Leidos Dental PPO Plan
The Leidos Dental PPO Plan allows participants to choose any provider they wish and receive benefits. Whether a participant sees a network provider or an out-of-network provider, the plan covers a broad range of dental services and supplies. The Leidos Dental PPO Plan is self-insured by Leidos, which means that Leidos fully funds the plan. The plan administrator is Delta Dental of VA.
Paying for Care
This section will help participants understand how they pay for care under the Leidos Dental PPO Plan.
Leidos and participants share the cost of coverage. Each pay period, a participant who enrolls in the Leidos Dental PPO Plan contributes a set dollar amount to help pay for the cost of the plan. Leidos pays for the rest of the cost. The contribution amount will vary based on the coverage level the participant has elected: employee only, employee plus spouse, employee plus one or more children or family coverage. These contributions are taken automatically from the participant's paycheck on a pre-tax basis. Premiums for domestic partners are paid by the participant on an after-tax basis.
The "deductible" is the initial $50 each participant must pay for dental services he or she receives each calendar year before the plan begins to pay benefits.
"Coinsurance" is the percentage of eligible expenses a participant pays for dental services once he or she meets the deductible.
Annual Maximum Benefit
The annual maximum benefit is the total amount a plan will pay for covered dental services for a participant each plan year. Once a participant meets this yearly maximum, the plan will not pay any more benefits until the next plan year.
Each year, the Leidos Dental PPO Plan will pay a maximum of $1,500 per participant.
There is a separate $1,500 lifetime maximum for orthodontic services per participant.
This section will help participants understand how the Leidos Dental PPO Plan pays benefits.
If a participant goes to a network dentist, he or she saves money because dentists in the network have agreed to charge discounted fees. For most services, the participant must first meet the $50 annual deductible. Then, whenever the participant receives dental services, the Leidos Dental PPO Plan pays a percentage of the cost. The participant pays the remaining amount (the coinsurance).
There are no claim forms to file because the network dentist submits claims for the participant.
When a participant uses a dentist who does not participate in the Delta Dental PPO plus Premier network, that dentist is considered to be out of network.
For most services, each participant must first meet the $50 annual deductible. Then, whenever the participant receives dental services, the Leidos Dental PPO Plan pays a percentage of the cost of services, up to the reasonable and customary limit. The participant pays the remaining percentage (the coinsurance) plus any amount above the reasonable and customary limit.
Participants who go to out-of-network providers may be responsible for filing their own claims for reimbursement from the Leidos Dental PPO Plan. Check with your provider for information on their payment and claim filing policies.
Reasonable and Customary Limit
The reasonable and customary limit is the maximum amount the Leidos Dental PPO Plan will pay for a covered service, based on what dentists in the participant's geographic area charge for similar services. The determination of what the reasonable and customary limit is for a specific dental procedure is within the sole discretion of the insurance provider and is not subject to challenge or review.
The Leidos Dental PPO plan includes only services in the list below.
- Oral exam (two per participant per calendar year);
- Teeth cleaning (prophylaxis treatment to include scaling and polishing; two per participant per calendar year);
- Topical fluoride (limited to participants ages 18 and under; two per participant per calendar year);
- Bitewing X-rays (two per participant per calendar year);
- Full mouth X-rays (one per participant every 36 consecutive months); and
- Emergency treatment to relieve dental pain when no other definitive dental services are performed (not including X-rays).
- Diagnostic X-rays used to diagnose a condition;
- Single X-ray films;
- Additional X-ray films;
- Fissure sealants (limited to participants ages 13 and under; once per participant every three calendar years);
- Simple extractions;
- Surgical extractions (soft tissue impaction, partial bony impaction, complete bony impaction);
- General anesthesia — only eligible in conjunction with the following:
- Removal of one or more impacted teeth on the same day;
- The extraction of five or more teeth;
- More than one surgical extraction involving more than one quadrant on the same day.
- Amalgam restoration of primary or permanent teeth;
- Composite restoration;
- Root canal therapy — any X-ray, test, lab exam, or follow-up care is part of the allowance for root canal therapy and not a separate dental service;
- Pulp capping;
- Apicoectomy and retro fill;
- Apicoectomy and retro fill on separate appointment;
- Subgingival curettage;
- Gingivectomy; and
- Space maintainers, fixed unilateral (limited to non-orthodontic treatment).
- Crowns (including, but not limited to, porcelain with gold, cast gold);
- Stainless steel crowns;
- Crown; or
- Complete upper or lower denture;
- Partial upper or lower denture;
- Denture and partial adjustments;
- Denture reline;
- Denture duplication;
- Denture and partial repairs; and
- Adding teeth or clasps to partial denture.
- X-rays and records;
- Initial banding;
- Periodic visits for comprehensive (usually 24 months) treatment for adults and children;
- Interceptive (extension of preventive orthodontics that may localize tooth movement) treatment; and
- Orthodontic retention (removal of appliances, construction and placement of retainer(s)).
Temporomandibular Joint Dysfunction (TMJ) Appliances
The Leidos Dental PPO Plan will cover TMJ appliances if the participant's medical plan does not cover them. In such a case, the plan will cover TMJ appliances at 50% after the deductible, and subject to the annual benefit maximum.
Prosthesis Replacement Rule
Certain replacements or additions to existing dentures or bridgework will be covered under the Leidos Dental PPO Plan. However, to be covered by the plan, satisfactory proof must be given that:
- The replacement or addition of teeth is required to replace those that were extracted after the present teeth or bridgework was installed, and the participant must have been covered when the tooth was extracted;
- The present denture or bridgework cannot be made serviceable and must be at least five years old; or
- The present denture is a temporary one and cannot be made permanent, so a permanent denture is needed. The participant must have been covered under this plan when the original tooth was extracted, and replacement must take place within 12 months from the date the temporary one was first installed.
The Leidos Dental PPO Plan does not cover, or provide any payment for, the following:
- Services and supplies not necessary, as determined by Delta Dental, for the diagnosis, care or treatment of the disease or injury involved. This applies even if the service or supply is prescribed, recommended or approved by the person's attending physician or dentist;
- Care, treatment, services or supplies that are not prescribed, recommended and approved by the person's attending dentist;
- Initial bridges and dentures for the replacement of missing teeth, which were already missing prior to the effective date of coverage in Leidos's plan;
- Services or supplies that are determined by Delta Dental to be experimental or investigational. A drug, device, procedure or treatment will be determined to be experimental or investigational if:
- Insufficient outcomes data is available from controlled clinical trials published in the peer reviewed literature to substantiate its safety and effectiveness for the disease or injury involved;
- Approval has not been granted for marketing, if required by the Food and Drug Administration;
- A recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental, investigational or for research purposes; or
- The written protocol or protocols used by the treating facility or the protocol or protocols of any other facility studying substantially the same drug, device, procedure or treatment or the written informed consent used by the treating facility or by another facility studying the same drug, device, procedure or treatment states that it is experimental, investigational or for research purposes;
- Services of a resident physician or intern rendered in that capacity;
- Charges that are not reasonable, as determined by Delta Dental;
- Charges that are made only because there is health coverage;
- Charges that a covered person is not legally obliged to pay;
- Services and supplies that are furnished or paid for, or for which benefits are provided or required:
- By reason of the past or present service of any person in the armed forces of a government; or
- Under any law of a government (this does not include a plan established by a government for its own employees or their dependents or by Medicaid);
- Plastic surgery, reconstructive surgery, cosmetic surgery or other services and supplies which improve, alter or enhance appearance, whether or not for psychological or emotional reasons, except to the extent needed to repair an injury that occurs while the person is covered under this plan. Surgery must be performed:
- In the calendar year of the accident that causes the injury; or
- In the next calendar year; and
- Acupuncture therapy, including when it is:
- Performed by a physician; and
- As a form of anesthesia in connection with surgery that is covered under this plan;.
- Orthodontic services and supplies for:
- Changes in treatment required by an accident
- Maxillofacial surgery
- Myofunctional therapy
- Treatment for cleft palate (unless for a child under 18)
- Treatment of micrognathia (abnormal smallness of jaws) or macroglossia (congenital enlargement of tongue)
- Treatment of primary or transitional dentition
- Invisible braces (Note: This will be covered for 2009.)
- Dental expense not specifically described in the plan.
Malocclusion (Occlusal Guards)
The Leidos Dental PPO Plan will not cover Occlusal Guards since the participant's medical plan already provides coverage for them.
Predetermination of Benefits
If a participant needs extensive dental work and the total charges will be in excess of $250, a Predetermination of Benefits is strongly recommended. This will help the participant and his or her dentist understand what is covered under the plan and what the participant's share of the costs will be before services are provided.
To request an advanced claims review, dentists may submit their treatment plan to Delta Dental for review and estimation of coverage before procedures are started. Delta Dental advises the patient and the dentist of what services are covered and what the payment would be. The actual payment for these predetermined services depends on eligibility, any plan limitations, coordination of benefits and the remaining maximum at the time services are performed.
A predetermination plan is subject to change based on the dentist’s participation status at the time of treatment and does not guarantee direct payment. Of course, predetermination is optional, but it is strongly recommended for dental services expected to exceed $250.
Coordination of Benefits
If a participant or a participant's dependents are covered under another dental plan, then that plan and the Leidos Dental PPO Plan will work together to pay up to 100% of the charges or the normal level of benefits, whichever is less.
When the Leidos Dental PPO Plan is the primary plan, benefits are paid without regard to any other plans. The participant is responsible for coordinating any benefits by submitting the Explanation of Benefits and itemized bill to the secondary plan.
Determining Which Plan Pays First
The plan that covers the participant as an employee is the primary payer. The plan that covers the participant as a dependent is the secondary payer.
For an employee's spouse or registered domestic partner, a plan that covers the spouse or registered domestic partner as an employee is the primary payer for his or her claims. If an employee has elected coverage for his or her spouse or registered domestic partner as a dependent and the spouse or registered domestic partner has coverage through another employer, the Leidos Dental PPO Plan is the secondary payer.
For an employee's dependent children, the plan of the parent whose birthday occurs first in the calendar year is usually the primary payer. If an employee's spouse's or registered domestic partner's plan does not follow this "birthday rule," then the "gender rule" applies. That is, the plan covering the child's father as an employee pays first.
In the case of divorced or separated parents, benefits are determined in the following order:
- The plan of the parent who has financial responsibility by court decree;
- The plan of the stepparent who is the spouse or registered domestic partner of the parent who has custody of the child; and
- The plan of the parent who does not have custody of the child.
When none of these rules establishes order, benefits are paid first by the plan that has covered the person for the longer period of time, except that a plan that covers a laid-off or retired employee is secondary to a plan that covers a person as an active employee.
If a participant receives dental care from an out-of-network provider, he or she needs to file a Delta Dental claim form. Submit all claims to:
Delta Dental of VA
4818 Starkey Road
Roanoke, VA 24018
If a participant has concerns about how a claim has been administered or wishes to appeal a claims decision, information on relevant procedures is available in Claims Appeal and Review Procedures Under ERISA in the Plan Information section.