The Plan offers two types of Dental Programs. You can choose to enroll in the Dental HMO Plan provided by BlueCare (hereafter called the “Dental HMO Plan”) or you can receive your dental benefits under the “Dental PPO Plan” provide by Dental Network of America, a Blue Cross Blue Shield of Illinois subsidiary.
You can only switch programs during the month of August.
Dental HMO Plan
The Dental HMO Plan is provided through the BlueCare Dental HMO. BlueCare has arranged a network of general dentists who will provide the stated HMO covered dental services to individuals who enroll in the HMO.
- The Dental HMO Plan has no deductibles and no yearly maximums. There is no charge to you for diagnostic and preventive services (check-ups, cleanings and x-rays). You pay the HMO dentist a stated co-payment for any other required dental care.
- When you enroll in the Dental HMO, you will receive a certificate of coverage that explains your co-pays, and includes a list of limitations and exclusions.
- You don’t have to submit claims to the Fund Office. If you or your covered dependents need dental procedures that require a co-payment from you, you pay the co-payment amount directly to the HMO dentist.
- When you enroll in the Dental HMO Plan, all family members are covered under the Dental HMO Plan. You can’t split family coverage between the Dental HMO Plan and the Dental PPO Plan.
- After enrolling in the Dental HMO Plan, in order to receive covered benefits, you and your covered dependents must use the dentist(s) you listed on your enrollment application form. If you or any family members want to change HMO dentists, you can do so by following the instructions in your Dental HMO Plan brochure or call the Dental HMO Plan customer service department at 1 (800) 323-7201.
- Once you have enrolled in the Dental HMO Plan, you must stay in that plan until the next open enrollment period. During August of each year, you will be given an opportunity to switch to the Dental PPO Plan if you wish to do so (see “Open Enrollment Period” section).
If you enroll in the Dental HMO Plan, you can call your selected dentist (named on your enrollment application form) for an appointment.
If you must miss an appointment, be sure to call and cancel it. If 24-hour notice of cancellation is not provided, the HMO dentist may charge you for the missed appointment.
Dental PPO Plan
If you choose not to enroll in the Dental HMO Plan, you and your covered dependents will receive your dental benefits under the Dental PPO Plan. Your benefits are paid according to the Schedule of Benefits and as explained below. You or your dentist must file claims with the Fund Office for dental benefits the same as you do for medical benefits. You and your covered dependents can go to any dentists you choose to receive your dental care.
There is no enrollment involved if you want to receive your dental benefits under the Dental PPO Plan. If you are covered under the Dental PPO Plan and want to switch to the Dental HMO Plan, you can do so during an annual open enrollment period.
Payment of Benefits
Dental Benefits – Each calendar year, the Plan will pay a percentage of the Type II and Type III covered dental expenses a covered person incurs up to the calendar year maximum benefit shown on the Schedule of Benefits. The Plan’s payment percentage is 90% of the reasonable and customary (R&C) charge. If you use a dentist in the dental PPO network, and 80% of the R&C charge if your dentist is not in the network. A $50 deductible applies to PPO and non-PPO Type II and Type III expenses each year before the Plan will start paying its percentage. You are responsible for paying amounts not paid by the Plan.
Orthodontia Benefits – The Plan will pay 80% of the Type III covered expenses a covered person incurs up to the lifetime maximum benefit shown on the Schedule of Benefits.
Covered Dental Expenses
“Covered Dental Expenses” are the reasonable and customary charges incurred by a covered person for the services and supplies listed below which are necessary for the treatment of a non-occupational dental condition.
Charges will be considered “reasonable and customary” only to the extent that they are the usual, reasonable and customary charges made for services and supplies customarily employed for treatment of that particular dental condition. They must be rendered in accordance with accepted standards of dental practice, be performed by a licenses dentist (except for services legally performed by a dental hygienist), and be received while the person is eligible for benefits under the Dental PPO Plan.
- TYPE I Expenses (diagnostic and preventive) include charges made for the following:- Routine oral examinations, diagnosis and preparation of reports
– Prophylaxis (scaling and cleaning of teeth)
– Application of sodium or stannous fluoride
– Dental x-rays as necessary
– Space maintainers
- TYPE II Expenses (restorative services) include charges made for the following:- Extractions
– Partial Bridges
– Periodontal treatment
– Oral surgery
– Partial dentures
– Initial complete dentures
The list shown above is only a partial list of covered services. If you want to find out if coverage is provided for a particular service that is not listed, contact the Fund Office.
- TYPE III (Orthodontia) include charges made for services and supplies provided by a dentist for necessary orthodontic treatment.
Dental Exclusions and Limitations
The following exclusions apply to the Dental PPO Plan only. The HMO Plan exclusions are in the BlueCare HMO certificate of coverage.
No Dental Benefits will be provided for any of the following:
- Services or supplies for which benefits are paid under the Comprehensive Benefit (for example, hospital services for a child age 5 or younger who requires dental work that cannot be performed in a dental office).
- Replacement of a lost, stolen, damaged or missing denture, bridgework and/or dental appliance which was previously supplied under either the Dental HMO Plan or the Dental PPO Plan.
- Duplicate prosthetic devices or any other duplicate appliances.
- Replacement of a denture unless there has been five years since the installation of the previous denture.
- Prosthetic devices, including bridges and crowns, and their installation, that are ordered while a person is not eligible for Dental Benefits.
- Services pertaining to the temporomandibular joint (TMI). (The Plan covers TMJ under the Comprehensive Medical Benefit.)
- Any cosmetic or beautifying procedure.
- Any elective or experimental procedure.
- Settings of fractures or dislocations; or treatment of malignancies, cysts, or neoplasm or congenital malformations.
- Services or supplies which are provided by anyone other than a dentist, except for cleaning and scaling of teeth performed by a licensed dental hygienist under the supervision and direction of a dentist.
- Services which, in the opinion of the attending dentist, are not necessary for the patient’s dental health.
- Procedures requiring fixed prosthodontic restoration which are necessary for complete oral rehabilitation or reconstruction, or procedures relating to the change and maintenance of vertical dimension or the restoration of occlusion.
- Services for injuries or conditions which are covered under the Workers’ Compensation or Employer’s Liability Laws; or services which are provided without cost to the person by any municipality, county or other political subdivision (this exclusion does not apply to services covered by Medicaid).
- Charges for second opinions.
- Prescription and non-prescription drugs; or pharmacological regimens.
- Any services, supplies or types of treatment for which no benefits are payable under the Plan as a whole as stated in the section – “What the Plan Does Not Cover”.
When Dental Charges are Considered Incurred
For payment purposes, treatment is considered incurred on the date the service is provided, except that:
- For full or partial dentures, when the impression is taken for the appliances.
- For root canal therapy, when the tooth is opened.
- For fixed bridgework, crowns and other gold restorations, when the tooth is first prepared.
Open Enrollment Period: August 1 – August 31
There is an open enrollment period during AUGUST of each year during which you can switch dental plans if you wish.
You can request a packet of materials about the BlueCare Dental HMO Plan, an enrollment application form, a Change of Staus form and a letter explaining how to make the change. (Information packets and enrollment applications are mailed only upon request.)
- If you want to change from the PPO to the HMO Plan, you must fill out the enrollment application form and return it to the Fund Office between August 1 – August 31.
- If you want to change from the HMO to the PPO Plan, you must send a written reques to the Fund Office between August 1 – August 31. Your letter should state that you want to drop the HMO coverage.
If you do not do anything to change dental plans during the August open enrollment period, you and your covered dependents will continue to be covered under your current dental program.