Description of Your Dental Plan:
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Who is eligible for all benefits described in this section?
- Member of the PFT bargaining unit that receives all the described Dental benefits (Teachers, Non-Teaching Assistants, Comprehensive Early Learning Centers, Food Service Managers, Para Professionals, Secretarial/Clerical, Pre-Kindergarten Head Start, Professional Technical, Supportive Services Assistants).
- The member’s spouse.
- Unmarried, dependent children under 26 years of age.
When are benefits available?
- When the member has completed the required waiting period.
How are the fees determined?
United Concordia Companies, Inc. Dental Program provides for payment on the basis of the “usual and Customary rather than on the basis of a fee schedule or table of allowances. The “usual and customary fee” is determined by the following:
- The usual fee charged by a dentist to the majority of his patients for the procedure performed.
- The customary fee charged in a particular geographical and economic area for services performed by dentists of similar training and experience.
- The reasonable fee charged for services performed which involve unusual circumstances requiring additional time, skill, special consideration.
- Limits determined by the Fund Administration.
What is a Participating Dentist?
A Participating Dentist is a dentist who has signed a contract with United Concordia. The Participating Dentist agrees to accept the total allowable chare determined by United Concordia. This becomes the basis for 100%, 80%, or 50% determination.
- The statement sent by United Concordia to the member will show the total charge allowed. This charge represents the “prevailing fee”.
- The Participating Dentist must accept the total allowed charge (“prevailing fee”) as his fee. United Concordia will pay him 100%, 80%, or 50% of the permitted total, depending upon the services. The member pays either nothing, 20% of the prevailing fee, or 50% of the prevailing fee, depending upon the services. If the charge of a Participating Dentist exceeds the charge permitted by United Concordia, please call the Health and Welfare Fund Office.
- A Non-Participating Dentist may charge more than the prevailing fee. In such cases, United Concordia will pay only 100%, 80%, or 50% of the total allowed fee, depending upon the services. The member may have to pay a fee even though the service is a 100% item. The member may also have to pay more than 20% or 50% of the total allowed charge. There are no controls over the fees of Non-Participating Dentists.
- When using a non-participating dentist, payment will made to the subscriber
- Payments are made directly to a participating dentist.
What are the benefits?
100% of the total allowable fee or the amount charged (whichever is lower) – no additional charge to the member – for the following basic services:
- Oral examination, including treatment plan if necessary (every 6 months).
- Periapical and bitewing x-rays as required (complete mouth x-rays are limited to once every three years unless special need is shown).
- Topical fluoride application for dependents under age 19, but not more than once in any period of six consecutive months.
- Prophylaxis, including cleaning, scaling and polishing (every 6 months). (See Periodontal Prophylaxis below).
- Repair of broken dentures.
- Palliative emergency treatment for conditions which cause dental pain.
- Fillings consisting of silver amalgam synthetic tooth color restorations.
- Simple extractions.
- Endodontics, including pulpotomy, pulp capping and root canal treatment.
- Anesthetic services performed by (or under the direct personal supervision of) and billed for by a dentist other than the operating dentist or his assistant in connection with the performance of covered services. The administration of local infiltrations or block anesthetic is not covered.
- Consultations, subject to a limit of one per consultant during any one period of hospitalization, when performed by a dentist and when:
- The condition of the subscriber requires consultation.
- The dentist in charge of the case requests the consultation.
- Space maintainers (not made of precious metals that replace lost teeth for dependent children under 19 years of age). (No payment for duplicate space maintainers).
Supplemental Basic Services – 80% of the total allowable charge fee or the amount charged (whichever is lower) for the following Supplemental Basic Services that are approved by United Concordia after the submission of a treatment plan:
- Inlay and single crowns (single and unconnected).
- Not part of a bridge or resulting from periodontal disease (Crowns as part of a fixed bridge are 50%).
- No payment will be made for precious metal restoration unless the tooth cannot be restored with another metal.
- Splints are not covered.
- Oral surgery consisting of cutting procedures.
- For the treatment of diseases, excluding periodontal disease.
- Including such post-operative care as is normally included as part of the dentist’s surgical charge.
- Including treatment of fractures and dislocations of the jaw.
- The extraction of impacted teeth when partially or totally covered by bone.
- For removal of teeth and maxillary or mandibular intrabony cysts.
- Procedures performed for the preparation of the mouth for dentures.
- Appicoectomy (dental root resection).
- Predetermination required for inlays, onlays and crowns.
- Replacement of inlays, onlays and crowns will be covered only if at least five years have elapsed since the date of the insertion of the existing inlay, onlay, or crown under this agreement, and only if the inlay, onlay, or crown is unserviceable and cannot be made serviceable.
Prosthetic Services – 50% of the total allowable charges fee or the amount charged (whichever is lower) for the following Prosthetic Services, if they are approved by United Concordia after the submission of the treatment plan:
- Dentures, full and partial and adjustments during the six-month period following Insertion.
- Removable bridges, including pontics and abutment crowns, inlays and onlays.
- Services for fixed bridges will be provided only when the replacement cannot be made by other methods.
- Services for full denture replacement or bridge replacement will be made after five years have elapsed since the date of the item to be replaced, provided the existing denture or bridge cannot be made serviceable.
- Services shall not be provided for any denture or bridge replacement made necessary by reason of the loss or theft of a denture or bridge.
- If in the construction of a denture or bridge, the subscriber and the dentist decide on personalized restoration or to apply special techniques as opposed to standard procedures, the services provided under this rider shall be limited to the standard procedures for prosthetic services, as determined by United Concordia.
- Repair of broken crown, inlay, onlays or bridges.
- Relining or rebasing of dentures more than six months old and not more than once in any 36 consecutive months.
- Preauthorization by United Concordia shall be required routinely for prosthetic services.
- If a cast chrome or acrylic partial denture will restore the dental arch satisfactorily, payment will be made for this. The payment may be applied toward a more elaborate service or item that the subscriber and dentist may choose. The balance of the cost is the responsibility of the subscriber.
- No payment will be made for veneers on other than the ten upper and ten lower anterior teeth.
Periodontic Services – 50% of the total allowable charges fee or the amount charged (whichever is lower) for the following Periodontic Services that are approved by United Concordia in the submission of a treatment plan:
- Periodontic examination.
- Periodontic Prophylaxis – 4 in any 12-month period – this is not in addition to the regular prophylaxis.
- Gingivectomy curettage.
- Gingivectomy and gingivoplasty.
- Osseous surgery, including flap entry and closure.
- Mucogingivoplastic surgery.
- Management of acute infection and oral lesions.
- Preauthorization by United Concordia shall be required routinely for periodontic services.
Orthodontic Services – 50% of the total allowable charges or the amount charged (whichever is lower) with a maximum allowance of $1,200.00. This is a lifetime maximum.
- The treatment plan must be approved by United Concordia.
- Orthodontic services must be for handicapping malocclusions performed by a dentist qualified in orthodontics.
- Payments shall be made quarter annually over a period not to exceed the length of the approved payment plan.
- The initial payment shall be no more than 25% of the total United Concordia liability.
- If the orthodontic services are terminated before completion of the approved orthodontic treatment for any reason, the responsibility of United Concordia will cease with payment through the month of termination.
- Any charges for the replacement and/or repair of any appliance furnished under the treatment plan shall not be paid by United Concordia.
- Diagnosis, including radiographs and study models.
- Retention treatment following active treatments.
Implants – 25% – Limited to endosseous, subperiosteal, transosseous, and unspecified implant procedures as a result of a congenital deformity.
What is Predetermination?
- Predetermination is the submission by the dentist of a treatment plan. United Concordia reviews the treatment plan and contacts the dentist if they feel the plan may be inadequate. It provides a review and check on the work.
- Predetermination is routinely required for:
- Periodontal surgery
- All services that cost $300 or more
What happens if a member has coverage from two plans?
- There is a coordination of benefits.
- The plan under which the member has been enrolled the longest will determine its benefits first.
- The plan covering the member, as an employee, will determine the benefits before the plan which covers the member as a dependent.
- When this dental plan is first, benefits will be paid without regard to coverage under any other plan.
- When this dental plan is not the first, but there are remaining expenses after other coverage, this plan will pay its regular benefit up to the amount of the remaining expenses. These remaining expenses must be for services covered by this plan.
- If an active, eligible spouse member retires and elects to purchase Retiree dental coverage and the other spouse is still in active service, the following coordination shall take place:
- The active spouse coverage shall be first.
- The Retiree Dental plan shall be second.
- This true for both Retiree Single or Retiree Family Coverage.
How does an eligible person obtain the benefit?
- When a member becomes eligible, he/she receives in the mail a United Concordia Dental Card.
- After receipt of the initial card, new dental cards are issued every April 30th and October 31st.
- The eligible member takes this card to the dentist.
- Participating Dentists should have United Concordia forms. If they do not, please call the Health and Welfare Fund Office.
- If you are using a Non-Participating Dentist, please call the Health and Welfare Fund Office, and we will send you a form.
- The form is sent to United Concordia.
- Payment is made directly to Participating Dentist by United Concordia.
- Payment for services performed by a Non-Participating Dentist is usually made directly to the member.
- Payments for uncovered portion of the prevailing fee may be required initially by a Participating Dentist. If this is the case, the member should keep copies of all bills in the event that a question arises concerning the allowed charge.
- Services received from a dental or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trustee or similar person or group.
- Services for which the subscriber incurs no charge.
- Services for any occupational conditions, ailment or injury arising out of and in the course of covered employment under Workman’s Compensation or Occupational Disease Laws, Federal Employers’ Liability Acts, or other similar State or Federal Legislation; or provided by the United States Veterans Administration; or provided without cost to the subscriber by any federal, state, county, or municipal hospital, agency, or instrumentality.
- Services with respect to congenital malformations (except Implants under special conditions) or primarily for cosmetic or esthetic purposes.
- Services, the cost of which has been or is later recovered in any action at law or in compromise or settlement of any claim.
- Services or supplies provided by any governmental body or instrumentality, whether federal, state or local, pursuant to any program under which any periodic payment or premium, rate, enrollment fee or other similar charge is made by or for the subscriber.
- Appliances or restorations used solely to increase vertical dimensions (splinting).
- Charges for services to the extent that such charges exceed the charge that would have been made and actually collected if no coverage existed hereunder.
- Services in a hospital performed by a dentist who in any case is compensated by the hospital for similar services when performed for patients.
- Local anesthesia when billed for separately by the dentist.
- Gold foil restorations.
- General anesthesia.
- Complete mouth x-rays are limited to no more than once in any three-year period, unless special need is shown.
- Oral examinations, periapical and bitewing x-ray, fluoride applications, and prophylaxis services are limited to once in any six-month period.
- In all cases involving covered services where there are optional methods of treatment, which carry different fees, United Concordia is liable only for the treatment procedure carrying lesser fee. In cases where the dentist and the patient agree on an optional procedure at a fee higher than the above limitation, the dentist may charge the patient the difference for any amount over that for which United Concordia is liable.
- In the event a subscriber transfers from the care of one dentist to that of another dentist during the course of treatment, or if more than one dentist performs services for one dental procedure, United Concordia shall be liable for no more than the amount it would have been liable for had but one dentist performed the service.
- Services other than those specifically covered herein.
- Unusual and experimental procedures and techniques.
- Plaque control.
- Sealants and oral hygiene and dietary instruction.
- Temporary items.
- Loss or theft replacements.
- Charges for the completion of any insurance forms.
- Implantology — except for congenital conditions.
What Benefits are Available for Dependents of Deceased Employees?
Spouses of Health and Welfare members who die will continue to be eligible for full benefits for the remainder of the current benefit period, and for all the next benefit period. Benefit periods last 6 months, May 1 to October 31, and November 1 to April 30.
Example: If a covered member dies on September 1, the spouse is covered for 8 months, September through the next April.
Benefit coverage is extended to eligible children of deceased employees as long as they remain dependent under the rules of the benefits involved.