⭐ Core Takeaway

This is a New York PPO dental insurance policy with in‑network and out‑of‑network coverage, a $50 annual deductible, no copays, and annual maximums that differ by network and plan year. Preventive care is fully covered in‑network, while major services have coinsurance and frequency limits. Out‑of-network care is allowed if receiving care from a non-participating provider.

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Coverage Structure (PPO)

You can see any dentist, but costs differ:

In‑Network

• Highest coverage level
• No balance billing
• Negotiated rates
• Many services covered at 0%–50% coinsurance depending on type

Out‑of‑Network

• Covered, but:
  • You pay coinsurance
  • You pay the difference between the dentist’s charge and the Allowed Amount“You will also be responsible for paying any difference between the Allowed Amount and the Non‑Participating Provider’s charge.”
  • Some services not covered out-of-network

Covered Procedures (High-Level)

Type 1 (Preventive)

• Exams (2/year)
• Cleanings (2/year)
• Bitewings (1/year)
• Fluoride
• X-rays (frequency limits apply)

Type 2 (Basic)

• Fillings (1 per tooth every 2 years)
• Extractions
• Palliative care (1 per 6 months)
• Desensitization
• Pin retention

Type 3 (Major)

• Crowns (1 per 5 years)
• Root canals (retreatment every 3 years)
• Periodontal surgery (1 per quadrant every 3 years)
• Dentures/partials (1 per 5 years)
• Implants (1 per 5 years)
• Bone grafts (linked to implant placement)
• Surgical extractions
• Anesthesia (when tied to covered dental procedure)

Each category has strict frequency limits.

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Costs: Deductible, Coinsurance, Maximums

Deductible

• $50 per person per plan year
• Applies to Type 2 and Type 3 procedures only
• Combined in-network/out-of-network deductible“Any deductible satisfied… will be applied to both the Participating Provider Deductible and the Non‑Participating Provider Deductible.”

Coinsurance

Procedure Type	In‑Network	Out‑of‑Network
Type 1 (Preventive)	0%	50%
Type 2 (Basic)	20% first year → 10% second year+	50%
Type 3 (Major)	50%	50%

Annual Maximums

Plan Year	In‑Network Max	Out‑of‑Network Max
1st Year	$750	$750
2nd+ Year	$3,500	$1,500

Preventive (Type 1) does not count toward the annual max.

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Plan Year & Renewal

• Plan Year: August 1 – July 31
• Renews automatically each August 1
• Premium due 1st of each month

Who’s Covered

Coverage types:

• Individual
• Individual + Spouse
• Individual + Children
• Family

Children covered until end of month they turn 26.

Domestic partners are treated as spouses with documentation requirements.

Key Rules & Requirements

Medical Necessity

Ameritas must determine services are medically necessary:

“The fact that a Provider… recommended the service does not make it Medically Necessary.”

Preauthorization

• Most dental services do not require preauthorization
• You can request a pre-treatment estimate

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Transitional Care

If your dentist leaves the network:

• You may continue care for 90 days at in-network rates If you join while in treatment with an out-of-network dentist:
• Up to 60 days of in-network-level coverage (for serious conditions)

Claims

• Out-of-network claims must be submitted within 120 days

Exclusions & Limitations (Important)

Not covered:

• Cosmetic dentistry (unless reconstructive after trauma)
• Experimental/investigational treatment (unless overturned on appeal)
• Medical services or hospital charges
• Services by family members
• Services normally provided at no charge
• War, military service, workers’ comp conditions
• Pre-existing conditions for 12 months unless you had prior creditable coverage“We do not Cover any conditions for which medical advice was given… within six (6) months before the effective date.”

Privacy

Ameritas follows HIPAA/HITECH. They do not sell your data. They share only with:

• Service providers
• Agents/brokers
• When required by law

Most Important Practical Points

• Preventive care is free in-network.
• Major work (crowns, implants, dentures) has 50% coinsurance and strict frequency limits.
• Out-of-network dentists can balance bill, making costs unpredictable.
• Annual maximum jumps from $750 → $3,500 after year 1 (in-network).
• Pre-existing condition exclusion applies for 12 months unless you had prior dental coverage.
• Deductible is small ($50) and applies only to Type 2/3.

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