If you’re looking to enhance your smile through cosmetic dentistry at Pacific Dental & Implant Solutions (PDIS) in Honolulu, understanding your GEHA dental coverage is important. As a leading federal employee dental insurance provider, GEHA offers two comprehensive plan options – High and Standard – each providing different levels of coverage for cosmetic and restorative dental procedures.
GEHA Dental Coverage Overview
GEHA’s dental coverage for cosmetic procedures depends on medical necessity and the specific treatment needed. Here are the key points:
- In-network coverage at PDIS can significantly reduce your out-of-pocket costs
- No waiting periods for any covered services on either plan option
- Annual maximums vary by plan ($2,500 for Standard in-network, unlimited for High)
- Pre-authorization may be required for some cosmetic procedures
Want help understanding your exact coverage and benefits?
Schedule a free insurance verification with our team, and we’ll break down your specific GEHA benefits before you begin treatment.
Network Status
GEHA’s provider network extends throughout Hawaii, with PDIS being an accessible option for dental care. When you visit PDIS as a GEHA member, your benefits include access to negotiated rates and streamlined claims processing. The practice will handle direct claim submissions to GEHA and assist with verifying your benefits. For High Option members, there are no deductibles to meet before coverage begins, while Standard Option members benefit from having no in-network deductible. PDIS can help coordinate your GEHA benefits with any additional insurance coverage you may have.
Coverage Limits
GEHA plans have specific parameters regarding cosmetic and major dental procedures. For High Option members, there is no annual maximum for Class A, B, and C services, providing extensive coverage throughout the year. Standard Option members have an annual maximum of $2,500 for in-network services. Both plans limit implant services to $2,500 annually per covered person. Coverage determinations are based on dental necessity and plan guidelines. Certain procedures may require pre-authorization to confirm coverage. PDIS can help submit the necessary documentation to GEHA for coverage review.
Waiting Periods
One significant advantage of GEHA dental plans is that there are no waiting periods for any covered services, including major procedures. You can begin using your benefits as soon as your coverage becomes effective. This applies to all categories of service – preventive, basic, and major procedures. Both High and Standard Option plans allow immediate access to covered services like cleanings, fillings, crowns, and even orthodontic treatment. This feature makes GEHA particularly attractive for those needing dental work soon after enrollment. PDIS can verify your coverage status and help you schedule treatment without delay.
What Cosmetic Dental Procedures Does GEHA Cover?
GEHA provides varying levels of coverage for different cosmetic dental procedures:
Dental Implants
- High Option: 50% coverage, $2,500 annual maximum for implant services
- Standard Option: 65% in-network coverage, subject to annual maximum
- Coverage includes implant body, abutment, and crown
Dental Crowns
- High Option: 50% coverage
- Standard Option: 65% in-network coverage
- Dental crowns are covered when medically necessary due to extensive decay or fracture
Dental Bridges
- High Option: 50% coverage
- Standard Option: 65% in-network coverage
- Coverage includes pontics and retainer crowns
All-On-Four
- Coverage follows implant and prosthetics guidelines
- Subject to annual maximums and medical necessity review
- Pre-authorization strongly recommended
How to Use Your GEHA Dental Insurance at PDIS
Verification Process
Our team helps maximize your GEHA benefits through comprehensive verification. We begin by confirming your current plan details, including whether you have the High or Standard Option. We’ll check your available benefits, verify there are no waiting periods affecting your care, and confirm your annual maximum – which is unlimited for High Option members and $2,500 for Standard Option members using in-network providers. We also review any limitations specific to your needed procedures and coordinate with any additional insurance coverage you may have.
Pre-authorization Requirements
While GEHA doesn’t require pre-authorization for most services, getting a pre-determination of benefits is recommended for extensive treatments. Our team will help submit the necessary documentation, including clinical records, radiographs, and a detailed treatment plan explaining the dental necessity. GEHA typically provides a coverage estimate within 2-4 weeks. This helps you understand your expected out-of-pocket costs before treatment begins. Pre-determinations are valid through the calendar year they are prepared or for 12 months, subject to continued eligibility.
Coverage Tiers and Network Details
Both GEHA plan options offer comprehensive coverage through their nationwide provider network. For High Option members, preventive services are covered at 100%, basic services at 80% (20% coinsurance), and major services at 50%. Standard Option members receive 100% coverage for preventive care in-network, with 55% coverage (45% coinsurance) for basic services and 35% coverage (65% coinsurance) for major services. Using in-network providers like PDIS helps you access negotiated rates and maximize your benefits. We handle all claims submission and processing directly with GEHA.
Understanding Your Out-of-Pocket Costs
Deductibles
With GEHA dental plans, High Option members have no deductible for either in-network or out-of-network services.
Standard Option members benefit from having no deductible for in-network services, but face a $75 combined deductible for out-of-network Class A, B, and C services per person, per calendar year.
Any covered charges applied to the deductible also count toward your plan’s annual maximum benefit limits.
PDIS, as an in-network provider, helps you avoid out-of-network deductibles.
Copayments and Coinsurance
Rather than fixed copayments, GEHA uses a coinsurance model where you pay a percentage of the allowed amount.
High Option members pay:
- Nothing for preventive care (Class A)
- 20% for basic services (Class B)
- 50% for major services (Class C)
- 30% for orthodontic services (Class D)
Standard Option members pay:
- Nothing for in-network preventive care
- 45% for in-network basic services
- 65% for in-network major services
- 50% for orthodontic services
Annual Maximums
The annual benefit maximum varies significantly between plans.
High Option provides an unlimited annual maximum for Class A, B, and C services, offering extensive coverage throughout the year.
Standard Option limits coverage to $2,500 annually for in-network services and $2,000 for out-of-network services.
Both plans limit implant services to $2,500 per person per year.
Class D orthodontic services have separate lifetime maximums of $3,500 for High Option and $2,500 for in-network Standard Option services.
Financing Options at PDIS
To help manage out-of-pocket expenses, we offer several payment solutions:
- Flexible payment plans
- Major credit cards accepted
- CareCredit healthcare financing
- Coordination with FSA/HSA accounts
Need help financing your dental work?
Next Steps: Schedule Your Consultation
Ready to use your GEHA benefits at PDIS? Schedule a consultation below. When you visit, please bring along your GEHA insurance card and a valid photo ID. We also recommend preparing a list of your dental concerns and bringing any previous dental records you may have available.
Having these materials ready will help us provide the most comprehensive evaluation of your needs and insurance coverage. We look forward to serving you soon!