This Aetna Dental
®
Preferred Provider Organization (PPO) insurance plan summary is provided by
Aetna Life Insurance Company (Aetna) for some of the more frequently performed dental procedures.
Under this plan, you may choose at the time of service either a PPO participating dentist or any
nonparticipating dentist. With the PPO plan, savings are possible because the PPO participating dentists
have agreed to provide care for covered services at the negotiated fee schedule.
Who is eligible
dependents enrolled in the Dependent Care health insurance plan are automatically enrolled in the Aetna PPO dental
insurance plan.
Coverage Dates
Coverage for all enrolled students will become effective at 12:01 AM on the Coverage Start Date indicated below and
will terminate at 11:59 PM on the Coverage End Date indicated.
Annual
09/01/2023-
08/31/2024
Winter
01/01/2024-
08/31/2024
Spring
04/01/2024-
08/31/2024
Spring/Summer
06/01/2024-
08/31/2024
Who provides the care
Just as the starting point for coverage under your plan is whether the services and supplies are eligible
dental services, the foundation for getting covered care is through our network.
This section tells you about in-network and out-of-network providers.
In-network providers
We have contracted with dental providers to provide eligible dental services to you. These dental
providers make up the network for your plan.
You may select an in-network provider from the directory or by logging on to our website at
www.aetnastudenthealth.com. You can search our online directory, for names and locations of dental
providers.
You will not have to submit claims for treatment received from in-network providers. Your in-network
provider will take care of that for you. And we will directly pay the in-network provider for what the plan
owes.
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Out-of-network providers
If you use an out-of-network provider to receive eligible dental services, you are subject to a higher out-
of-pocket expense and are responsible for:
• Paying any out-of-network deductibles
• Your out-of-network coinsurance
• Any charges over our recognized charge
• Submitting your own claims
Description of Benefits
The Plan excludes coverage for certain services (referred to as exceptions and exclusions in the certificate
of coverage) and has limitations on the amounts it will pay. While this Plan Design and Benefit Summary
document will tell you about some of the important features of the Plan, other features may be
important to you and some may further limit what the Plan will pay. To look at the full Plan description,
which is contained in the Certificate of Coverage issued to you, go to www.aetnastudenthealth.com. If
any discrepancy exists between this Benefit Summary and the Certificate of Coverage, the Certificate will
control.
This Plan will pay benefits in accordance with any applicable California Insurance Law(s).
Policy year Deductible
You have to meet your policy year deductible before this plan pays for benefits.
In-network coverage
Out-of-network coverage
Policy year deductible
Individual $25
Family $75
Individual $50
Family $150
The policy year deductible applies to all eligible dental services except Type A expenses. Eligible dental services
applied to the out-of-network deductibles will be applied to satisfy the in-network deductibles. Eligible dental
services applied to the in-network deductibles will be applied to satisfy the out-of-network deductibles.
Coinsurance listed in the schedule of benefits
The coinsurance listed in the schedule of benefits below reflects the plan coinsurance percentage. This is the
coinsurance amount that the plan pays. You are responsible for paying any remaining coinsurance.
Coinsurance
In-network coverage
Out-of-network coverage
Type A expenses
100% of the negotiated charge
50% of the recognized charge
Type B expenses
80% of the negotiated charge
50% of the recognized
Type C expenses
Not covered
Not covered
Stanford University 2023-2024 Page 3
Orthodontic treatment
In-network coverage
Out-of-network coverage
Orthodontic treatment
Not covered
Not covered
Policy year maximum
In-network coverage
Out-of-network coverage
Policy year maximum
$1,000
$1,000
This policy year maximum applies to in-network and out-of-network eligible dental services combined.
Dental emergency services maximum
In-network coverage
Out-of-network coverage
Dental emergency maximum
N/A
$75
Eligible dental services
Type A expenses: Diagnostic & preventive care
Visits and exams
•
Office visit during regular office hours for oral examination (2 routine visits and 2 problem focused visits
per year)
•
Prophylaxis (cleaning) or scaling-moderate/severe inflammation–full mouth, (2 treatments per year)
•
Topical application of fluoride if you are under age 16, (1 applications per year)
•
Sealant repair - per tooth (for permanent molars only and if you are under age 16)
•
Sealants, per tooth (1 application every 3 years for permanent molars only and if you are under age 16)
Images and pathology
•
Bitewing images (1 set per year)
•
Entire dental series, including bitewings or panoramic film (1 set every 3 years)
•
Vertical bitewing images (1 sets every 3 years)
•
Periapical images
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Space maintainers - Only when needed to preserve space resulting from premature loss of deciduous teeth.
(Includes all adjustments within 6 months after installation.)
•
Fixed or removable (unilateral or bilateral)
•
Recementation or removal
Type B expenses: Basic Restorative Care
Visits and exams
•
Office visit after hours (we will pay either for the office visit charge or for the eligible dental services
performed, whichever is more)
•
Emergency palliative treatment, per visit
Images and pathology
•
Intra-oral, occlusal view
•
Extra-oral
•
Accession of tissue
Restorative - Excluding inlays, onlays and crowns. Multiple restorations in 1 surface will be considered as a single
restoration.
•
Amalgam restorations
•
Resin-based composite restorations, (other than for molars)
•
Protective restoration
•
Reattachment of tooth fragment, incisal edge or cusp
•
Interim therapeutic restoration – primary dentition
•
Pin retention, per tooth, in addition to restoration
•
Recementation
•
Prefabricated crowns, primary teeth only (excluding temporary crowns)
Periodontics
•
Periodontal maintenance (following active therapy, 2 per year)
•
Occlusal adjustment, (other than with an appliance or by restoration)
•
Root planing and scaling, 1 to 3 teeth per quadrant, (1 per site every 2 years)
•
Root planing and scaling, 4 or more teeth per quadrant, (1 separate quadrants every 2 years)
•
Surgical revision procedure, per tooth
•
Gingivectomy/gingivoplasty, 1 to 3 teeth per quadrant, (1 per site every 3 years)
•
Gingivectomy/gingivoplasty, 4 or more teeth per quadrant, (1 per quadrant every 3 years)
•
Gingival flap procedure, 1 to 3 teeth per quadrant, (1 per site every 3 years)
•
Gingival flap procedure, 4 or more teeth per quadrant, (1 per quadrant every 3 years)
•
Apically positioned flap
•
Unscheduled dressing change (by someone other than treating dentist or their staff)
Endodontics
•
Pulp cap
•
Pulpal debridement
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• Pulpal therapy
• Pulpotomy
• Apexification/recalcification
• Apicoectomy
• Root canal therapy and retreatment once per lifetime
o
Anterior
o
Bicuspid
• Pulpal regeneration
• Periradicular surgery without apicoectomy
• Hemisection
• Retrograde filling
• Root amputation
• Treatment of root canal obstruction
• Incomplete endodontic surgery
• Internal root repair of defect
Oral surgery
• Extractions – coronal remnants – deciduous tooth
• Extractions erupted tooth or exposed root
• Surgical removal of impacted tooth (bony, including wisdom teeth)
• Surgical removal of erupted tooth
• Surgical removal of residual tooth roots
• Primary closure of a sinus perforation
• Oroantral fistula closure
• Tooth transplantation
• Surgical access of unerupted tooth
• Mobilization of erupted or malpositioned tooth to aid eruption
• Placement of device to facilitate eruption of impacted tooth
• Biopsy of oral tissue
• Exfoliative cytological sample collection
• Alveoloplasty
• Removal of odontogenic cysts or tumors
• Removal of exostosis
• Removal of torus
• Surgical reduction of osseous tuberosity
• Incision and drainage of abscess
• Removal of foreign body
• Sequestrectomy
• Suture of wounds
• Frenectomy/frenuloplasty
• Excision of hyperplastic tissue per arch
• Excision of pericoronal gingiva
• Surgical reduction of fibrous tuberosity
• Removal of impacted tooth-Soft tissue
• Sialolithotomy
• Closure of salivary fistula
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Periodontics
• Osseous surgery, (including flap and closure), 1 to 3 teeth per quadrant (1 per site every 3 years)
• Osseous surgery, (including flap and closure), 4 or more per teeth per quadrant (1 per quadrant every 3
years)
• Soft tissue graft procedures
• Full mouth debridement (1 per lifetime)
Endodontics
• Root canal therapy and retreatment once per lifetime
o
Molar
General exceptions and exclusions
The following are not eligible dental services under your plan:
Charges for services or supplies
• Provided by in-network providers in excess of the negotiated charge
• Provided by an out-of-network provider in excess of the recognized charge
• Provided for your personal comfort or convenience, or the convenience of any other person,
including a dental provider
• Cancelled or missed appointment charges or charges to complete claim forms
• Charges for which you have no legal obligation to pay
• Charges that would not be made if you did not have coverage, including:
- Care in charitable institutions
- Care for conditions related to current or previous military service
- Care while in the custody of a governmental authority
Charges in excess of any benefit limits
Any charges in excess of the benefit, dollar, visit, or frequency limits stated in the schedule of
benefits.
Cosmetic services and plastic surgery (except to the extent coverage is specifically provided in
the Eligible Dental Services section of the schedule of benefits)
• Cosmetic services and supplies including:
- Plastic surgery
- Reconstructive surgery
- Cosmetic surgery
- Personalization or characterization of dentures or other services and supplies which improve,
alter or enhance appearance
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- Augmentation and vestibuloplasty and other services to protect, clean, whiten, bleach alter the
appearance of teeth whether or not for psychological or emotional reasons
Facings on molar crowns and pontics will always be considered cosmetic
Court-ordered services and supplies
• Includes those court-ordered services and supplies, or those required as a condition of parole,
probation, release or as a result of any legal proceeding.
Dental services and supplies
• Acupuncture, acupressure and acupuncture therapy
• Crown, inlays and onlays, and veneers unless for one of the following:
- It is treatment for decay or traumatic injury and teeth cannot be restored with a filling material
- The tooth is an abutment to a covered partial denture or fixed bridge
• Dental implants, false teeth, prosthetic restoration of dental implants, plates, dentures, braces,
mouth guards, and other devices to protect, replace or reposition teeth and removal of implants
• Dentures, crowns, inlays, onlays, bridges, or other prosthetic appliances or services used for the
purpose of splinting, to alter vertical dimension, to restore occlusion, or correcting attrition,
abrasion, or erosion
• First installation of a denture or fixed bridge, and any inlay and crown that serves as an abutment
to replace congenitally missing teeth or to replace teeth, all of which were lost while you were not
covered
• General anesthesia and intravenous sedation, unless specifically covered and done in connection
with another eligible dental service
• Instruction for diet, tobacco counseling and oral hygiene
• Mail order and at-home kits for orthodontic treatment
• Dental services and supplies made with high noble metals (gold or titanium) except as covered in
the Eligible Dental Services section of the schedule of benefits
• Services and supplies directly related to treatment or care that is not covered under the plan,
(meaning the service or supply is only provided because the noncovered service or supply is
provided)
• Replacement of a device or appliance that is lost, missing or stolen, and for the replacement of
appliances that have been damaged due to abuse, misuse or neglect and for an extra set of
dentures
• Replacement of teeth beyond the normal complement of 32
• Services and supplies provided where there is no evidence of pathology, dysfunction or disease,
other than covered preventive services
• Space maintainers except when needed to preserve space resulting from the premature loss of
deciduous teeth
• Surgical removal of impacted wisdom teeth when removed only for orthodontic reasons
• Temporomandibular joint dysfunction/disorder
Stanford University 2023-2024 Page 8
Dental services and supplies that are covered in whole or in part:
• Under any other plan of group benefits provided by the policyholder
Examinations
Any dental examinations needed:
• Because a third party requires the exam. Examples include examinations to get or keep a
job, or examinations required under a labor agreement or other contract.
• Because a court order requires it.
• To buy insurance or to get or keep a license.
• To travel.
• To go to a school, camp, or sporting event, or to join in a sport or other recreational
activity.
Experimental or investigational
• Experimental or investigational drugs, devices, treatments or procedures
Non-U.S .citizen
• Services and supplies received by a covered person (who is not a United States citizen) within the
covered person’s home country but only if the home country has a socialized medicine program
Other primary payer
• Payment for a portion of the charge that another party is responsible for as the primary
payer
Outpatient prescription drugs, and preventive care drugs and supplements
• Prescribed drugs, pre-medication or analgesia
Personal care, comfort or convenience items
• Any service or supply primarily for your convenience and personal comfort or that of a
third party
Providers and other health professionals
• Charges submitted for services by an unlicensed provider or not within the scope of the
provider’s license
Stanford University 2023-2024 Page 9
Services paid under your medical plan
• Your plan will not pay for amounts that were paid for the same services under a medical plan
covering you. When a dental service is covered under both plans, we will figure the amount that
would be payable under this plan if you did not have other coverage, then subtract what was paid
by your medical plan. If there is any difference, this plan will pay it. If the amount paid by your
medical plan is equal to or more than the benefit under this plan, this plan will not pay anything
for the service.
Services provided by a family member
• Services provided by a spouse, civil union partner, domestic partner, parent, child, step-
child, brother, sister, in-law or any household member
Services, supplies and prescription drugs received outside of the United States
• Services, supplies, and prescription drugs received outside of the United States. They are not
covered even if they are covered in the United States under this certificate of coverage.
Dental emergency
Eligible dental services include dental services provided for a dental emergency. The care provided must
be a covered benefit.
If you have a dental emergency, you should consider calling your dental in-network provider who may be
more familiar with your dental needs. However, you can get treatment from any dentist including one
that is an out-of-network provider. If you need help in finding a dentist, call Member Services at the toll-
free number on the back of your ID card.
If you get treatment from an out-of-network provider for a dental emergency, the plan pays a benefit at
the in-network cost-sharing level of coverage up to the dental emergency services maximum. For follow-
up care to treat the dental emergency, you should consider using your in-network dental provider so that
you can get the maximum level of benefits. Follow-up care will be paid at the cost-sharing level that
applies to the type of provider that gives you the care.
Stanford University 2023-2024 Page 10
What rules and limits apply to dental care?
Several rules apply to the dental benefits. Following these rules will help you use your plan to your
advantage by avoiding expenses that are not covered by your plan.
Alternate treatment rule
Sometimes there are several ways to treat a dental problem, all of which provide acceptable results.
If a charge is made for a non-eligible dental service or supply and an eligible dental service that would
provide an acceptable result, then your plan will pay a benefit for the eligible dental service or supply.
If a charge is made for an eligible dental service but another eligible dental service that would provide an
acceptable result is less expensive, the benefit will be for the least expensive eligible dental service.
The benefit will be based on the in-network provider’s negotiated charge for the eligible dental service or,
in the case of an out-of-network provider, on the recognized charge.
You should review the differences in the cost of alternate treatment with your dental provider. Of course,
you and your dental provider can still choose the more costly treatment method. You are responsible for
any charges in excess of what your plan will cover.
Reimbursement policies
We have the right to apply Aetna reimbursement policies. Those policies may reduce the negotiated
charge or recognized charge. These policies take into account factors such as:
• The duration and complexity of a service
• When multiple procedures are billed at the same time, whether additional overhead is required
• Whether an assistant surgeon is necessary for the service
• If follow up care is included
• Whether other characteristics modify or make a particular service unique
• When a charge includes more than one claim line, whether any services described by a claim line
are part of or incidental to the primary service provided and
• The educational level, licensure or length of training of the provider
Aetna reimbursement policies are based on our review of:
• The Centers for Medicare and Medicaid Services’ (CMS) National Correct Coding Initiative (NCCI)
and other external materials that say what billing and coding practices are and are not
appropriate
• Generally accepted standards of dental practice and
• The views of providers and dentists practicing in the relevant clinical areas
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We use commercial software to administer some of these policies. Some policies are different for
professional services than for facility services.
Replacement rule
Some eligible dental services are subject to your plan’s replacement rule. The replacement rule applies to
replacements of, or additions to existing:
• Crowns
• Inlays
• Implants
• Complete dentures
• Removable partial dentures
• Fixed partial dentures (bridges)
• Other prosthetic services
These eligible dental services are covered only when you give us proof that:
• While you were covered by the plan:
– You had a tooth (or teeth) extracted after the existing denture, bridge, or other prosthetic item
was installed.
– As a result, you need to replace or add teeth to your denture, bridge, or other prosthetic item.
– The tooth that was removed was not an abutment to a removable or fixed partial denture,
bridge, or other prosthetic item installed during the prior 8 years.
• The present item cannot be made serviceable, and is:
– A crown installed at least 8 years before its replacement.
– An inlay, complete denture, removable partial denture, fixed partial denture (bridge), implant,
or other prosthetic item installed at least 8 years before its replacement.
• While you were covered by the plan:
– You had a tooth (or teeth) extracted.
– Your present denture is an immediate temporary one that replaces that tooth (or teeth).
– A permanent denture is needed, and the temporary denture cannot be used as a permanent
denture. Replacement must occur within 24 months from the date that the temporary denture
was installed.
Tooth missing but not replaced rule
The first installation of complete dentures, removable partial dentures, fixed partial dentures (bridges),
and other prosthetic services will be covered if:
• The dentures, bridges or other prosthetic items are needed to replace one or more natural teeth
that were removed while you were covered by the plan. (The extraction of a third molar tooth
does not qualify.)
• The tooth that was removed was not an abutment to a removable or fixed partial denture
installed during the prior 8 years.
Stanford University 2023-2024 Page 12
Any such appliance or fixed bridge must include the replacement of an extracted tooth or teeth.
The Stanford University Dental® Preferred Provider Organization (PPO) S tudent Dental Plan is
underwritten and administered by Aetna Life Insurance Company (ALIC). Aetna Student Health
SM
is the
brand name for products and services provided by these companies and their applicable affiliated companies.
IMPORTANT NOTICES:
• Notice of Non-Discrimination:
Aetna Life Insurance Company does not discriminate on the basis of race, color, national origin,
disability, age, sex, gender identity, sexual orientation, or health status in the administration of the
plan including enrollment and benefit determinations.
• Sanctioned Countries:
If coverage provided under this student policy violates or will violate any economic or trade sanctions,
the coverage will be invalid immediately. For example, we cannot pay for eligible health services if it
violates a financial sanction regulation. This includes sanctions related to a person or a country under
sanction by the United States, unless it is allowed under a written license from the Office of Foreign
Asset Control (OFAC). You can find out more by visiting http://www.treasury.gov/resource-
center/sanctions/Pages/default.aspx.
Assistive Technology
Persons using assistive technology may not be able to fully access the following information. For assistance, please call
1-877-480-4161.
Smartphone or Tablet
To view documents from your smartphone or tablet, the free WinZip app is required. It may be available from your App
Store.
Non-Discrimination
Aetna is committed to being an inclusive health care company. Aetna does not discriminate on the basis of ancestry, race,
ethnicity, color, religion, sex/gender (including pregnancy), national origin, sexual orientation, gender identity or
expression, physical or mental disability, medical condition, age, veteran status, military status, marital status, genetic
information, citizenship status, unemployment status, political affiliation, or on any other basis or characteristic prohibited
by applicable federal, state or local law.
Aetna provides free aids and services to people with disabilities and free language services to people whose primary
language is not English.
These aids and services include:
Stanford University 2023-2024 Page 13
• Qualified language interpreters
• Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Qualified interpreters
• Information written in other languages
If you need these services, contact the number on your ID card. Not an Aetna member? Call us at 1-877-480-4161.
If you have questions about our nondiscrimination policy or have a discrimination-related concern that you would like to
discuss, please call us at 1-877-480-4161.
Please note, Aetna covers health services in compliance with applicable federal and state laws. Not all health services are
covered. See plan documents for a complete description of benefits, exclusions, limitations, and conditions of coverage.
Language accessibility statement
Interpreter services are available for free.
Attention: If you speak English, language assistance service, free of charge, are available to you. Call 1-877-480-
4161 (TTY: 711).
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ይደውሉ 1-877-480-4161 (መስማት ለተሳናቸው: 711).
Arabic/
1-877-480-4161
711
Farsi/
Ɓsɔ̍ɔ̀ Wɖ/Bassa
Ddnkdyk dyi s-w-po-nyjn, nwuu kkpo-po gbo kpa.
1-877-480-4161 (TTY: 711).
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Stanford University 2023-2024 Page 14
4161
TTY: 711 1-877-480-
Attention : en composant le 1
877-480-4161 (TTY: 711).
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કૉલ કર 1-877-480-4161 (TTY: 711).
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Tumawag sa 1-877-480-4161 (TTY: 711).
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Yorùbá/Yoruba
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k
ે k
Stanford University 2023-2024 Page 15
711)
1-877-480-4161 (TTY: .
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary
companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna).
Stanford University 2023-2024
Page 16
kys: Bo b, rnlwlrèdè, lf, wf1-877-480-4161 (TTY: 711).
