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Dental Benefit

DENTAL BENEFITS AT MARTIN'S POINT

The Martin’s Point Generations Advantage Dental Benefit is administered by Northeast Delta Dental (NEDD). With our dental coverage, there’s no waiting period—so you can start using your benefit as soon as you need it and low or no copays and coinsurance amounts make important preventive care affordable.

For more information, please see your Evidence of Coverage or call Northeast Delta Dental at 1-800-832-5700 (TTY: 1-800-332-5905).

Dental Benefit Overview by Plan

In-Network: To obtain these supplemental dental benefits at the in-network rates, you must use a Delta Dental network provider in Maine, New Hampshire, or Vermont.

Out-of-Network: For a higher cost share, Select plan members may also see dentists who accept Medicare outside of this network.

Coverage Effective: 1/1/2023

Member Cost Shares (No Waiting Period)
Amounts under Categories A, B, and C Show What MEMBER Pays

DENTAL BENEFITS BY AREA CALENDAR-YEAR MAXIMUM PAID BY PLAN**  A  DIAGNOSTIC / PREVENTATIVE  B  BASIC RESTORATIVE  C  MAJOR RESTORATIVE

Prime (HMO POS) Counties:

MAINE: Lincoln, Oxford, Piscataquis, Somerset, and Waldo

NEW HAMPSHIRE: Belknap, Carroll, Coos, and Grafton

All services must be received in network.

 $500 per Member No Deductible

$50 Office Visit Copay		 $50 Office Visit Copay and 50% Coinsurance $50 Office Visit Copay and 50% Coinsurance
Calendar Year Deductible per Person: $50

Prime (HMO POS) Counties:

MAINE: Aroostook, Franklin, Hancock, Knox, Penobscot, and Washington

All services must be received in network.

 $750 per Member No Deductible

$50 Office Visit Copay		 $50 Office Visit Copay and 50% Coinsurance $50 Office Visit Copay and 50% Coinsurance
Calendar Year Deductible per Person: $50

Prime (HMO POS) Counties:

MAINE: Androscoggin, Cumberland, Kennebec, Sagadahoc, and York 

NEW HAMPSHIRE: Cheshire, Hillsborough, Merrimack, Rockingham, Strafford, and Sullivan

All services must be received in network.

 $1,000 per Member No Deductible

$50 Office Visit Copay		 $50 Office Visit Copay and 50% Coinsurance $50 Office Visit Copay and 50% Coinsurance
Calendar Year Deductible per Person: $50

Select (LPPO) Counties:

NEW HAMPSHIRE: Belknap, Carroll, and Grafton

$1,000 per Member No Deductible

$50 Office Visit Copay

0% Coinsurance for in-network

50% Coinsurance for out-of-network provider		 Not Covered Not Covered

Alliance (HMO) Counties:

All Maine and New Hampshire Counties.

All services must be received in network.

 $2,500 per Member No Deductible

$0 Office Visit Copay		 No Deductible

20% Coinsurance		 No Deductible

20% Coinsurance

Value Plus (HMO) Counties:

MAINE: Aroostook, Franklin, Hancock, Kennebec, Knox, Lincoln, Oxford, Penobscot, Piscataquis, Sagadahoc, Somerset, Waldo, Washington

All services must be received in network.

 $1,000 per Member No Deductible

$50 Office Visit Copay		 $50 Office Visit Copay and 50% Coinsurance $50 Office Visit Copay and 50% Coinsurance
Calendar Year Deductible per Person: $50

Focus DC (HMO SNP) Counties:

MAINE: Cumberland County

All services must be received in network.

 $1,000 per Member No Deductible

$50 Office Visit Copay
 $50 Office Visit Copay and 50% Coinsurance
 $50 Office Visit Copay and 50% Coinsurance
Calendar Year Deductible per Person: $50
**Expenses incurred by the plan for covered dental services accrue to your annual maximum benefit.
 A  DIAGNOSTIC/PREVENTATIVE  B  BASIC RESTORATIVE  C  MAJOR RESTORATIVE

DIAGNOSTIC:

  • Problem-focused exams as needed
  • X-rays (complete series or panoramic film)
    once in a 5-calendar-year period
  • Bitewing X-rays once in a calendar year
  • X-rays of individual teeth as necessary

PREVENTIVE:

  • Oral exam and routine cleaning*

*Note: Cleanings are limited to one per calendar year for Prime, Focus DC, and Value Plus plan members and two per calendar year for Alliance plan members; you may choose from either a routine cleaning (Coverage A) or a periodontal cleaning (Coverage B). Cleanings are limited to once per calendar year for Select plan members and periodontal maintenance (cleaning) is not a covered benefit.

RESTORATIVE:

  • Amalgam (silver) fillings†
  • Resin restorations on anterior teeth and
    the buccal surface of bicuspids only

ORAL SURGERY:

  • Surgical and routine extractions

ENDODONTICS:

  • Root canal therapy

PERIODONTICS:

  • Periodontal maintenance (cleaning)*
  • Treatment of gum disease
  • Clinical crown lengthening once per tooth per lifetime

DENTURE REPAIR:

  • Repair of a removable denture to its original condition

EMERGENCY RELIEF OF PAIN:

  • Brush biopsy once in a calendar year

†Additional costs may apply for resin fillings, please reach out to Northeast Delta Dental for more information.

PROSTHODONTICS:

  • Removable and fixed
    partial dentures (bridge);
    complete dentures
  • Rebase and reline (dentures)
  • Crowns
  • Onlays
  • Implants