Our incentive PPO product offers the same flexibility as our traditional PPO plan with a higher level of benefits to members who choose to visit preferred providers.
This plan design is available as part of a Dental Blue® or Dental Blue PPO® plan. The Dental Blue Preventive plan offers coverage for diagnostic and preventive benefits. It offers members access to dental services while enabling dental professionals to educate new patients about their complete oral health care needs.
Dental Blue 65 is for Massachusetts residents ages 65 and older. It can be purchased as a direct-pay plan or with Medicare Advantage. Members may receive care from our network of Dental Blue Indemnity-participating dentists. Three dental plan options are available:
- Dental Blue 65 Preventive®: Coverage includes certain preventive and diagnostic services that are available with no deductible or annual maximum.
- Dental Blue 65 Basic®: Coverage includes certain preventive and diagnostic services that are available without a waiting period, plus some basic dental services available after the member has been enrolled in the plan for 6 months or more. Members are covered 100% for preventive services and at 50% for other services. There is a $100 deductible and a $1,250 calendar-year maximum.
- Dental Blue 65 Premier®: Coverage includes certain preventive and diagnostic services that are available without a waiting period. Basic dental services are available after the member has been enrolled in the plan for 6 months or more, and there is a 12-month waiting period for major restorative services. Members are covered at 100% for preventive services, at 80% coverage for minor restorative services, oral surgery, periodontics, endodontics, prosthetic maintenance, and other services; 50% coverage for major restorative services, prosthodontics/tooth replacements, crowns, inlays, onlays, implants, and other services other services. There is a $50 deductible and a $1,250 calendar-year maximum.
The largest selection of network dentists, plus the ability to see out-of-network dentists, gives members the most choice. They can visit any dentist in our Dental Blue and Dental Blue PPO networks and receive the most coverage. If they go out-of-network, they’re still covered, but they may have to pay higher out-of-pocket costs.
The chart below shows how we determine your reimbursement for covered services based on your patient’s plan and the plan(s) in which you participate, and what you may collect from your patient:
| If you participate in: | And your patient's plan is: | Then we'll base payment on: | And you can collect from your patient: |
|---|---|---|---|
| Dental Blue only | Dental Blue | The lower of the Dental Blue maximum allowable charge for your location and specialty or your charge | Applicable co-insurance and deductible* |
| Dental Blue PPO | The lower of the PPO fee schedule or your charge based on your patient’s contract | Any balance up to your charge | |
| Dental Blue Freedom | The lower of the Dental Blue maximum allowable charge for your location and specialty or your charge | Applicable co-insurance and deductible* | |
| Dental Blue and Dental Blue PPO | Dental Blue | The lower of the Dental Blue maximum allowable charge for your location and specialty or your charge | Applicable co-insurance and deductible* |
| Dental Blue PPO | The lower of the Dental Blue PPO fee schedule or your charge | Applicable co-insurance and deductible* | |
| Dental Blue Freedom | The lower of the Dental Blue PPO fee schedule or your charge | Applicable co-insurance and deductible* | |
| Dental Blue PPO only | Dental Blue | No payment because you are a non-participating Dental Blue dentist** | Any balance up to your charge |
| Dental Blue PPO | The lower of Dental Blue PPO fee schedule or your charge | Applicable co-insurance and deductible* | |
| Dental Blue Freedom | The lower of Dental Blue PPO fee schedule or your charge | Applicable co-insurance and deductible* |
* You may collect your patient’s co-insurance at the time of the visit. However, please do not collect your patient’s deductible until we’ve processed the claim and you’ve received our PPA and PDA. Once your patient's annual maximum has been met, you may collect your full fee for any additional services.
** If the member’s employer purchases a policy that allows members to see a non-participating dentist, then you could be reimbursed for services; however, in these cases, payment is made directly to the member and he/she must reimburse the dental provider.
