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Medicare Advantage Dental Participation and Benefit Summary

Audience: Participating Dentists, Dental Office Managers and Staff

All dental providers participating with Excellus BlueCross BlueShield must also participate with Original Medicare (i.e., not opt-out) to receive payment for dental services provided to Medicare Advantage members. We pay dental providers directly based on the Excellus BCBS commercial dental fee schedule.

We encourage you to remain a participating dental provider with Original Medicare. If you opt out of Original Medicare, Excellus BCBS cannot reimburse your practice for services rendered to Medicare Advantage members. Additionally, in accordance with Federal regulations, Medicare Advantage members are not permitted to submit dental claims and request reimbursement directly from Excellus BCBS from providers who have opted-out of Original Medicare.

We’ve included a summary of the dental benefits available to our direct pay Medicare Advantage members in this notice. At each visit, please check your patient’s member card and call Customer Care at 1-800-724-1675 to verify benefits and eligibility.

Thank you for your continued participation, and for the quality care and service that you provide to our valued members.

Medicare Advantage Dental Benefit Summary

  COMPLEMENTARY DENTAL FULL COMPREHENSIVE DENTAL
  Available to go with our plans that already include preventive dental coverage: (2 cleanings, 2 oral exams & 2 bitewing x-rays per year) Available to go with our plans that don’t provide preventive dental coverage
Preventive Dental Already covered by the Medicare Advantage Plan *NEW for 2021: $10 copay per service for Medicare Blue PPO BlueEssential (Syracuse region)

2 cleanings, 2 oral exams & 2 bitewing x-rays per year

No cost-share to member for in-network services.

Restorative
  • Amalgam Restorations (once per tooth every 12 months)
  • Resin Filling (once per tooth every 12 months)
  • Composite Restorations (once per tooth every 12 months)

Member cost-share: 20% coinsurance (in-network) 50% coinsurance (out-of-network)

  • Amalgam Restorations (once per tooth every 12 months)
  • Resin Filling (once per tooth every 12 months)
  • Composite Restorations (once per tooth every 12 months)

Member cost-share: 20% coinsurance (in-network) 50% coinsurance (out-of-network)

Periodontics
  • Scaling and root planning (once per quadrant per 24 months)
  • Periodontal Maintenance (twice every calendar year)
  • Osseous Surgery Gingivectomy or Gingivoplasty
  • Gingival Flap Procedure

Member cost-share: 50% coinsurance (in-network) 55% coinsurance (out-of-network)

  • Scaling and root planning (once per quadrant per 24 months)
  • Periodontal Maintenance (twice every calendar year)
  • Osseous Surgery Gingivectomy or Gingivoplasty
  • Gingival Flap Procedure

Member cost-share: 50% coinsurance (in-network) 55% coinsurance (out-of-network)

Oral Surgery
  • Surgical Extractions
  • Partial and Full Bony Extractions
  • Simple Extractions Incisional Biopsy of Oral Tissue- hard or soft. This benefit covers biopsies of oral tissue that are not covered under the medical benefit.
  • Alveoloplasty- without or without extractions. Only covered when preparing the mouth for dentures
  • Incision and Drainage of Abscess

Member cost-share: 50% coinsurance (in-network) 55% coinsurance (out-of-network)

  • Surgical Extractions
  • Partial and Full Bony Extractions
  • Simple Extractions Incisional Biopsy of Oral Tissue- hard or soft. This benefit covers biopsies of oral tissue that are not covered under the medical benefit.
  • Alveoloplasty- without or without extractions. Only covered when preparing the mouth for dentures
  • Incision and Drainage of Abscess
Member cost-share: 50% coinsurance (in-network) 55% coinsurance (out-of-network)
Endodontics
  • Root Canal
  • Endodontics Therapy (once per tooth per lifetime)
  • Apicoectomy Pulp Vitality Test

Member cost-share: 50% coinsurance (in-network) 55% coinsurance (out-of-network)

  • Root Canal
  • Endodontics Therapy (once per tooth per lifetime)
  • Apicoectomy Pulp Vitality Test

Member cost-share: 50% coinsurance (in-network) 55% coinsurance (out-of-network)

Prosthodontics & Prosthetic Maintenance
  • Crowns (once per tooth every 5 years)
  • Complete Dentures (once every 5 years)
  • Partial Dentures (once every 5 years)
  • Temporary Partial Dentures Inlays/Onlays - Single (once per tooth every 5 years)
  • Fixed Bridges (once per tooth every 5 years)
  • Crown Recement
  • Denture Adjustments
  • Denture Repairs Denture Recline & Rebase (once every 36 months)
  • Bridge Repairs Bridge Re-cementation
  • Inlays/Onlays - Re-cementation

Member cost-share: 50% coinsurance (in-network) 55% coinsurance (out-of-network)

  • Crowns (once per tooth every 5 years)
  • Complete Dentures (once every 5 years)
  • Partial Dentures (once every 5 years)
  • Temporary Partial Dentures Inlays/Onlays - Single (once per tooth every 5 years)
  • Fixed Bridges (once per tooth every 5 years)
  • Crown Recement
  • Denture Adjustments
  • Denture Repairs Denture Recline & Rebase (once every 36 months)
  • Bridge Repairs Bridge Re-cementation
  • Inlays/Onlays - Re-cementation

Member cost-share: 50% coinsurance (in-network) 55% coinsurance (out-of-network)

Annual Deductible (for Restorative and Major Dental Services) $100 a year for Comprehensive Dental services (In & Out-of-network) $100 a year for Comprehensive Dental services (In & Out-of-network)
Annual Maximum Benefit (for Restorative and Major Dental Services) $1,000 a year for Comprehensive Dental services (In & Out of network) $1,000 a year for Comprehensive Dental services (In & Out of network)
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Category

Excellus

Benefits & Eligibility

Dental