Why Choose Foundation Dental?
What types of services are covered?
Foundation Dental plans include coverage for necessary dental treatments in three different classes of service, which may be subject to age or frequency limitations.
- Diagnostic & Preventative Services – X-Rays, Oral Exams, Prophylaxis, Sealant, Space Maintainers, and Topical Application of Fluoride
- Basic Services – Amalgam, Anterior and Posterior Restorations; Simple Extractions, Sedative
- Fillings, Emergency Palliative Treatment, Full Mouth X-Rays, Problem Focused Exams
- Major Services – Oral Surgery, Periodontics, Endodontics, Bridges, Crowns, Dentures
Though network discounts may apply, not all classes of service have benefits payable for all plan levels. Choose the plan level with the coverage that’s right for you.
Who is eligible to apply for this insurance?
Foundation Dental is available to Med-Sense Guaranteed Association members age 18 and older, their spouses/domestic partners, and their dependent unmarried children under 19 years old or up to age 26.
Are there both In-Network and Out-of-Network Benefits?
You may choose to use a provider who participates with the Maximum Care Network or a
non-participating provider. Benefits are determined and payable in either case. If a participating provider is
chosen, the covered person will generally have less out-of-pocket cost.
Is there a Plan Year Maximum Benefit?
The Plan Year Maximum Benefit is the maximum benefit payable by the Policy for all Covered
Procedures completed in each calendar year, January 1st through December 31st. The Plan Year Maximum Benefit
depends on which plan is chosen and is listed in the Schedule of Benefits.
How does a Deductible affect a Covered Person’s Benefits?
Deductibles are per person, per calendar year. A covered person must pay any applicable
deductible amount before covered benefits are payable under the plan chosen.
How are Covered Expenses determined?
The Covered Expense is based on the Maximum Reimbursement for your plan, as shown in the
Schedule of Benefits. For your plan (in all states except MA, NJ and VA), the Maximum Reimbursement is based on
MAC (Maximum Allowable Charge), the amount that a Participating Provider has agreed to accept as payment in full
for dental services. MAC is also used for non-participating providers; non-participating providers may bill for
the difference between the original billed charge and the MAC. In MA, NJ and VA, the Maximum Reimbursement for
all providers is based on CMAC (Customary Maximum Allowable Charge), which is the reasonable and customary
charge determined from within a range of charges made for the same service by other providers in that geographic
area. Providers may bill for the difference between the original billed charge and the CMAC.
How does a Benefit Waiting Period affect a Covered Person’s Benefits?
If a Covered Procedure is started before the Benefit Waiting Period for that procedure ends,
that procedure is not covered under the Policy. The Benefit Waiting Periods for Covered Procedures are listed in
the Schedule of Covered Procedures and vary by class of service.
If Benefits are not paid at 100%, how does the Percentage of Covered Expense affect Benefits?
The Percentage of Covered Expense is the percentage of the
Covered Expense that We will pay for a Covered Procedure. The percentage applicable to a Covered Person may vary
by Covered Procedure and is shown in the Schedule of Benefits.
- Any Services which are not included in the Schedule of Covered Procedures
- Any procedure We determine is not necessary, does not offer a favorable prognosis, does not have uniform professional endorsement or is experimental in nature
- Crowns, inlays, onlays, cast restorations, or other laboratory prepared restorations on teeth, which may be satisfactorily restored with an amalgam or composite resin filling
- Any treatment which is elective or primarily cosmetic in nature and not generally recognized as a generally accepted dental practice by the American Dental Association, as well as any replacement of prior cosmetic restorations unless such procedure is listed in the Schedule of Covered Procedures
- Replacement of bridges unless the bridge is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable and replacement of full or partial dentures unless the prosthetic appliance is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable
- Replacement of crowns, inlays or onlays unless the prior restoration is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable
- Prescription drugs, premedication, pharmaceuticals, or analgesia
- Any charge for a Service for which benefits are available under Worker’s Compensation or an Occupational Disease Act or Law, even if You did not purchase the coverage that is available to You
- Any charge for a Service performed outside of the United States other than for Emergency Treatment. Benefits for Emergency Treatment performed outside of the United States are limited to a maximum of 0100 per Plan Year
- Local anesthetic, including light anesthetic, as a separate fee
- Dental services performed in a hospital and related hospital fees
- Services covered under an existing medical plan
- The portion of an expense which is in excess of the reasonable charge
- General anesthesia and I.V. sedation, unless deemed medically necessary as determined by a professional