2024 CarePartners of Connecticut HMO Dental Coverage

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Explore 2024 CarePartners of Connecticut HMO Dental Coverage

Carepartners of Connecticut HMO Plan Members

The CarePartners of Connecticut HMO Dental Coverage is administered by Dominion National, a leading administrator of dental benefits. The plan includes access to thousands of dentists across the region. You get complete dental coverage for no additional premium, including a $0 deductible, $0 for preventive services such as routine cleanings, oral exams, fluoride treatments, and bitewing x-rays; 20% coinsurance for restorative services such as fillings and x-rays other than bitewing images and 50% coinsurance for major services such as extractions, dentures, bridges, crowns, and implants.

Dental Benefit Essentials

Benefit

HMO Preferred Embedded Benefits

Premium

HMO Preferred Embedded Benefits

$0
Or

Annual Deductible 

HMO Preferred Embedded Benefits

$0
Or

Calendar Year Maximum

HMO Preferred Embedded Benefits

$3,000
Or

Class I

Member Cost Share for Diagnostic & Preventative Services

Diagnostic & Preventative Services

Benefit

HMO Preferred Embedded Benefits

Periodic oral evaluation

Two per year.

HMO Preferred Embedded Benefits

$0
Or

Comprehensive oral exam

Including the initial dental history and charting of teeth. Once every 36 months.

HMO Preferred Embedded Benefits

$0
Or

Intra oral bitewing X-ray images (X-rays of the crowns of the teeth) when oral conditions indicate need
Two per year.

HMO Preferred Embedded Benefits

$0
Or

Prophylaxis (routine cleaning, scaling, and polishing of teeth)
Two per year.

HMO Preferred Embedded Benefits

$0
Or

Fluoride treatments
Two per year.

HMO Preferred Embedded Benefits

$0
Or

Class II

Member Cost Share for Basic Services

Basic Services

Benefits

HMO Preferred Embedded Benefits

Emergency oral evaluation problem focused exams
Once every 12 months.

HMO Preferred Embedded Benefits

20% coinsurance
Or

Intra oral X-ray image of the entire mouth (panoramic image)
Once every 60 months.

HMO Preferred Embedded Benefits

20% coinsurance
Or

Intra oral X-ray image of the entire mouth (full mouth series)
Once every 60 months.

HMO Preferred Embedded Benefits

20% coinsurance
Or

Single tooth X-ray images
As needed.

HMO Preferred Embedded Benefits

20% coinsurance
Or

Silver fillings and white fillings
Once every 24 months per surface, per tooth.

HMO Preferred Embedded Benefits

20% coinsurance
Or

Minor treatment for pain relief
Only if no services other than exam and X-rays were performed on the same date of service.

HMO Preferred Embedded Benefits

20% coinsurance
Or

Class III

Member Cost Share for Major Restorative Services

Protective Restorations & Oral Surgeries

Benefits

HMO Preferred Embedded Benefits

Protective restorations
Once per tooth.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Simple extractions

Once per tooth.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Surgical extractions

Once per tooth.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Periodontics

Benefits

HMO Preferred Embedded Benefits

Periodontal surgery

One surgical procedure per lifetime; gingivectomy or gingivoplasty and osseous surgery covered as needed.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Bone grafts and guided tissue regeneration

Once per lifetime.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Periodontal cleaning
Once every 6 months following active periodontal therapy, not to be combined with regular cleanings.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Scaling and root planing

Once in 24 months, per quadrant.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Scaling in presence of generalized moderate/severe gingival inflammation
Once per 24 months after oral evaluation and in lieu of a covered prophylaxis.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Full mouth debridement
Once per lifetime.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Endodontics

Benefits

HMO Preferred Embedded Benefits

Root canal treatment

Once per tooth per lifetime.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Retreatment root canal therapy

Once per tooth per lifetime after 24 months of initial root canal therapy.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Apicoectomy

Covered as needed.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Prosthetic Maintenance

Benefits

HMO Preferred Embedded Benefits

Bridge or denture repair

Once every 24 months per bridge or denture.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Tissue conditioning

One treatment per denture every 84 months.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Adding teeth to existing partial or full dentures

Once per tooth, per denture, per 24 months.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Rebase or reline of dentures

Once per denture every 24 months.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Adjunctive Services

Provided in conjunction with the primary treatment.

Benefits

HMO Preferred Embedded Benefits

Local Anesthesia and Inhalation of Nitrous Oxide/Analgesia, Anxiolysis

Local Anesthesia and inhalation of nitrous oxide/analgesia, anxiolysis are provided in conjunction with covered oral surgery or periodontal surgery and are integral to the primary treatment.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Prosthodontics

Benefits

HMO Preferred Embedded Benefits

Dentures (complete or partial dentures)
One per arch within 84 months.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Fixed bridges
Once per 84 months. Note: A posterior fixed bridge and a removable denture are not covered in the same arch within 84 months; if a denture in the same arch as the fixed bridge was covered within 84 months, there will be no benefit for the fixed bridge.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Temporary partial dentures
Once per 84 months. Note: To replace any of the six upper or lower front teeth, but only if the temporary partial dentures are installed immediately following the loss of teeth during the period of healing.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Surgical implant placement Implants (only in lieu of a 3-unit bridge)
Implants are limited to 1 per tooth per 5 years.  Implant coverage is limited to the surgical placement of an endosteal implant (in lieu of a 3-unit bridge), abutment supported porcelain and cast metal crowns, and implant supported crowns. Exclusions: the following implant related procedures are excluded: implant maintenance, repairs, re-cement/re-bond, removal of implants, implant and abutment supported fixed partial denture retainers, and implant/abutment supported removable dentures.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Major Restorative Services

(Teeth must have good prognosis)

Benefits

HMO Preferred Embedded Benefits

Crowns and onlays (initial placement)
When teeth cannot be restored with regular fillings due to fracture or decay, once within 84 months per tooth. Note: If a member chooses a porcelain/ceramic crown, porcelain fused to high noble metal crown, or a titanium/titanium alloy crown, the maximum allowed by the Plan will be for the less expensive alternate treatment which is the porcelain fused to predominately base metal crown and the member will be responsible for the difference between the two crown procedures.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Recement of crowns and onlays
Once per tooth, per 12 months.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Inlays
Once per tooth, per 84 months.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Post and core or crown buildup

When needed to retain a crown on a tooth with excessive breakdown due to caries and/or fractures. Once per tooth every 84 months.

HMO Preferred Embedded Benefits

50% coinsurance
Or

Dental FAQs

Dental services are covered in and out of network —you can see any licensed dentist who accepts Medicare. If you go to an out-of-network dentist, you may need to pay out of pocket and submit a request for reimbursement. A dental claim form is available on our website at carepartnersct.com/forms. Services received from an in-network dentist will be covered at the time of service. The dental network is provided by Dominion National. Dominion National provides you with access to hundreds of participating dentists. To view the list of participating dentists in the Dominion PPO Network, go to carepartnersct.com/search-dentists.

You will receive a Dominion National ID card by mail to use for your dental coverage. If you don’t receive your card within 3 weeks of joining the plan, call Member Services at 1-888-341-1507 (TTY: 711).

Services include a cleaning, periodic oral evaluation, and sometimes bitewing X-rays. A comprehensive oral exam only occurs for a new patient or to evaluate an issue.

We recommend asking your dentist to submit a pre-treatment estimate to Dominion National before your treatment begins. The dentist can submit the exact services or procedures they plan to provide in your treatment plan and Dominion National will respond with confirmation of whether the service will be covered and the estimated out-of-pocket cost you will be expected to pay.

  • The pre-treatment estimate will be reviewed, and an estimate statement will be issued to you or the provider. The statement will include details of the services that will be covered by your plan along with your estimated responsibility and potential payment to the dental office.
  • The pre-treatment estimate is based on eligibility and benefits available at the time it is processed. A pre-treatment estimate is not required to obtain care.
  • A pre-treatment estimate is not a guarantee of payment. The claim for services performed will be based on eligibility and available benefits at the time it is submitted for payment. Other procedures performed, especially in the same area/quadrant/tooth, could affect the actual claim determination/payment.

A simple dental extraction is the procedure of removing teeth that are visible and easily accessible. In contrast, surgical dental extraction often involves an incision to get access to the tooth to be removed.

Inlays and onlays use the same materials as crowns and they both serve the same function, but they cover different areas of the tooth when there is tooth decay. The difference between an onlay and an inlay is that an onlay will treat the cusp, whereas an inlay only restores the area between the cusps.

Fillings can be performed using either composite (tooth-colored/white) or amalgam (metal/silver) restorative materials. If a tooth-colored filling is submitted for a back tooth, the coverage provided will be for a comparable metal filling. You and your dentist may still choose a white filling, but you will be responsible for the difference in cost between the white and silver fillings. If you would like a better estimate of your payment, we urge you to ask your dentist to submit a pre-treatment estimate.

Bone grafting and guided tissue regeneration are two separate but related procedures that your dentist can use to save natural teeth from failing due to the loss of healthy tissue from gum disease. By regenerating the lost bone and tissues surrounding a tooth, these restored structures will create the protective, strong foundation a tooth needs to remain healthy long term.

Crowns can be manufactured from a variety of materials, such as high noble metals, base metals, porcelain fused to metal (PFM) and ceramic compounds. Your dental plan covers crowns manufactured with porcelain fused to predominantly base metal. You and your dentist may still choose a crown made from more costly materials, but you will be responsible for the difference in cost between the predominantly base metal crown and the crown of your choosing. If you would like a better estimate of your payment, we urge you to ask your dentist to submit a pre-treatment estimate.

Dental Glossary

  • A

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    Apicoectomy

    The removal of inflamed gum tissue and the end of the tooth's root, while leaving the top of the tooth in place.

  • B

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    Bitewing X-rays

    Provide details of the upper and lower teeth in one area of the mouth. Each bitewing shows a tooth from its crown (the exposed surface) to the level of the supporting bone. Many dentists include bitewing X-rays as part of routine diagnostic care.

    Bone Grafting

    Bone grafting is a surgical procedure that uses transplanted bone to replace missing or damaged bone in your mouth. If you’re getting a dental implant, you may also need a bone graft because it provides additional support. The bone graft is performed first, and you’ll need to wait 3 to 4 months for it to heal before getting the implant. Please note that implants are not covered with your dental plan.

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    Comprehensive Oral Exam

    Performed by a dentist when evaluating a patient. Applies to new patients or established patients who have had a change in health or have been absent from treatment for three or more years.

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    Front Teeth

    Includes canines and all teeth in front of canines.

    Full Mouth Debridement

    The removal of plaque and tartar that interfere with the ability of the dentist to perform an oral examination. This is the most extensive cleaning procedure.

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    Guided Tissue Regeneration

    Guided tissue regeneration is a procedure designed to remove infected soft tissue in your mouth, while stimulating the regrowth of healthy gum tissue.

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    Inlays

    A dental inlay is a pre-molded restorative filling fitted into the grooves of your tooth. It restores cavities that are centered in your tooth instead of along the outer edges or "cusps."

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    Maximum Allowable Charge/Allowed Amount (MAC)

    Amount that is negotiated with providers in the Dominion National dental network. This is the maximum allowed amount you can be charged for a service. For services with coinsurance, the amount you pay is calculated by multiplying the coinsurance rate with the MAC.

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    Onlays

    An onlay is a treatment, like an inlay, which restores the cusp(s) of the tooth. The cusp (or cusps) of the tooth refer to the angled topmost surface of the tooth. Canine teeth have a single cusp, while bicuspids have two and molars may have four or five.

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    Periodic Oral Exam

    Exam performed by a dentist as part of a routine checkup.

    Periodontal Cleaning

    Like a regular teeth cleaning, periodontal maintenance removes tartar buildup from the teeth. Unlike a normal, preventive cleaning, periodontal maintenance is a treatment prescribed to combat periodontal (gum) disease. It involves both scaling and root planning, meaning tartar must be removed from deep between the teeth and gums.

    Periodontal Surgery

    Consists of three different potential surgeries. Your dentist will determine which one is needed. The three different surgeries could be:
    - Gingivectomy—The surgical removal of gum tissue. A gingivectomy is necessary when the gums have
    pulled away from the teeth creating deep pockets. The pockets make it hard to clean away plaque and
    calculus.
    - Gingivoplasty—The surgical reshaping of gum tissue around the teeth.
    - Osseous surgery—Removes diseased gum tissue and bone from infected sites within the m

    Posterior/Back Teeth

    Includes any teeth behind the canines but does not include the canine teeth.

    Protective Restorations

    The placement of a restorative material to protect a tooth and/or surrounding tissue. This procedure may be used to relieve pain, promote healing, and prevent further deterioration.

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    Quadrants

    Quadrants mean the four parts of your mouth. Your dentist sections the interior of your mouth into four parts for reference when providing treatment. The split is between the front teeth, split into upper right, upper left, lower right, lower left.

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    Rebase Denture

    Rebasing may be recommended when the teeth of your denture are still in good condition and have not worn out in comparison to the denture base material. Rebasing is the process of replacing the entire acrylic denture base providing a stable denture without replacing the denture teeth.

    Reline Denture

    A denture reline is a simple procedure to reshape the underside of a denture so that it fits more comfortably on the user's gums. Relining is periodically necessary as dentures lose their grip in the mouth.

    Retreatment Root Canal Therapy

    A denture reline is a simple procedure to reshape the underside of a denture so that it fits more comfortably on the user's gums. Relining is periodically necessary as dentures lose their grip in the mouth.

    Root Canal

    A root canal is performed when the endodontist removes the infected pulp and nerve in the root of the tooth, cleans the inside of the root canal, then fills and seals the space. After completing a root canal your dentist will place a crown on the tooth to protect and restore it to its original function.

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    Scaling and Root Planning

    Scaling and root planning is when your dentist removes all the plaque and tartar above and below the gumline, making sure to clean all the way down to the bottom of the tooth.

    Scaling in Gresence of Generalized Moderate/Severe Gingival Inflammation

    The removal of plaque and stains from above and below the gumline when there is generalized gum inflammation. This procedure is for patients who have swollen, inflamed gums and bleeding on probing. This procedure is performed on the entire mouth rather than just one quadrant. It is also a higher degree of cleaning for patients with more advanced periodontal disease.

    Single Tooth X-Rays

    Also sometimes referred to as a "periapical X-ray" a single tooth X-ray is one that captures the whole tooth. It shows everything from the crown (chewing surface) to the root (below the gum line).

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    Tissue Conditioning

    Tissue conditioning is an effort to restore the health of the tissues of the denture foundation area prior to denture treatment.