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Public Entity Members

Dental Plan

Check with your employer to see if this plan is offered.

Delta Dental of Missouri (DDMO) offers comprehensive dental benefits through a nationwide network of participating providers. These benefits include:

  • Diagnostic and preventive care services
  • Basic and restorative services
  • Major services

Members may visit a dentist of their choice, but out-of-pocket costs may vary depending on dentist selection. Visit Delta Dental to find a participating dentist. ID cards can be requested through DDMO.

Benefit Chart

Coverage Service Description Frequency You Pay
Diagnostic & Preventive Exams1 All types Twice per calendar year2 No deductible
0% coinsurance
Prophylaxis1 Teeth cleaning, scaling and polishing, periodontal maintenance visits Twice per calendar year2
Fluoride For eligible dependents under age 14 Once per calendar year
Bitewing X-rays1   Once per calendar year
Sealants Limited to caries-free occlusal surfaces of the first and second permanent molars Once every 5 years
Basic & Restorative Emergency Palliative Treatment Minor procedures to temporarily reduce or eliminate pain As needed $50/person deductible3
20% coinsurance
Space Maintainers Replaces prematurely lost teeth, except for accidental injuries. For eligible dependents under age 14 Once every 5 years
Minor Restorative Services Fillings that use amalgam, synthetic porcelain and plastic material Once every 2 years per tooth unless accidental injury
Periapical X-rays   As required
Full-mouth X-rays Includes panoramic film with or without other films, as well as multiple X-rays on the same date of service One every 5 years
Simple Extractions Routine removal (through use of forceps) of tooth structure, minor smoothing of socket bone, and closure As needed
Major Services

12-month waiting period required

Waiting period is waived with proof of prior 12-month dental coverage
Oral Surgery Includes surgical extractions, such as the cutting of gingiva and bone when removing tooth As needed 50/person deductible3
50% coinsurance
Periodontics Treatment of gum disease and bone supporting the teeth Surgery on the same site: One every 3 years
Therapy: One every 2 years
Endodontics Root canal and pulpal therapy. Re-treatment of the same tooth is allowed when performed by a different dental office One every 2 years per tooth
Prosthetic Devices Bridges, dentures and partials. An alternate benefit allowance (based on cost) will be provided for a fixed bridge. Once every 7 years
Major Restorative Services New or replacement crown, jacket, labial veneer, inlay or onlay. Excludes accidental injury. Once every 7 years
General Anesthesia In conjunction with covered surgical procedures  
Dentures Repairs and relines.  
Implants An allowance toward a removable partial denture or fixed bridge and related bone grafts. Once every 7 years
  1. Individual plan maximum does not apply
  2. Two additional cleanings allowed per calendar year for members who are pregnant, diabetic, have a suppressed immune system or a history of periodontal therapy. To be eligible, members must submit a completed Self-Report form unless periodontal therapy has already been reported on claims.
  3. Coinsurance amounts apply after the $50 individual deductible is met under either Basic and Restorative or Major Services combined.

 

Limitations & Exclusions

Type Service Description
Limitations Alternative Treatments If available, DDMO will cover the least costly treatment
Coverage Coverage is limited to $1,000 per person per calendar year
Preauthorizations Non-emergency procedures with a cost estimate of more than $200 may be subject to a preauthorization. This provides an advanced estimate of what the dental coverage will pay and what the member will pay.
Transferring Care If two or more providers are used for the same procedure, benefits will not exceed what would have been paid for one provider.
Exclusions Analgesic Services Includes nitrous oxide
Cosmetic Services  
Congenital Malformations Except newborns with congenital dental defects
Dentures Excludes coverage of lost or stolen dentures, as well as adjustments for the first six months
Experimental Services  
Occlusal Services Includes athletic mouthguards, nightguards, bruxism and bite therapy appliances
Orthodontia Services  
Temporomandibular joint syndrome (TMJ) Services Involves the hinge joint connecting the upper and lower jaws
Third Molar Removal When absent of symptoms

Summary of excluded services: For a complete list, visit DDMO’s website.

How the Dental Plan Works

  1. The member may visit a network or non-network provider.
    1. DDMO offers two provider networks: the Delta Dental PPO Network and the Delta Dental Premier Network. Both networks offer members cost-control and claim-filing benefits. However, out-of-pocket expenses may be higher with the Delta Dental Premier Network.
    2. If utilizing a non-network provider, the member will be responsible for paying the provider in full, as well as submitting a claim form to DDMO. The out-of-pocket costs will most likely be higher.
  2. The cost of the visit will also depend on the type of service the member received.
    1. Diagnostic and preventive services are covered at 100 percent.
    2. Members receiving basic and restorative or major services must meet a $50 deductible. Once the deductible is met, members will pay coinsurance (see Benefit Chart for more information).
  3. Coverage is limited to $1,000 per person per calendar year.
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