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Oregon Dental Insurance > HealthNet of Oregon > Dental Coverage Rates & Benefits


To be eligible, these optional benefits must be purchased along with a HealthNet Health Insurance

Dental & Vision Rider Rates
All Ages
Subscriber
Subscriber & Spouse
Subscriber & Child(ren)
Subscriber & Family
$30.00
$60.00
$60.00
$90.00
Rates shown below are for residents of all Oregon counties


Dental Net Benefit Schedule
Deductible per Member
$50 per Calendar Year
Maximum family deductible
$150 per Calendar Year
Maximum Benefit
All services combined
$1,000 per Member per Calendar Year
Waiting Periods
Part A Services
None
Part B Services
None
Part C Services
12 Months
Covered Services
Plan Pays*
Benefit Limitations
Part A Services: Diagnostic and Preventive Services
Periodic Oral Examinations
80%
2 times per consecutive 12 months
Dental Prophylaxis (cleaning)
80%
2 times per consecutive 12 months
Bitewing X-Rays
80%
1 series of films per Calendar Year
Full Mouth or Panoramic X-Rays
80%
1 time per consecutive 36 months
Extraoral X-Rays
80%
2 films per Calendar Year
Fluoride Treatments
80%
Under age 16, 2 times per Calendar Year
Sealants
80%
Under age 16, once per first or second permanent molar every 5 years
Part B Services: Basic Services
Space Maintainers
80%
Under age 16, once per lifetime
Amalgam Restorations (fillings)
80%
1 restoration per surface every 3 years
Composite Resin Restorations (fillings)
80%
1 restoration per surface every 3 years
Sedative Filling
80%
Covered as a separate benefit only if no services other than exam and x-rays were performed on the same tooth during the visit.
Palliative Treatment (relief of pain)
80%
Covered as a separate benefit only if no services other than exam and x-rays were performed on the same tooth during the visit.
General Anesthesia
80%
Covered only for patients under age 7 or who are physically or developmentally disabled
Occlusal Guards
80%
For habitual grinding, 1 per 60 consecutive months
Diagnostic Casts
80%
1 time per 24 consecutive months
Pin Retention
80%
2 pins per tooth, not covered in addition to cast restoration
Part C Services: Major Services
Root Canal Treatment
50%
Post and Core
50%
Covered only for a tooth that has had root canal therapy
Scaling and Root Planing
50%
1 time per quadrant per consecutive 24 months
Periodontal Surgery
50%
1 time per consecutive 36 months per surgical area
Osseous Grafts
50%
1 time per consecutive 36 mohths per quadrant or surgical site
Periodontal Maintenance
50%
2 times per consecutive 12 months following active and adjunctive periodontal therapy within the prior 24 months, exclusive of gross debridement
Mouth Debridement
50%
1 time per consecutive 36 months
Simple Extraction
50%
Surgical Extraction, including impacted wisdom teeth
50%
Crowns, Inlays, Onlays
50%
1 time per tooth per consecutive 60 months
Fixed Bridges
50%
1 time per tooth per consecutive 60 months.  Alternate benefits for a partial denture may be applied
Full Dentures
50%
1 time per consecutive 60 months. No allowance for overdentures or customized dentures.
Partial Dentures
50%
1 time per consecutive 60 months. No allowance for precision or semi-precision attachments.
Recement Crowns, Inlays, Onlays, Bridges
50%
1 time per 6 months per restoration
Relining and Rebasing Dentures
50%
1 time per consecutive 12 months, and more than 6 months after initial insertions
Repairs to Bridges, Full Dentures, Partial Dentures
50%
Repairs and adjustments more than 12 months after initial insertion

Access: With this Health Net of Oregon Dental Plan, you can see any licensed dentist and receive Benefits for covered services.  You do not have to go to a specific network of Providers. However, if you do see a Participating Provider, charges for covered services will be limited to Health Net’s contracted amount with the Provider.

*Your Plan Benefits are based on who provides your dental services. Benefits are based on an Allowed Amount as determined by us. There is usually a difference between the amount your Provider actually charges for a service and how much of that billed charge is covered by your Plan Benefits. If you see a Participating Provider, the Provider has agreed to accept the Allowed Amount as payment in full, and you are not responsible for any billed amounts above that amount. If you see a Nonparticipating provider, you are responsible for any billed charges above the Allowed Amount paid by us.

The deductible is the amount you pay before your plan begins paying Benefits for covered services.
** The deductible does not apply to Part A services.

This document presents general information only. Refer to the plan contract for complete details, limitations and exclusions.

 
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