Dental

Dental

Self-Funded Dental

Members and dependents covered by the I.B.E.W./NECA Sound and Communications Health and Welfare Trust Fund have the opportunity for substantial savings—both for your out-of-pocket expenses and your dental plan’s expenses. Please read the information contained in the announcement carefully.

Dental Expense Benefits

If you or your Dependent incur Covered Dental Charges, this Plan will pay for the expenses actually incurred, but not to exceed the percentages of Usual, Customary and Reasonable Charges when performed by a legally qualified dentist for oral examinations and treatment of accidentally injured or diseased teeth and supporting bone or tissue.

Preferred Provider Dentists

Under this plan you are free to use any dentist. However, the Trustees have negotiated lower charges with certain dentists through Anthem Blue Cross, called “preferred providers.” The network of preferred providers is called “Dental Preferred Provider Organization” or “Dental PPO”. Because the Plan saves money when you use a preferred provider dentist, you as a participant also save money when you use a preferred provider dentist.

Charges incurred at a PPO Dentist are paid at the In-Network level of 100% of the Contract Rate for Class I services, 80% of the Contract Rate for Class II services and 60% of the Contract Rate for Class III services. Class III Services are subject to a $25 per person per year deductible.

Obtaining services from a preferred provider dentist does not necessarily mean the services will be covered. Services which are not covered by the Plan are excluded regardless of where or by whom services are provided.

Non-PPO Dentist

Charges incurred at a Non-PPO Dentist will be paid at the Out-of-Network benefit level of 100% of Usual, Customary and Reasonable Charges for Class I Services, 80% of Usual, Customary and Reasonable Charges for Class II Services and 60% of Usual, Customary and Reasonable Charges for Class III Services. Class III Services are subject to a $25 per person per year deducible.

Usual, Customary and Reasonable Charges are charges that the Fund Administrator determines fall within a range of those most frequently made for services, supplies and treatments in our service area by those who provide them. If you receive a covered service that costs more than this Usual, Customary and Reasonable Charge, the Plan will pay benefits based only on the amount considered Usual, Customary, and Reasonable.

Alternate Courses of Treatment

If alternate procedures, services, or courses of treatment may be performed for the treatment of the injury or disease concerned or to accomplish the desired result, the amount included as Covered Dental Expense will not exceed the Usual, Customary and Reasonable Charge for the least expensive procedure, service, or course of treatment which, as determined by the Fund Administrator, will produce a professionally adequate result.

The benefits are subject to the Definitions, Exclusions, and Limitations of this booklet.

Pre-Estimation of Costs

Pre-estimation of treatment is requested for claims $300 and over.

After the attending Dentist’s statement with pre-estimation of costs has been returned to your dentist, you should discuss the computations with him/her.

The Fund Administrator as a condition for payment for services, may require that reasonable evidence of the extent or character of services be submitted or that you be examined by a dental consultant retained by the Fund Administrator in or near your community of residence.

Plan Summary

Maximum Benefits

Benefits are payable up to a maximum of $1,500 per person each calendar year, orthodontics up to $1,000 per person for lifetime.

Covered Dental Services

“Covered Dental Services” shall be deemed to have been incurred on the date the dental service is performed. Covered dental services are organized into four (4) “classes” that start with diagnostic preventative care and advance into specialized dental procedures.

Class I – Diagnostic and Preventative Services

  1. Routine oral examinations including prophylaxis, cleaning, scaling, and polishing, up to two (2) examinations in any twelve (12) consecutive month period.
  2. Topical fluoride applications, up to two (2) in any twelve (12) consecutive month period; for dependent children who have not attained age 15, up to four (4) in any twelve (12) consecutive month period.
  3. Supplementary bitewing X-rays up to twice each calendar year.
  4. Space maintainers for replacement of deciduous prematurely lost teeth for dependent children who have not attained age 15. Space maintainers for primary anterior teeth or missing permanent teeth are not covered.
  5. Sealant benefits for unrestored, occlusal surfaces of permanent bicuspids and molars. Benefits are limited to one sealant per tooth, during any five (5) year period.

Class I Services will be covered at 100% of the Usual, Customary and Reasonable Charges. No deductible applies.

Class II – Basic Services

  1. Dental X-rays – other than bitewing.
  2. Oral Surgery, including excision of impacted teeth.
  3. General anesthetics administered in connection with oral surgery or other covered dental services.
  4. Prescribed drugs, premedication or analgesia (nitrous oxide).
  5. Injections of antibiotic drugs by the attending dentist.
  6. Space maintainers.
  7. Treatment of periodontal and other diseases of the gums and tissues of the mouth.
  8. Endodontic treatment, including root and canal therapy.

Class II Services will be covered at 80% of the Usual, Customary and Reasonable Charges. No deductible applies.

Class III – Major Services

  1. The initial installation (including adjustments during the six-month period following installation) of full or partial removable dentures or fixed bridgework.
  2. The replacement, or alteration of, full or partial dentures, or fixed bridgework which is necessary because of: (a) oral surgery resulting from an accident; or (b) oral surgery for repositioning muscle attachments or for removal of a tumor, cyst, torus or redundant tissue, but only if this occurs after the protected person or Dependent has become insured under this provision and the replacement or alteration is completed within twelve (12) months after such surgery.
  3. The replacement of a full denture which is necessary because of: (a) structural change within the mouth, but only if more than five (5) years has elapsed since the initial placement; (b) the initial placement of an opposing full denture, but only after the protected person or Dependent has been covered under this provision for at least two (2) years; or (c) the prior installation of an immediate temporary denture, but only within twelve (12) months of the installation of the temporary.
  4. Replacement of, or addition of teeth to, an existing partial or full removable denture or fixed bridgework by a new denture or by a new bridgework, but only if (a) the replacement or addition of teeth is required to replace one or more additional natural teeth extracted while insured under this provision and after the existing denture or bridgework was installed; or (b) the existing denture or bridgework was installed at least five (5) years prior to its replacement, and the existing denture or bridgework cannot be made serviceable.
  5. The replacement of a crown restoration, provided the original crown was installed more than five (5) years prior to the replacement.
  6. Inlays, gold fillings, crowns, including precision attachments for dentures.
  7. Repair or recementing of crowns, inlays, bridgework, or dentures or relining of dentures.

Class III Services will be covered at 60% of the Usual, Customary and Reasonable Charges, subject to a $25 per person per year deductible.

Class IV – Orthodontic Services

Orthodontic benefits, which include orthodontic care, treatment, services and supplies (except for missing primary teeth) including correction of malocclusion, will be provided to employees and their eligible Dependents.

Class IV Services will be covered at 60% of the Usual, Customary and Reasonable Charges subject to a $25 per person per year deductible.

The maximum lifetime amount payable for orthodontic benefits is $1,000 per person.

Plan Information

How Are Savings Obtained?

On behalf of the Trust, Anthem Blue Cross evaluates and contracts with participating dentists. Participating dentists agree to a reduced fee schedule, and agree to adhere to professionally accepted standards of care.

For a current listing of participating dentists, contact your administrator toll free at 1-877-827-4239, or check the Anthem Blue Cross web-site at www.anthem.com/ca. Click on “Find a doctor” on the right hand side. Under plan/ network , select “Dental Blue 100/ 200/ 300”

Advantages To Members

  1. Use of participating dentists results in substantial savings in your out-of-pocket expenses.
  2. Use of participating dentists will reduce costs to your dental plan, lowering costs for both the Trust and employee alike. With the reduced costs, more dental care is available within the plan benefits.
  3. Participating dentists are evaluated for standards of care.

 

Must I Use A Participating Dentist?

You may use any licensed dentist when services are necessary. However, when you or your covered dependents receive services from a participating dentist, the charges are less and your out-of-pocket expenses are lower.

Emergencies

For emergencies requiring immediate care, use the most readily available qualified help.

Billing Procedures

Participating dentists have agreed to accept assignment of benefits. This means that their offices agree to bill the Trust and not require payment by the patient at the time of service.  Any billing for the patient’s portion is after the plan has paid and sent its Explanation of Benefits to the patient and to the dentist.

If necessary, remind participating dentist billing offices of this procedure.

Important Reminders

This announcement explains the participating dentist program. It is not a detailed description of benefits. For such information, please refer to your Summary Plan Description benefits booklet.

Remember to tell your dentist that treatment plans with proposed charges over $100 should be pre-authorized by the Trust’s Administrative Office for determination of allowable costs.

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