Dental Benefit

DENTAL BENEFITS ARE NOT PROVIDED FOR RETIREES AND THEIR SPOUSES.

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.

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. 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:

• 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
• Sealants
• Space maintainers

2. Restorative services include charges made for the following:

• Extractions
• Fillings
• Oral surgery
• Crowns
• Partial and complete bridges and dentures
• Periodontal treatment

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.

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:

1. Services or supplies for which benefits are paid under the Comprehensive Medical Benefit (for example, hospital services for dental work that cannot be performed in a dental office).
2. 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 Dental PPO Plan.
3. Duplicate prosthetic devices or any other duplicate appliances.
4. Replacement of a denture unless there has been five years since the installation of the previous denture.
5. Prosthetic devices, including bridges and crowns, and their installation, that are ordered while a person is not eligible for dental benefits.
6. Services pertaining to the temporomandibular joint (TMJ). (The Plan covers TMJ under the Comprehensive Medical Benefit.)
7. Any cosmetic or beautifying procedure.
8. Any elective or experimental procedure.
9. Implantation.
10. Setting of fractures or dislocations; or treatment of malignancies, cysts, or neoplasm or congenital malformations.
11. 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.
12. Services which, in the opinion of the attending dentist, are not necessary for the patient’s dental health.
13. Services for injuries or conditions which are cov-ered under 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).
14. Prescription and non-prescription drugs; or pharmacological regimens.
15. Any services, supplies, or types of treatment for which no benefits are payable under the Plan as a whole as stated in the “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 Status form, and a letter explaining how to make the change. (Information packets and enrollment applications are only mailed 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 and August 31.
• If you want to change from the HMO to the PPO Plan, you must send a written request to the Fund Office between August 1 and 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 cov-ered under your current dental program.
 
If you change dental plans, the change will become effective September 1.