Leidos Dental PPO Plans (Low & High)
Leidos offers two Dental PPO (Plus Premier) plan options: Dental PPO Low and Dental PPO High. Both plans are administrated by Delta Dental of VA and allow 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.
Paying for Care
This section will help participants understand how they pay for care under the Leidos Dental PPO (Plus Premier) Plans.
Employee Contributions
Leidos and participants share the cost of coverage. Each pay period, a participant who enrolls in a Leidos Dental PPO (Plus Premier) plans contributes a set dollar amount to help pay for the cost of the plan. 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.
Annual Deductible
The deductible is the initial $50 each participant must pay for basic and major dental services each calendar year before the plan begins to pay benefits.
Coinsurance
Coinsurance is the percentage of eligible expenses a participant pays for dental services after the deductible is met.
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. Preventive care and diagnostic services (typically x-rays, exams and cleanings) do not count against the annual benefit maximum.
Each year, the Leidos Dental PPO High Plan will pay a maximum of $1,500 per participant. Those enrolled in the Leidos Dental PPO Low Plan will have a maximum benefit of $1,000 annually per participant.
If you are enrolled in the Leidos Dental PPO High Plan, there is a separate $1,500 lifetime maximum for orthodontic services per participant.
Plan Design
This section will help participants understand how the Leidos Dental PPO (Plus Premier) Plans pay benefits.
Network Benefits
By visiting a network dentist, a participant 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 (Plus Premier) Plans pay a percentage of the cost. The participant pays the remaining amount (the coinsurance).
Participants have access to both of Delta’s PPO and Premier networks. Thus, participants have a wider selection of in-network dentists. However, participants will generally have a higher out-of-pocket cost if they use a dentist in the Delta Dental Premier network. For more information, visit https://deltadentalva.com/members/leidos.
There are no claim forms to file because the network dentist submits claims for the participant.
Refer to the brochure for additional details on the Delta Dental (Plus Premier) network.
Out-of-Network Benefits
When a participant uses a dentist who does not participate in the Delta Dental PPO network, that dentist is considered to be out of network.
For most services, each participant must first meet the $50 annual deductible. Once the deductible is satisfied, the Leidos Dental PPO (Plus Premier) Plans pay a percentage of the cost of services, up to the non-participating provider allowance. The participant pays the remaining percentage (the coinsurance) plus any amount above the non-participating provider allowance.
Participants who go to out-of-network providers may be responsible for filing their own claims for reimbursement from the Leidos Dental PPO (Plus Premier) Plans. Check with your provider for information on their payment and claim filing policies.
Non-Participating Provider Allowance
Delta Dental’s Non-Participating Provider Allowance is the maximum amount the Leidos Dental PPO (Plus Premier) Plans will pay for a covered service rendered by an out-of-network provider. The allowance for a specific dental procedure is within the sole discretion of Delta Dental and is not subject to challenge or review.
Coverage
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Both Leidos Dental PPO (Plus Premier) plans provide coverage for services in the list below.
Preventive and Diagnostic Services
- 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 age 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 60 consecutive months);
- Diagnostic X-rays used to diagnose a condition;
- Single X-ray films;
- Additional X-ray films;
- Sealants and preventive resin restorations (limited to participants under the age of 16; once per participant every three calendar years); and
- Palliative emergency treatment of dental pain - minor procedure
Basic Services
- Simple extractions;
- Surgical extractions (soft tissue impaction, partial bony impaction, complete bony impaction);
- Impactions;
- General anesthesia — only eligible in conjunction with the following:
- Removal of one or more impacted teeth on the same day;
- The extraction of three 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;
- Pulpotomy;
- Apicoectomy and retro fill;
- Apicoectomy and retro fill on separate appointment;
- Subgingival curettage;
- Gingivectomy;
- Space maintainers, fixed unilateral (limited to non-orthodontic treatment);
- Stainless steel crowns;
- Adjustments to complete and partial dentures;
- Repairs to complete and partial dentures;
- Adding teeth or clasps to partial denture; and
- Recementation:
- Inlay;
- Crown; or
- Bridge;
Major Services
- Bridges;
- Complete upper or lower denture;
- Partial upper or lower denture;
- Denture reline;
- Implants; and
- Temporomandibular Joint (TMJ) Dysfunction
Orthodontic Services (Leidos Dental PPO High plan only)
- 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)).
- Invisible braces
Temporomandibular Joint Dysfunction (TMJ) Appliances
The Leidos Dental PPO (Plus Premier) Plans cover TMJ appliances. The plan will cover TMJ appliances at 60% in-network/ 50% out-of-network under the PPO High Plan and 50% in-network/40% out-of-network under the PPO Low Plan. This is covered subject to the deductible and annual benefit maximum. -
The Leidos Dental PPO (Plus Premier) Plans do not cover, or provide any payment for, the following unless specifically identified as a covered benefit:
- 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;
- 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;
- Dental services for restoring tooth structure lost from wear (abrasion, erosion, attrition or abfraction), for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing the teeth. Such services include but are not limited to equilibration and periodontal splinting;
- Services provided by someone other than a licensed dentist or a qualified dental hygienist working under the supervision of a dentist;
- 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 that Delta Dental determines are for correcting congenital malformations; also surgery for cosmetic purposes;
- Services for injuries or conditions that may be covered under workers’ compensation or similar employer liability laws or other medical plan coverage;
- Services provided before the date the participant enrolled under the Plan. Except as otherwise provided under the Plan, benefits for a course of treatment that began before the participant was enrolled under the Plan;
- Dental services provided after the date you are no longer enrolled or eligible for coverage, except as otherwise provided under the Plan;
- Prescription and non-prescription drugs, pre-medications, preventive control programs, oral hygiene instructions and relative analgesia, except as provided for under the Plan;
- General anesthesia when less than three (3) teeth will be routinely extracted during the same office visit;
- Splinting or devices used to support, protect or immobilize oral structures that have loosened or been re-implanted, fractured or traumatized;
- Charges to complete a claim form, copy records, or respond to Delta Dental’s request for information;
- Charges for failure to keep an scheduled appointment;
- Services or treatment provided to an immediate family member by the treating Dentist. This would include the Dentist’s parent, spouse or child;
- Dental services and supplies for the replacement device or repeat treatment for lost, misplaced or stolen prosthetic devices including space maintainers, bridges and dentures (among other devices);
- Services billed under multiple procedure codes in which Delta Dental, in its sole discretion, determines that the service was either a component part of or inclusive of a more comprehensive or primary procedure code. This exclusion is subject to any and all internal and external appeals available. Delta Dental bases its payment on the Plan Allowance for the primary code, not the Plan Allowance for the underlying component code;
- Services billed under a dental procedure code that Delta Dental, in its sole discretion, determines should have been billed under a code that more accurately describes the dental service. Delta Dental bases its payments in its determination of the more accurate dental service code; and
- Amounts that exceed the Plan Allowance for covered benefits;
- Replacement retainers
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 the 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 (Plus Premier) 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 (Plus Premier) 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
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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.
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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 (Plus Premier) 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 the primary payer. If both parents have the same birthday, the Plan that covered the parent longer is primary. 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, the primary plan is determined in the following order:
- The plan of the parent who has financial responsibility by court decree;
- If there is no court order, the Plan of the natural parent with legal custody.
- If one parent re-marries or both parents re-marry, the Plan of the natural parent with legal custody is the primary plan. The Plan of the child’s custodial step-parent is the secondary plan. Plan benefits for the child’s parent without legal custody are determined third. The non-custodial step-parent’s plan benefits are determined fourth.
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.
Filing Claims
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 24018-8510
The participant may also submit the claim form via email to [email protected]
Participants must submit all claims for dental benefits within twelve (12) months of the date services are completed. For orthodontic services, a claim for benefits should be filed at the time of banding.
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.