Hollywood Smile 2000
A. Enrollment and Eligibility
Individuals who are 18 years of age and older, and their eligible dependents (unmarried children from birth to age 26) are eligible to apply for coverage. Eligible ages for dependents may vary by state. Dependents named in the application must be approved by Ameritas Life Insurance Corp. as eligible. Specific criteria for dependent eligibility may vary by state.
B. Your Effective Date
For a 1st of the month effective date, apply by the 10th of that same month. Incomplete enrollment forms, or failure to submit the required initial premium amount may cause an initial delay in issuance of insurance. Do not cancel any other insurance or assume you are insured under the Plan until you receive your certificate of insurance.
C. How does the Ameritas plan work?
As long as you meet the plan's general eligibility requirements and pay the applicable premium, your acceptance is automatic. This Plan helps pay the cost of most dental care services, including exams, cleanings, fillings, extractions, crowns, bridges, and dentures.
Expenses must be incurred while the policy is in force and the person is covered by the policy. To be an eligible expense, the dental service or procedure must be performed by:
- a Dentist
- a Dental Assistant; or
- a Dental Hygienist.
An eligible expense is considered incurred on the following dates:
- For dentures - the date the final impression is taken.
- For fixed bridges, crowns, inlays and onlays - the date the teeth are first prepared.
- For root canal therapy - the date the pulp chamber is opened.
- For periodontal surgery - the date surgery is performed.
- For all other services - the date the service is performed.
Predetermination of Benefits: It is recommended that a treatment plan/course of treatment be submitted when the total cost of eligible expenses for any insured is expected to exceed the amount shown on the coverage schedule. This should be submitted to us before the work is started. If actual services submitted do not agree with the treatment plan, or if a treatment plan is not sent in, we will base our payment on treatment consistent with reasonable and customary charges. Predetermination of benefits is not a guarantee of what we will pay. The estimated benefit payment is based on your current eligibility and benefits in effect at the time of the completed service. Submission of other claims or changes in eligibility or this policy may alter final payment.
D. Calendar Year Deductible & Maximum Benefit Amount
The calendar year deductible is the amount of covered dental charges incurred by an insured person or on behalf of your insured dependent before Ameritas starts paying benefits. Combined calendar year deductible of $100 will apply to each insured person for Preventive, Basic and Major Services. The Maximum Benefit Amount is the maximum amount payable for all eligible dental expenses in any calendar year as shown on the Coverage Schedule. The Maximum Benefit Amount will apply to each insured person.
E. Choice of Provider
The Ameritas Network features:
- Discounted fees, typically 30% below average charges in your community
- Immediate network discounts
- One of the largest nationwide networks with over 400,000 access points and 100,000 unique providers
Network plans are designed for those who will visit an Ameritas dental network provider.
If you visit an in-network provider, your out-of-pocket costs will almost always be less because of the contracted fees (MAC/maximum allowable charge).
If you visit an out-of-network dentist, you pay the difference between what the plan pays and the dentist’s actual charge (MAB/maximum allowable benefit), which may result in higher out-of-pocket costs.
PPO Plans not available in all states.
F. Specialty Care/Specialist Referrals
Specialty Care can be utilized and the benefits will be applied based on the type of service needed, provided the applicable, if any, waiting periods have been satisfied.
G. Emergency Dental Services
Emergency services can be utilized and the benefits will be applied based on the type of service needed, provided the applicable, if any, waiting periods have been satisfied.
H. Cancellation Policy
You may cancel your policy at any time by notifying Ameritas of your request in writing.
I. Termination of Policy
Coverage terminates on the earliest of the following dates:
- The last day of the month in which your dependent is no longer a dependent, as defined.
- Subject to the grace period, the last day of the month for which a premium has been paid by you or on your behalf.
- The date the policy ends.
Dental Expenses will not include, and benefits will not be payable, for any of the following:
- Covered Dental Expenses for appliances, restorations, or procedures to do any of the following:
- Alter vertical dimension.
- Restore or maintain occlusion.
- Splint or replace tooth structure lost as a result of abrasion or attrition.
- Covered Dental Expenses for any procedure begun after the insured person’s insurance under this contract terminates.
- Covered Dental Expenses to replace lost or stolen appliances.
- Covered Dental Expenses for any treatment which is for cosmetic purposes.
- Covered Dental Expenses for any procedure not shown in the Table of Dental Procedures. (Frequency and other limitations may apply. Please see the Table of Dental Procedures for details.)
- Covered Dental Expenses for orthodontic treatment unless orthodontic expense benefits have been included in this policy. Please refer to the Schedule of Benefits and Orthodontic Expense Benefits provision.
- Covered Dental Expenses for which the Insured person is entitled to benefits under any workers’ compensation or similar law, or charges for services or supplies received as a result of any dental condition caused or contributed to by an injury or sickness arising out of or in the course of employment.
- Covered Dental Expenses for charges which the Insured person is not liable or which would not have been made had no insurance been in force, except for those benefits paid under Medicaid.
- Covered Dental Expenses for services that are not required for necessary care and treatment or are not within the generally accepted parameters of care.
- Covered Dental Expenses because of war or any act of war, declared or not.
- Alternative Procedures – Occasionally two or more procedures are considered adequate and appropriate treatment to correct a certain condition under generally accepted standards of dental care. In this case, the amount of the Covered Expense will be equal to the charge for the least expensive procedure. This provision is NOT intended to dictate a course of treatment. This provision is designed to determine the amount of the plan allowance for a submitted treatment when an adequate and appropriate alternative procedure is available. You may choose to apply the alternate benefit amount determined under this provision toward payment of the received treatment.
Underwritten by Ameritas Life Insurance Corp. This provides a very brief description of some of the important features of this insurance policy. It is not the insurance policy and does not represent it. A full explanation of benefits, exceptions and limitations is contained in the Individual Dental Policy Form Indiv. 9000 Rev. 07-16 and/or Vision Policy Form Indiv. 9000 Ed. 07-16-V. Premium rates may change upon renewal. This policy is renewable at the option of the insured. This product may not be available in all states and is subject to individual state regulations.