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100 percent coverage for routine exams, cleanings and other preventive dental care

When you enroll in Freedom Vital, Balance or Ultimate, you have the option to buy supplemental dental coverage.

You can enroll for dental coverage when you enroll for coverage in the Freedom plan.

If you’re a current Freedom plan member, you can add dental coverage from October 15 through December 31. Enroll by filling out this form and then sending it to us. (The mailing address and fax number are on the form.)

How much will I pay?

  • Monthly dental premium: $39.90
  • Annual deductible: $50 for regular and restorative care, special restorative care and prosthetics
  • Annual maximum: $1,100 per calendar year. $200 may be applied to out-of-network services.
    • In Freedom Vital, preventive and diagnostic services do apply toward the annual maximum. In Freedom Balance and Ultimate, preventive and diagnostic services do not apply toward the annual maximum.

What’s included in the dental coverage?

You have 100 percent coverage for:

  • Preventive and diagnostic care, including:
    • Routine examinations and cleanings
    • Other preventive services

You have 50 percent coverage for:

  • Sealants, including pit and fissure sealants
  • Regular and restorative care, including:
    • Fillings
    • Oral surgery
    • Periodontics (gum treatment)
    • Endodontics (root canal therapy)
  • Special restorative care, including:
    • Restorative crowns
    • Onlays
  • Prosthetics, including:
    • Bridges
    • Dentures
    • Partial dentures

To receive the coverage listed above, you must use in-network dental providers and facilities. View your Evidence of Coverage (EOC) for more information.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary.

HealthPartners MSHO is a health plan that contracts with both Medicare and the Minnesota Medical Assistance (Medicaid) program to provide benefits of both programs to enrollees. HealthPartners Freedom is a Cost plan with a Medicare contract. Enrollment in HealthPartners depends on contract renewal.

Last updated October 2015
H2422_91303 Approved 10/16/2015
H2462_91303 Approved 10/16/2015

For coverage to start in November or December, 2015, visit our 2015 website.