The Plan offers two types of Dental Programs. You can choose to enroll in the Dental HMO Plan provided by BlueCare or you can receive your dental benefits under the Dental PPO Plan provided by Dental Network of America, a Blue Cross Blue Shield of Illinois subsidiary.
You can only switch programs during the month of August.
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.
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.
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. You and your covered dependents can go to any dentists you choose to receive your dental care. 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.
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
Covered preventive and diagnostic dental services are paid at 100% in or out-of-network. Restorative services are paid at 90% in-network and 80% out-of-network. A $50 deductible applies to restorative services each year. Benefits are limited to a maxi-mum of $1,500 each calendar year for all in-network and out-of-network preventive and restorative ser-vices. You are responsible for paying amounts not paid by the Plan.
The $1,500 annual benefit maximum does not apply to covered preventive and diagnostic services for persons ages 0-18.
Orthodontia is paid at 90% under DNOA and 80% out-of-network up to a lifetime maximum benefit of $2,000.
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.
1. Diagnostic and preventive services include charges made for the following:
2. Restorative services include charges made for the following:
The list shown above is only a partial list of cov-ered services. If you want to find out if coverage is provided for a particular service that is not listed, contact the Fund Office.
3. Orthodontia includes charges made for services and supplies provided by a dentist for necessary orthodontic treatment.
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:
When Dental Charges are Considered Incurred
For payment purposes, treatment is considered incurred on the date the service is provided, except that:
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 Status form, and a letter explaining how to make the change. (Information packets and enrollment applications are only mailed upon request.)
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 cov-ered under your current dental program.
If you change dental plans, the change will become effective September 1.