Frequently Asked Questions

Plan Eligibility

Does my dental health history have any impact on rates or coverage?

Absolutely not!

What is guaranteed acceptance?

Regardless of your current or past dental history, your acceptance into this plan is guaranteed as long as you are between the ages of 18-99 and live in an approved state.

Will my same-sex partner/domestic partner be eligible for spouse coverage?

Yes.

Plan Details

How many check-ups and cleanings does the plan cover?

All of our insurance plans cover 2 check-ups and cleanings at the dentist every year, one time every six months.

Does this plan cover tooth extractions?

Absolutely! Tooth extractions (oral surgery) are covered by all plans. Waiting periods for this procedure will vary depending on the plan you choose. Please check the Dental Plans page for full details.

Do any of these plans cover braces or orthodontia?

Unfortunately, our plans do not cover orthodontia at this time.

What is an annual deductible?

Each year, you will have an annual deductible which is the amount you will pay out-of-pocket before benefits are paid. This amount does not include co-payments.

What is my co-payment?

Your co-payment is any amount not covered by the plan's coverage percentages. For example, if the plan covers 50% for the service you are receiving, your co-payment would be the outstanding 50%, after your deductible is paid (if applicable).

Do these plans have a deductible each year?

There is no deductible for preventative and diagnostic dental care. For basic or major dental work, you pay the first $50 each year (your deductible). For family coverage, there is a $150 maximum deductible per family, per year.

Is Encore Dental a discount plan, or an insurance plan?

The plans we offer are dental insurance plans.

When seeing an out-of-network dentist, will I pay the same amount?

If you decide to see an out-of-network dentist, you will also pay for any amount above the "eligible expense". An Eligible Expense for a Dental Service is the smaller of (1) the amount a Dentist charges an Insured; (2) the Medium Charge (see below for more details); or (3) 85% of the usual and customary (also see below for more details) charge for the geographical region where the Dental Service is received. (Example: If we determine that the Medium Charge in your geographic region is $100.00 and your Dentist charges $125.00, we consider $100.00 to be the Eligible Expense. If, however, 85% of the usual and customary charge equals $95.00, then we consider $95.00 to be the Eligible Expense. If your Dentist charges $75.00, we consider $75.00 to be the Eligible Expense.)

We pay the same percentage of an Eligible Expense when a covered Dental Service is provided by a Network or non-Network Dentist. The percentages that we pay for Preventative, Basic, and Major Dental Services Level are shown under "Coverage" on the Dental Plans page as well as on the Certificate Schedule. You are responsible for paying the difference between the benefit amount that we pay and the Eligible Expense. This difference is the Co-Payment. You are also responsible for paying any amounts charged by a non-Network Dentist that exceed an Eligible Expense.

What is a "medium charge?"

A Medium Charge is the amount that half the Dentists in a geographical region charge more and half charge less for the same Dental Service. No benefits are payable for any portion of a Dentist's charge that exceeds an Eligible Expense.

What does "usual & customary" mean?

The average cost a dentist charges for services in your area.

What does "necessary" dental services mean?

"Necessary" means Dental Services and supplies which are determined by us to be appropriate and:

a) Necessary to meet the basic dental needs of the Insured

b) Rendered in the most cost-effective manner and type of setting appropriate for the delivery of the Dental Service;

c) Consistent in type, frequency, and duration of treatment with scientifically based guidelines of national clinical, research, or health care coverage organizations or governmental agencies that are accepted by us;

d) Consistent with the diagnosis of the condition;

e) Required for reasons other than the convenience of an Insured or his Dentist; and

f) Demonstrated through prevailing peer-reviewed medical and/or dental literature to be either: a) safe and effective for treating or diagnosing the Dental Disease or condition for which their use is proposed; or b) safe with promising efficacy for treating a life threatening Dental Disease or condition, in a clinically controlled research setting, or using a specific research protocol that meets standards equivalent to those defined by the National Institute of Health.

Will my premium increase?

You will never be singled out for a premium increase due to your claims or usage or age. Premiums are guaranteed to stay the same for the first twelve months. After that, premiums could increase on an annual basis to all insureds in your Class.

Are there penalties if I cancel the coverage?

You have the right to cancel this coverage at any time for any reasons with no penalties. If you cancel this coverage, we can reject any new dental insurance application/enrollment form you submit during the one year period following the date of cancellation.

Are there any waiting periods with Encore Dental?

The waiting period depends on the plan you choose. With the Encore Dental® 1-2-3 Insurance Plan there are no waiting periods for any type of service - including Major! Our Encore Dental® Standard Plan A or Plan B has no waiting period for Preventative and Basic services, and a 12 month waiting period for Major services. Please check the Dental Plans page for full details.

Are there any other reasons my coverage could stop?

Coverage can stop for any of the following reasons:

1. The Group Policy stops.
2. Coverage is cancelled for everyone in your class.
3. The insured performs an act of fraud or makes a material misrepresentation regarding this coverage.
4. If you fail to pay the premium when due after the 31 day Grace Period ends.
5. We receive your written request to cancel.

If coverage is to be discontinued due to reasons 1 or 2, we will notify you 60 days in advance.

Dentists & Networks

Do I have to see a network dentist or can I see my own dentist?

You can see your own dentist or any dentist you like. You do NOT have to use an in-network dentist. Of course, you may find you will have fewer out-of-pocket expenses if you choose to use an in-network dentist because they all guarantee to charge lower pre-negotiated prices to Encore Dental® certificate holders. If you choose to see an out-of-network provider, you will also have to complete a claim form and submit it for review and approval.

How do I find out if my dentist is in the network?

You can use the Find a Dentist search, or call 1-866-605-2642. Please remember, you do not have to use an in-network dentist for this plan to provide coverage. You have the flexibility to use any licensed dentist and still receive benefits for covered services.

How do I locate an in-network dentist?

You can use the Find a Dentist search, or call 1-866-605-2642 for assistance.

What are advantages of using an in-network dentist?

In-network dentists agree to charge fixed, pre-negotiated prices for their services which can provide you an opportunity to save more. In addition, when using an in-network dentist you do not have to submit a claim form - they will handle the claim's paperwork for you.

How are my claims reimbursed?

When going to an in-network dentist, there are no claim forms to fill out, and the dentist will submit the bill for you. When going to an out-of-network provider, you will need to submit a claim form and then we will send you a check for what your benefits cover. You can obtain a claim form by visiting the Claim Information page or by calling 1-866-605-2642.

I'm a dentist and am interested in joining the provider network, who should I contact?

If you are a dentist that would like to become part of the network, or have questions about the Encore Dental Plan, please call 1-800-445-9090 for more information.