The Indemnity Plan
- What dental services are covered under the Indemnity Plan?
- How can I know in advance what my treatment will cost?
- How do I receive services from a dentist?
- If your dentist participates in Delta Dental
- If your dentist does not participate in Delta Dental
- How do I submit dental claim forms?
- Are there any limitations or restrictions on the Indemnity Plan?
- Reimbursement table for the Indemnity Plan
What dental services are covered under the Indemnity Plan?
The Fund’s Indemnity Plan is administered by Delta Dental of Massachusetts. The dental procedures covered under the Indemnity Plan and the Fund’s reimbursement schedule are listed in the Indemnity Plan Reimbursement Schedule. Under the Indemnity Plan you may see any licensed general dentist or specialist you wish. Patients are responsible for the difference between the Fund payment and the dentist’s charges.
How can I know in advance what my treatment will cost?
Before starting any dental treatment which you consider costly, you are strongly encouraged to request that your dentist submit a pre-treatment estimate to Delta Dental of Massachusetts. Delta Dental of Massachusetts will tell you, in writing, the maximum reimbursement you will receive. Your benefit is limited to your plan maximum.
If you are enrolled in the Indemnity Plan and receive services from an MPE Exclusive Provider Network (EPN) dentist, claims will be paid according to the Indemnity Plan reimbursement schedule.
How do I receive services from a dentist?
Under the Indemnity Plan, you may visit any licensed general dentist or specialist you wish. The Fund will reimburse up to the amount listed in the Fund’s Indemnity Plan reimbursement schedule
Because the Fund retains the services of Delta Dental of Massachusetts to provide third-party administrative services, Fund members are able to take advantage of some benefits offered to Delta Dental members. Your out-of-pocket costs may differ based on whether your dentist participates in Delta Dental in Massachusetts, Delta Dental outside of Massachusetts, or does not participate with Delta Dental. You should confirm with your dentist whether they participate with Delta Dental.
If your dentist participates in Delta Dental:
Your dentist agrees to accept a fee for service that is determined by Delta Dental. This fee is called a “maximum allowable fee”. You are responsible for the difference between the Fund’s reimbursement schedule and the dentist’s maximum allowable fee.
Delta Dental manages the Delta Dental Premier network and the Delta Dental PPO network. If you dentist participates in one of those networks, s/he agrees to accept a fee for service that is determined by Delta Dental of Massachusetts. You are responsible for the difference between the Fund’s reimbursement and this fee. If your dentist is a “participating Delta Dental PPO provider”, the savings to you may be greater.
Your dentist will submit your claim directly to Delta Dental of Massachusetts.
You will receive an Explanation of Benefits (EOB) form after your claim is filed by your participating dentist. The patient payment column of your EOB shows the amount you owe your dentist.
If your dentist does not participate in Delta Dental:
You must pay your dentist’s actual charges directly.
You must submit a claim form to Delta Dental of MA, and Delta Dental will reimburse you directly.
How do I submit dental claim forms?
You can obtain claim forms by calling the MPE Unit at Delta Dental of MAat (800) 553-6277. Completed claim forms should be submitted to:
MPE Claims
PO Box 2907
Milwaukee, WI 53201-2907
When benefit payments are made directly to you it is your responsibility to pay your dentist. You are responsible for the difference between the Fund’s Indemnity Plan reimbursement schedule and the dentist’s full charge
Are there any limitations or restrictions on the Indemnity Plan?
The Fund will pay up to $1,600* per person, per plan year, for covered dental procedures under the Indemnity Plan, exclusive of reimbursements for orthodontics, preventive, diagnostic, periodontal scaling and root planing services and immediate and complete dentures. There is a separate Annual Plan Maximum of $1,175 for surgical placement of an implant.
Delta Dental of Massachusetts reserves the right to reimburse you for an alternate course of treatment based on the materials and method of treatment which cost the least and which meet generally accepted dental standards. You will be reimbursed only the benefit allowed on the procedures specified under this alternate course of treatment. You have the right to appeal this determination in accordance with the procedure noted on the EOB form and in accordance with the Appeal Process.
You must submit your Indemnity Plan claim forms to Delta Dental of Massachusetts within one year of the date on which you received dental treatment or you will not be reimbursed.
The Fund will pay no more than $1,200 per person, per lifetime, for orthodontic treatment.
If you change your dental plan prior to completion of orthodontic treatment, no further payments will be made by the Fund.
*This annual plan maximum amount became effective with the plan year beginning July 1, 2023. Commonwealth of Massachusetts Seasonal Employee annual plan maximum is equal to 50% of stated maximum.