Understanding your day-to-day dental benefits and how we fund them
Recognising the integral role dental health plays in overall well-being, we take immense pride in providing our members with robust benefits designed to maintain and achieve optimal dental health. We invite you to explore your dental benefits and make the most of these benefits for your optimal dental health.
Value Care Plan
On the Value Care Plan, you access dental benefits through Prime Cure network dentists. This arrangement means no co-payments for you, and dentists are paid at the Prime Cure agreed rate. You can find your Prime Cure network dentist on the Value Care Plan app, website or by calling 0861 665 665.
For preventative care, every beneficiary can receive a cleaning, scaling, polishing and fluoride treatment once a year. If you need more than just preventative care, every beneficiary is entitled to one consultation per year, which includes fillings, x-rays, extractions and consultations.
In case of dental emergencies, such as sepsis, pain or extractions, beneficiaries can also make use of one visit atnon-network providers, paid at the Prime Cure agreed rate. For children under 7 years old who need to be admitted to the hospital for the removal of impacted third molars and trauma, a referral from your Prime Cure Dentist and authorisation is required for it to be paid from the Family Hospital Limit.
For specialised dentistry, members over the age of 21 needing acrylic dentures can, after obtaining authorisation, access two sets every three years per family with a 20% co-payment, as well as denture repairs after a period of six months.
Standard Care Plan
Your Standard Care Plan also has a network arrangement with the Dental Risk Company (DRC), our dental benefit management partner, which is responsible for paying and managing benefits and authorising specialised dental services. This network allows you to access basic dentistry throughout the year, regardless of the availability of savings or limited dental benefits, and without co-payments. (You can also use a non-network dentist, but, in this case, you need to pay the difference between 80% of the Scheme Reimbursement Rate and the claimed amount.) To find a DRC dentist, use the provider search on https://www.angloms.co.za/portal/ams/maps, the AMS app or by calling us on 0860 222 633. Please always confirm with the dentist that they are still on the network when making your appointment.
These benefits are available for basic dentistry:
- Every 180 days: one consultation, one scaling, polishing and fluoride treatment
- Two intra-oral radiographs per visit
- One local anaesthetic per visit
- Four extractions per year
- Five restorations (amalgam or resin) per year
- One panoramic radiograph every 36 months
- One pair of plastic dentures every four years, including one annual relining and repair per year
If you would need to make use of all these services, this would be a benefit worth R10,956 per beneficiary.
Many members ask us about orthodontic benefits. Orthodontic benefits pay from the additional basic and specialised dentistry benefits, which, for a family of three, would be R4,050 per year (R1,800 per adult and R450 per child). Orthodontic treatment usually takes between 12 and 18 months. If you start orthodontic treatment, for example, in September or October, you might be able to access up to three benefit years, which would equal up to R12,150
Children under 7 years of age are funded in hospital for extensive basic dentistry; plus the removal of impacted wisdom teeth is funded in hospital, with zero co-payment for theatre or hospital. The fact that these theatre cases are funded without a co-payment is unique in the industry.
Overall, from a dental benefits point of view, Standard Care Plan performs currently above average compared to other schemes, if you measure the dental benefit against contributions.
Managed Care Plan
On the Managed Care Plan, you have freedom of choice and can use whichever dentist you prefer. Not only do you have a Family Limit (R4,885 per adult and R1,845 per child) for conservative treatments including fillings, x-rays, extractions and oral hygiene, it can also be used for specialised treatments including crowns, bridges, inlays, study models, dentures, orthodontics, osseo-integrated implants and periodontics.
Once this benefit is depleted, you can use your Medical Savings Account (MSA) to supplement the treatment. For non-Prescribed Minimum Benefits (PMB) specialised dental services, the Scheme pays up to 125% of the Scheme Reimbursement Rate (SRR) from the limit. If what the dental specialist charges is higher, you can instruct us to pay it from available benefits in your MSA.
Additionally, dental hospitalisation (including medicine and related products) is funded in the case of trauma or for patients under the age of 7 years requiring anaesthetic, the removal of impacted molars, maxillo-facial and oral surgery (PMB conditions). After obtaining authorisation, the Scheme pays a Top-Up rate of up to 230% of the SRR for specialist services, or in full if it is a PMB.
As you can see, like for any benefit category, it is all about understanding your benefits and using them wisely. We are here to help you make the most of your dental benefits. If you have any questions, don't hesitate to reach out to us.
Published July 2024