a partial denture. Also, the table shows the cost if you use a non-network provider who charges $3,000.
For this example: A claim is submitted for an initial bridge on teeth numbers 8-10, with tooth 9 as the missing tooth which will be replaced with a porcelain bridge (pontic). For this example, an alternate benefit of a partial denture is approved. The negotiated fee for the alternate course of treatment of a partial denture is $1000.00. For the Non-network example the reasonable and customary amount is $1,000 for the partial denture.
Note: When an alternative course of treatment is applied, reimbursement for the other missing teeth in the arch related to the initial bridge are subject to the alternative course of treatment benefit for the partial denture.
Recovery of overpayment
If you or your beneficiary receives a distribution of any amount from the Plan to which you are not entitled, you or your beneficiary will be required to repay the amount of the overpayment to ExxonMobil or the Plan. The plan administrator may make reasonable arrangements with you for repayment.