DENTAL PLUS: CONTENTS

Transcription

1 DENTAL PLUS: CONTENTS THE DENTAL PLUS PLAN 2 IMPORTANT PHONE NUMBERS AND WEBSITE 2 PARTICIPATING DENTIST NETWORK 2 WHAT TERMS DO I NEED TO KNOW? 2 ELIGIBLE DENTAL PROVIDERS 3 PREDETERMINATION OF BENEFITS 3 HOW DOES THE PLAN WORK? 3 EXPENSES COVERED FROM THE DATE SERVICE IS COMPLETED 4 COVERED EXPENSES 4 WHAT EXPENSES ARE NOT COVERED? 7 HOW ARE CLAIMS PAID? 8 1

2 This document contains the Dental Plus Plan Specific Benefits Document for Target and its affiliates (referred to as Target). Read this document carefully so you understand the benefits under this Plan. You should also read the Medical and Dental Common Administration Document to understand the requirements of the plan. The Medical and Dental Common Administration Document and Plan Specific Benefits Document combined create your Summary Plan Description (SPD) and should be read completely. Many of its provisions are interrelated; reading just one or two provisions may give you a misleading impression. If you have any questions after reading it, the Plan Manager will be able to help you find the answers. April 1, 2011 THE DENTAL PLUS PLAN The Dental Plus Plan (Plan) is provided by Target to encourage preventive dental care and help ease the financial burden of many dental expenses by paying for part of those expenses. The Plan is a Closed List Plan. This means that only the services listed under Covered Expenses are covered. Delta Dental of Minnesota Customer Service (800) Monday Thursday 7 am 7 pm (CST) Friday 8 am 7 pm (CST) IMPORTANT PHONE NUMBERS AND WEBSITE Call Delta Dental Customer Service if you have questions on your claims, network providers, what the Plan covers, need claim forms or ID cards. Target (800) Monday Friday 8 am 4:30 pm (CST) Call this number if you are unable to get satisfactory answers to your questions or concerns from Delta Dental Customer Service. Target Benefits Center Monday Friday 9 am 7 pm (CST) PARTICIPATING DENTIST NETWORK When enrolled in the Plan, you and your covered dependents can take advantage of Delta Dental s two largest networks of dentists. These networks are called Delta Dental PPO and Delta Dental Premier. All dentists in both networks have agreed to accept a negotiated fee for services generally below the normal charges made by other dentists in your local community. Delta Dental PPO is a small network that offers the largest discounts available. Delta Dental Premier is a very large network that still offers discounts over non-network benefits. You can see any dentist you want. If you seek care from a Delta network dentist, Preventive services will be covered at 100% after the deductible. Preventive services will be covered at 80% if you receive care from a non-network dentist. There is no difference in the percentage the Plan pays for Basic or Major services whether provided by a Delta network dentist or non-network dentist. You are responsible for all treatment charges made by a non-network dentist. When services are obtained from a non-network dentist, any benefits payable under the group contract are paid directly to the covered person. To participate in the Delta Participating Dentist Network: Visit Delta s website to obtain a list of network providers in your area: Choose either Delta Dental PPO or Delta Dental Premier as the product/network. Call Delta s customer service at to obtain a list of providers in your area. Call and ask your dentist if he/she participates in either the Delta Dental PPO or Delta Dental Premier network. Make your dental appointment. Identify yourself as a member of the Delta Dental Plan and confirm the dentist is a participating provider. Show your dental identification card at each dental visit. Your identification card lets your dentist know that you are a Delta subscriber. This information is important to communicate when receiving services. Delta s customer service phone number and claims address is listed on the back of your card. WHAT TERMS DO I NEED TO KNOW? Change in Status Change in marital status, affirmation or dissolution of domestic partnership, change in the number of eligible dependents, change in employment status, or change in cost or coverage. 2

3 Closed List Plan The Plan only covers the services listed in this document subject to any exclusion in the section What Expenses Are Not Covered? Benefits will be paid only for services listed as covered expenses. Covered Dental Expense The Plan Payment Obligation for services which are dental necessities and covered by the Plan. Delta Dental Delta Dental of Minnesota. Dental Necessity Any treatment or service ordered by a dentist that is customarily recognized throughout the dental profession as appropriate for the treatment of disease or injury. Non-Participating Dentist A licensed Dentist who has not signed and filed a participation agreement with his/her local Delta Dental Plan. Participating Dentist A licensed Dentist who has signed and filed with Delta Dental or his/her local Delta Dental organization, a Dentist Membership and Participation Agreement which is in effect at the time any part of this Plan becomes applicable with respect to the provision of any Dental Service for which payment is claimed under the Plan. Table of Allowances A schedule of fixed dollar maximums established by Delta Dental for services rendered by a licensed Dentist who is a Non- Participating Dentist. You You generally refers to any covered person; in some contexts, you refers to a Team Member only. ELIGIBLE DENTAL PROVIDERS To be eligible for reimbursement by this Plan, the dental service must be performed by: A dentist giving the services for which he or she is licensed, A physician giving the dental services for which he or she is licensed, A licensed hygienist acting under supervision of a qualified dentist, or A dental student supervised and directed by a qualified dentist. PREDETERMINATION OF BENEFITS The plan includes a predetermination of benefits procedure. Predetermination of benefits involves a determination of Plan benefits before treatment. All dental work estimated over $300 should be predetermined before treatment begins. By using this feature of the Plan, you will learn in advance the estimated benefits the Plan will pay. You and your provider can then decide on how the treatment will be done. To predetermine Plan benefits, get a dental claim form from Delta Dental. You and your provider should complete the form and check the predetermination box. Your dentist should send the form and a treatment plan to Delta Dental at the address listed on the form. Treatment Plan A treatment plan is the provider s report of recommended treatment which: lists the dental procedures required, and itemizes the charge for each procedure. If a predetermination of benefits is not done prior to beginning a dental treatment, your dental benefits may be denied or reduced based on a dental review. Alternative Treatment Many dental conditions can be properly treated in several ways. If different procedures will adequately treat the dental condition, the Plan covers the least expensive treatment. For example, if either a filling or a crown will restore a tooth satisfactorily, the Plan will cover the filling. If you choose the more expensive treatment, you must pay the additional cost. A predetermination of benefits may suggest an alternate treatment that will reduce your costs and still preserve the health of your teeth and gums. Paying Expenses that have been Predetermined The Plan will pay for expenses as they are actually completed. Any payment arrangements made with your provider will not be considered. Benefits will be paid according to the Plan provisions, taking into account alternate procedures and courses of treatment based upon accepted standards of dental practice. The Plan may deny your claim or may pay benefits at an amount less than what you anticipated. HOW DOES THE PLAN WORK? Choice of Dentists In - Network Out - of - Network Delta Network Dentist enrolled in the Delta Dental PPO or Delta Dental Premier Networks. A Non-Delta Network Dentist When you DO use a Delta Network Dentist, plan benefits are based on a negotiated fee schedule. You are responsible for paying the difference between the negotiated fee and the percentage the plan pays after the plan year deductible. 3

4 When you DO NOT use a Delta Network Dentist, reimbursement for covered services is based on Health Insurance Association of America (HIAA) data. (HIAA data is based on U&C Usual & Customary charges by dentists in your area.) If you choose to seek care outside of the network, the Plan generally pays Benefits at a lower level. You are required to pay the amount that exceeds the Eligible Expense. Deductible LIFETIME Pay it once if Diagnostic, Preventive, and Basic services are used while enrolled in the plan. ANNUAL Must be paid each year if major services are used. $50 One member $100 Two members $150 Three members $200 Four or more members Covered Services In - Network Out - of - Network Diagnostic and Preventive Care After Lifetime Deductible has been Satisfied. Plan Pays 100% You Pay 0% After Lifetime Deductible has been Satisfied. Basic Care Services Major Care Services After Lifetime Deductible has been Satisfied. After Annual Deductible has been Applied After Lifetime Deductible has been Satisfied. After Annual Deductible has been Applied Orthodontia Coverage Maximum Benefit Not Covered $1,500 per plan year per member. Your decision to participate in the Dental Plus Plan is completely independent of your decision to participate in a medical plan. You do not have to enroll in a medical plan to enroll in the Dental Plus Plan. EXPENSES COVERED FROM THE DATE SERVICE IS COMPLETED The majority of procedures under this Plan are procedures that are performed on and billed with the same date of service. There are several other dental services that are considered multistage procedures that require multiple appointment dates. The Plan benefits multistage procedures upon the completion date of the procedure. The Plan considers an expense to be completed on the following dates: For full and partial dentures on the date the denture is inserted. For fixed bridges, crowns, inlays and onlays on the date the appliance is cemented. For root canal therapy on the date the canal spaces are completely filled. You must have coverage on the date the service is completed to receive benefits for these services. If you lost coverage prior to a multistage procedure being completed, you will not be eligible for payment for that procedure under this Plan. COVERED EXPENSES The Plan is a Closed List Plan with services divided into Preventive, Basic and Major categories. The dental services listed in this section are the only services eligible under the Plan. Call Delta Dental Customer Service at (800) with any questions about covered expenses. For a dental expense to be a covered benefit, Delta Dental determines: Whether or not the treatment is considered to be a dental necessity, Whether or not the treatment has a good chance of being successful, and If the treatment is on the Closed List of covered expenses. The Plan pays for benefits according to the Plan Payment Obligations. Preventive Care Oral examination Getting your teeth, gums and mouth checked. Limited to 1 examination in any 6 consecutive month period. Note: Initial new patient exams will be allowed 1 time per dental office. Any additional new patient exams performed by the same dental office will be benefited as a periodic oral evaluation and will be subject to the 1 time per 6 month limitation. Complete mouth x-rays Includes bitewings or panoramic x-ray. Limited to 1 time in any 36 consecutive month period. Bitewing x-rays X-rays of back teeth, usually for cavity detection. Limited to 1 set of x-rays in any 12 consecutive month period. 4

5 Individual periapical x-rays X-rays of entire tooth and root. Limited to 7 in any 12 consecutive month period. Occlusal x-rays Larger film than periapical or bitewing. Limited to 2 films in any 12 consecutive month period. Extraoral x-rays X-ray from outside the mouth. Limited to 2 films in any 12 consecutive month period. Dental prophylaxis Teeth cleaning, scaling and polishing. Limited to 1 time in any 6 consecutive month period. NOTE: A prophylaxis performed on a Covered Person under the age of 14 will be benefited as a child prophylaxis. A prophylaxis performed on a Covered Person age 14 or older will be benefited as an adult prophylaxis. Fluoride Treatment Fluoride is a chemical put on teeth to help prevent decay. Only for children under age 16. Limited to 2 treatments in any 12 consecutive month period. Applications of sealants Putting a seal on the grooves of the teeth to prevent decay. Only for children under age 14. Limited to 1 application to the first and second permanent molars per lifetime. Space maintainers Keeps a space open so the permanent tooth can come through. Used when a baby tooth is lost prematurely. Only for children under age 16. Includes all adjustments made in the first 6 months. Basic Care Emergency oral examination Biopsy Removal of tissue from the mouth for microscopic examination. Palliative (emergency) treatment Treatment (minor procedure) for pain relief only. Paid for separately if no other dental work, except x-rays, is done during the visit. Limited to one time in any 12 consecutive month period. Prescription drugs Drugs that must be ordered for a dental condition. A copy of the receipt must be attached to the submitted claim form. Therapeutic drug injections Antibiotics needed for treatment. Restorative Basic coverage for restorative expenses excludes inlays, onlays, crowns and bridges. Multiple restorations in one surface will be considered a single surface restoration. Multiple restorations in the same tooth will be combined for benefit determination. Diagnostic casts A replica of your teeth made from an impression. Limited to one time in any 36 consecutive month period. Amalgam (silver) and Composite (white) Resin Restorations (Fillings) - Treatment to restore decayed or fractured permanent or baby teeth. Anterior (front) Teeth Posterior (back) Teeth Pin retention Covered only with an amalgam or composite restoration. Repair or recementing of crowns, inlays, onlays, bridgework or dentures Only covered when done more than 12 months after the original insertion. Tissue conditioning Soft material placed in a denture to correct tissue irritation. Limited to one time in any 12 consecutive month period. Oral Surgery Simple extraction Having a tooth pulled. Surgical extraction of an erupted tooth Having dental surgery to remove a tooth already through the gum. Extraction of impacted teeth Removing teeth that have not come through the gum. 5

6 Root Recovery Incision and drainage of a soft tissue abscess in or out of the mouth Cutting an abscess to help it drain and relieve pain. Laboratory and pathology reports Reports of lab tests. When needed for oral surgery. General anesthesia or IV sedation A drug to cause loss of consciousness/awareness of pain when medically necessary as determined by the Plan Manager. Must be given by a provider who has been approved to administer anesthesia. Major Care Temporary restorations and appliances and one year of follow-up are included in the allowance for the final appliance or restoration. Restorative Inlays Benefit shall equal an amalgram (silver) restoration for the same number of surfaces. Onlays and crowns To restore lost tooth structure. If under age 16 Limited to plastic or stainless if the tooth cannot be restored with a filling. If age 16 or over Covered 1 time per 7 year period per tooth. Crown buildup/post and core Rebuilding a broken down tooth to provide retention before placing a crown. Periodontics Scaling and root planing Removal of plaque and hard deposits under the gum. Limited to 1 time per quadrant of the month in any 12 consecutive month period. Periodontal maintenance prophylaxis This is in addition to the dental prophylaxis listed under Preventive Care. Limited to 1 time in any 12 consecutive month period. Gingivectomy, gingival curettage, mucogingival surgery, osseous surgery, osseous, pedicle and free soft tissue grafts Surgery used to treat gum disease. Limited to one complex surgical periodontal service in the same quadrant of the mouth in any 24 consecutive month period for a single tooth or multiple teeth. Occlusal guard appliances Protects the teeth from the harmful effects of grinding (bruxism) and clenching. Limited to 1 appliance in any 24 consecutive month period. Dentures and Bridges (Prosthodontics) Full dentures A complete set of upper and lower false teeth. No additional benefits for: - over-dentures and associated procedures - customized and duplicate dentures - specialized techniques Partial dentures A partial set of false teeth. Includes all clasps, rests and teeth. No additional benefits for precision or semi-precision attachments. Fixed bridges an appliance that cannot be removed by the patient that is replacing missing teeth. Maryland bridges A type of fixed bridge requiring very little tooth preparation. Replacement of bridges and dentures Must be a participant in the Plan for at least 12 consecutive months. The bridge or denture must be at least 7 years old. Repair must be impossible. If replacement is needed because of disease or extraction of a functioning tooth and the repair is impossible, the 7-year rule does not apply. Denture adjustments Limited to 1 time in any 12 consecutive month period. Must be done more than 12 months after dentures are first put in. Denture relining Limited to 1 time in any 36 consecutive month period. Must be done more than 12 months after dentures are first put in. 6

7 Single Tooth Implant Body, Abutment and Crown Limited to 1 time in any 7 consecutive year period. Oral Surgery Surgical exposure of an impacted or unerupted tooth to aid eruption Removal of covering tissue to help the tooth erupt into the mouth (not associated with orthodontic treatment). Alveoloplasty A treatment to help get the mouth ready for a denture after teeth are removed. Stomatoplasty/vestibuloplasty Mouth repair or reconstruction. Removal of exostosis Removing extra bone. Frenectomy (frenulectomy) Removing the tissue (frenum) under the upper/lower lip or tongue. Excision of hyperplastic tissue Removing enlarged or overgrown tissue. Excision of pericoronal tissue Endodontics Pulpotomy Removing pulp from a tooth. Limited to baby teeth. Root canal therapy Treatment of a diseased tooth by removing pulp and placing a filling material in the canal(s) in the root(s). Apicoectomy and retrograde filling Removing part of the root of the tooth. Hemisection Cutting a tooth in half. WHAT EXPENSES ARE NOT COVERED? The following is a non-exhaustive list of items and procedures that are not covered under the Plan. If you have a question about whether a dental expense is covered by the Plan, contact Delta Dental Customer Service at (800) The portion of any charge for a service in excess of the Plan Payment Obligation. The completion and filing of claim forms. Broken appointments. Procedures that are: - not included in the list of covered expenses, - not necessary, - not likely to have a good chance of being successful, - not customarily recognized throughout the dental profession as appropriate for the treatment of disease or injury, or - temporary treatment. Experimental/investigational services, supplies and treatment procedures. Appliances, restorations or procedures to alter vertical dimension, to restore or maintain occlusion, for splinting or replacing tooth structure lost from attrition, erosion or abrasion. Overdentures and associated procedures endodontic treatment, posts, copings, etc. General anesthesia for any reasons not listed under Basic Care Oral Surgery. Analgesia (nitrous oxide) and non-iv sedation. Appliances, restorations or procedures for restoration of misalignment of teeth. Orthodontia treatment. - Orthodontic services - Orthodontic retention/retainer as a separate service Cosmetic procedures such as teeth whitening and bonding. Tooth replants or transplants. Replacement of full and partial dentures, bridges, inlays, onlays, or crowns that are: - replaced within 7 years of last placement. This exclusion does not apply if replacement is necessary because a functioning natural tooth is pulled. Replacement of bridges, full and partial dentures, crowns, inlays, or onlays that can be repaired and restored to function. Implants and related services, unless listed under covered services. Repair or replacement of lost, broken, or stolen appliances. Myofunctional therapy. Athletic mouthguards. Precision or semi-precision attachments. Denture duplication. Orthognathic surgery Surgery to correct a problem with the jaw bones such as maxillary or mandibular osteotomy. Oral hygiene including: - instruction, - plaque control, and 7

8 8 - prescription or take-home fluoride. Diagnostic photographs. Hospital expenses and related anesthetic expenses, except as specifically described in this document. Correction of congenital or developmental abnormalities/malformations. Bacteriologic studies, caries susceptibility tests and pulpal vitality tests. Nutritional and tobacco counseling. Recementation of space maintainers. Veneers. Crown lengthening. Biologic materials and chemotherapic agents. Guided tissue regeneration. Provisional splinting. Interim dentures Pediatric fixed dentures. Consultations. Examinations, diagnostic procedures, surgical or nonsurgical treatment of jaw joint problems. This includes: - temporomandibular joint dysfunction (TMJD), - TMJD pain syndromes, - Craniomandibular disorders, - Myofacial pain dysfunction, and - other conditions of the joint linking the jawbone and skull and the complex of muscles, nerves and other tissues linked to that joint. Expenses for dental work done before you were covered under this Plan. Procedures which are begun prior to Plan coverage. Procedures which are completed when not covered under the Plan. Services which in the opinion of Target do not have a reasonably favorable prognosis. Treatment by a dentist who is a family member. Family members include: - your spouse or domestic partner, - your or your spouse s or domestic partner s children, brothers or sisters, - your or your spouse s or domestic partner s parents and grandparents, and - your or your spouse s or domestic partner s aunts and uncles. Treatment provided for which there is not normally a charge. Charges from providers who waive deductibles and coinsurance to be paid by the covered person. Conditions resulting from war or any act of war. This does not apply if you are a U.S. expatriate or an employee on temporary assignment outside your country of residence. Conditions related to occupational causes that may be reimbursed by the Workers Compensation Act/Occupation Injury and Illness or any federal, state, or local government agency. Monthly treatment visits that are inclusive of treatment cost. Retreatment and/or services for any treatment due to relapse. Inpatient or outpatient hospital expenses. Provisional splinting, temporary procedures or interim stabilization of teeth. Cone beam images. Anatomical crown exposure. Temporary anchorage devices. Sinus augmentation. Brush biopsy and the accession of a brush biopsy. Bone Grafts Dental Services that may be Covered Under Medical Plans If you are enrolled in a medical plan in addition to this dental plan, you may have coverage for some services not covered by this Plan. The services listed below may be covered under your medical plan. You must contact your medical plan to determine if coverage for a particular service is available. Examples of services which may be covered under your medical plan include: Treatment of a fractured jaw. Treatment of a cleft lip and palate. Treatment for damage to sound natural teeth when the damage results from a non-occupational dental injury. Excision of a tumor, cyst, or foreign body. Removal of salivary stones. Laboratory and pathology reports associated with oral surgery. Surgical treatment of TMJD (temporomandibular joint dysfunction). Facility and anesthesia charges. HOW ARE CLAIMS PAID? Submitting a Claim You are not responsible for submitting claims for services received from participating providers. These providers will submit claims directly to Delta Dental for you and payment will be made directly to them. If you receive services from a nonparticipating provider you may have to submit the

9 claims yourself. Claim forms can be obtained from Delta Dental or visiting their website If the provider does not submit the claim for you, send the claim to the address provided below: Delta Dental of Minnesota PO Box 908 Minneapolis, MN You must fill out a separate form for each person treated. You should keep copies of the claims that you submit. You should submit all claims for the Plan Year (beginning April 1 and ending on the last day of March) no later than October 1 of the year following the end of the Plan Year. Claims submitted after October 1 will be denied. If you have any questions on how to submit a claim, call Delta Dental Customer Service at (800) Proof of Claim Delta Dental Customer Service may require verification of any claim and may request additional information. This information includes but may not be limited to: A complete dental chart showing extractions, missing teeth, fillings, prostheses, periodontal pocket depths, and the date of any work previously done. An itemized bill for all dental care. Pre-operative x-rays, study models, and laboratory and/or hospital reports. A dental examination of any participant by a dentist chosen by the Plan Manager (the Plan will pay for this). Claim Payment Claim payments for participating providers will be made directly to the participating provider. You will be responsible for any non-covered services, as well as applicable deductible and coinsurance amounts listed in the How Does the Plan Work section. Nonparticipating provider claim payments are sent directly to you. Any benefits which may be payable under this dental benefit Plan are not assignable. 9