Understanding Your Dental Benefits
Know Before You Get Dental Care
Your plan includes dental coverage to help you take care of your teeth and gums. Before you make an appointment, it’s important to know how your dental benefit works, where you can get care, and whether approval is needed for certain services.
Your Network at a Glance
In-Network Dental Care
In-network dentists have agreed to provide services at a negotiated rate set by DentaQuest. If you visit an in-network dentist, you will not be billed more than the negotiated fee schedule on covered services.
Your cost: [$0] copayment on covered services
Your dentist submits the claim to DentaQuest directly on your behalf. You generally do not need to file a claim yourself.
Out-of-Network Dental Care
Your plan also covers dental services from out-of-network dentists. All covered services have a [$0] copayment — the same cost-sharing applies in and out-of-network.
Important: Out-of-network benefits are subject to the same in-network benefit maximums, limitations, and exclusions.
Out-of-network dentists often submit claims for you. If they do not, you will submit the claim directly (see below).
Benefits at a Glance
Original Medicare does not cover most dental care. Your Elderplan for Medicaid Beneficiaries (HMO-POS D-SNP) plan adds dental as a supplemental benefit — including preventive, diagnostic, and comprehensive services. We recommend requesting a treatment estimate from your dentist before any dental care.
Preventive & Diagnostic Care
Supplemental Diagnostic & Preventive Dental
Covered: Oral exams, cleanings, dental x-rays, screenings, and other preventive services
Your cost: [$0] copayment
Common frequency limits:
- Oral exam: 1 every 6 months
- Cleanings (prophylaxis): 1 every 6 months
- Bitewings: 1 every 6 months
- Panoramic film: 1 every 36 months
Full frequency schedule in your Evidence of Coverage.
Comprehensive Care
Supplemental Comprehensive Dental
Covered: Fillings, crowns, root canals, periodontal treatment, dentures, and other restorative and prosthetic services
Your cost: [$0] copayment
Key coverage rules:
- Coverage is limited to selected service codes
- Frequency limits apply per ADA guidelines — generally 1 service per tooth, arch, or quadrant
- An annual benefit maximum applies across both categories
How to Submit a Dental Claim
In-Network Visits
When you see an in-network dentist, your dentist submits the claim on your behalf. You do not need to take any action.
Out-of-Network Visits
When you see an out-of-network dentist, the dentist will often submit the claim for you. If they do not, you can submit the claim yourself. Claims must be submitted within 365 days from the date of service.
What to Include
Your claim must contain all of the following:
- Full member name and Elderplan Member ID number
- Name and Address of dentist
- List of dental services received with the corresponding ADA code(s)
- Proof of payment — an itemized receipt showing payment and a zero patient balance
Where to Send Your Claim
Mail or fax your completed claim to:
DentaQuest Claims PO Box 2906 Milwaukee, WI 53201-2906
Or fax to: 262-834-3589
Payment will be sent to the address on file for your account. To update your address or get help submitting a claim, contact Member Services.
Processing time: Dental claims are paid within 30 days. An Explanation of Payment (EOP) will accompany your check payment.
Important Reminders
About Using Your Dental Benefit
Annual maximum applies
Covered services have a [$0] copayment, but your dental benefits include an annual benefit maximum. Once that maximum is reached, you may be responsible for costs beyond it.
Service limitations apply
Frequency limits apply depending on the type of service — for example, cleanings are covered once every 6 months, and certain X-rays have 12- or 36-month limits. Benefit frequency may also be limited per ADA guidelines (e.g., 1 service per tooth, per arch, or per quadrant).
Out-of-network benefits use in-network limits.
Benefits received from out-of-network dentists are subject to the same maximums, limitations, and exclusions as in-network benefits.
Informed consent
Your dentist may ask you to sign an informed consent document detailing the risks, benefits, costs, and alternatives to all recommended treatments