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Dental Maintenance Organization (DMO®)* - Frequently Asked Questions (FAQs)
Coverage | Member Advantages | Plan Types | Dental Health | FAQs

* In Illinois, DMO plans provide limited out-of -network benefits. However, in order to receive maximum benefits, members must select and have care coordinated by a participation primary care dentist. Illinois DMO is not an HMO.

  1. How does my DMO plan work?
  2. How will my primary care dentist (PCD) know I am an eligible dental plan member?
  3. Will I get a DMO member ID card? If so, when will I receive it?
  4. Do I have to select a primary care dentist (PCD)?
  5. How do I find a dentist who participates in your network?
  6. Can I change my primary care dentist? If so, when will the change take effect?
  7. Do I need a referral to see a specialist?
  8. Can a pediatric dentist be a primary care dentist?
  9. How will my dentist get reimbursed under my DMO® plan?
  10. What is the co-pay amount I need to pay for dental services?
  11. What can I do if I think my dentist is overcharging me?
  12. What if I need emergency care and my primary care dentist is unavailable?
  13. Are all dental services covered by my plan?
  14. Are composite fillings (white fillings) covered?
  15. Which orthodontic treatments are covered?
  16. Are there any restrictions in replacing missing teeth with dentures, bridges or implants?
  17. How often will my plan replace crowns, bridges and other devices?
  18. What will my plan cover if a service started before my plan start date?
  19. Frequency limitations - Are there restrictions to how often a service can be performed?
  20. How will I know if the treatment I need will be covered?
  21. How are oral surgery services covered by my dental plan?
  22. When is periodontal maintenance covered?
  23. I was in orthodontic treatment before my plan effective date. Is there a way to continue that care? Do I need to change orthodontists?
  24. I am new dental plan member and want to start orthodontic care. How does my plan work?

1 How does my DMO®* benefits plan work?
  • Choose a primary care dentist who participates in our network. Each covered family member can select his or her own. Visit DocFind®, our online provider directory, to find one in your area.
  • Show your member ID card when you visit your dentist for covered services.
  • Depending on your plan, you may pay for dental care in one of two ways:
    1. Copay - You pay a set dollar amount at the time of service, or
    2. Coinsurance - You pay a percentage of covered expenses at the time of service
  • There are no deductibles or annual dollar maximums.
  • There are no claim forms to fill out. Your dentist will submit your claims for you.
* In Illinois, DMO plans provide limited out-of-network benefits. However, in order to receive maximum benefits, members must select and have care coordinated by a participation primary care dentist. Illinois DMO is not an HMO.

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2 How will my primary care dentist know I am an eligible dental plan member?
Your dentist has many ways to verify your eligibility:
  • Review the member rosters we send each month
  • Visit our secure dentist website at www.aetnadental.com, or
  • Call our toll-free self-service dentist line
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3 Will I get a DMO* member ID card? If so, when will I receive it?
You will get a member ID card after you select a primary care dentist. You will receive your card about seven to ten days after you enroll.

* In Illinois, DMO plans provide limited out-of -network benefits. However, in order to receive maximum benefits, members must select and have care coordinated by a participation primary care dentist. Illinois DMO is not an HMO.

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4 Do I have to select a Primary Care Dentist?
Yes. You must select a primary care dentist. Your primary care dentist is responsible for managing your care. Your primary care dentist will make referrals to a dental specialist when necessary.

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5 How do I find a dentist who participates in your network?
It's easy to find a network dentist. Just visit DocFind®, our online provider directory at www.aetna.com. You can search for a dentist by:
  • Name
  • Specialty
  • Zip code
  • Miles/distance
  • City and state or county and state

You will even find maps and directions to your dentist's office.

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6 Can I change my Primary Care Dentist? If so, when will the change take effect?
You can change your primary care dentist as often as once a month. Just log on Aetna Navigator®, your self-service member website. Make your change by the 15th of the month, and it will be effective by the first day of the following month. You can call member services for help, too.

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7 Do I need a referral to see a specialist?
Yes. Your primary care dentist makes referrals to specialists if needed. Referrals for orthodontic care are not required. The orthodontist must participate in our network.

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8 Can a pediatric dentist be a primary care dentist?
Unless required by state law, a pediatric dentist is considered a specialist and not a primary care dentist. Most primary care dentists can treat children.

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9 How will my dentist get reimbursed under my DMO®* plan?
The dental plan pays your dentist an agreed rate for services. Depending on your plan, you must pay a:
  • Copay - You pay a set dollar amount at the time of service, or
  • Coinsurance - You pay a percentage of covered expenses at the time of service
* In Illinois, DMO plans provide limited out-of -network benefits. However, in order to receive maximum benefits, members must select and have care coordinated by a participation primary care dentist. Illinois DMO is not an HMO.

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10 What is the copayment amount I need to pay for dental services?
We have agreements with all network DMO* providers. The agreements list what they can charge for covered services. Your copayment or copay is based on:
  • A percentage of those services, or
  • A low flat dollar amount
The amount you pay is typically listed on your member ID card. You pay it at the time you visit your dentist.

There is no deductible. That means you do not need to pay anything other than your copay before the plan starts to pay. There is no yearly coverage maximum, too.

* In Illinois, DMO plans provide limited out-of -network benefits. However, in order to receive maximum benefits, members must select and have care coordinated by a participation primary care dentist. Illinois DMO is not an HMO.

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11 What can I do if I think my Dentist is overcharging me?
Please contact member services. We can review your treatment plan and discuss your options.

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12 What if I need emergency care and my primary care dentist is unavailable?
Please contact us. We can give you authorization for emergency care.

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13 Are all dental services covered by my plan?
Your plan documents describe the services covered by your plan. See your employer benefits specialist if you need a copy.

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14 Are composite fillings (white fillings) covered?
Please see your plan documents for coverage details. You may also call member services at the number listed on your member ID card.

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15 Which orthodontic treatments are covered?
Not all dental plans include orthodontic care. Please see your plan documents for coverage details. You may also call member services at the number listed on your member ID card.

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16 Are there any restrictions in replacing missing teeth with dentures, bridges or implants?
Please see your plan documents for coverage details. You may also call member services at the number listed on your member ID card.

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17 How often will my plan replace crowns, bridges and other devices?
Please see your plan documents for coverage details. You may also call member services at the number listed on your member ID card.

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18 What will my plan cover if a service started before my plan start date?
Please see your plan documents for details. You may also call member services at the number listed on your member ID card. Here are some facts you should know:
  • Your previous plan's extension of benefits provision may continue coverage for some services until that service is complete.
  • Some plans have a work-in-progress exclusion. If you were not covered by another plan and began treatment for a service, that service may be ineligible under your new plan, if your plan has a work-in-progress exclusion.

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19 Are there any restrictions as to how often a service can be performed?
Yes. There are services that will have a frequency limitation. Please see your plan documents for coverage information. You may also call member services at the toll-free number listed on your member ID card.

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20 How will I know if the treatment I need will be covered?
The easiest way is to ask your dentist to send us a pretreatment estimate. This will let you and your dentist know what the benefit will be if the service is done. You or your dentist may also call member services at the toll-free number on your ID card.

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21 How are oral surgery services covered by my dental plan?
For general information about how oral surgery is covered, please visit our page on oral surgery. Please see your plan documents for coverage information. You may also call member services at the toll-free number listed on your member ID card.

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22 When is periodontal maintenance covered?
This care is for members who have previously been treated for periodontal disease. DMO®* plans require a surgical periodontal history.

* In Illinois, DMO plans provide limited out-of -network benefits. However, in order to receive maximum benefits, members must select and have care coordinated by a participation primary care dentist. Illinois DMO is not an HMO.

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23 I was in orthodontic treatment before my plan effective date. Is there a way to continue that care? Do I need to change orthodontists?
If orthodontic care is included in your plan, you may find the information you need by visiting our page on orthodontic care. Please note that you do not have to change your orthodontist if you began treatment before your plan's effective date.

For eligibility questions, call the toll-free member services number on your member ID card.

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24 I am new dental plan member and want to start orthodontic care. How does it work?
Please visit our page on orthodontic care for general information. See your plan documents for details specific to your plan. If you still have a question, call our toll-free member services number on your member ID card.

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