Washington Farm Bureau Plan 3

Transcription

1 Washingtn Farm Bureau Plan 3 Delta Dental f Washingtn Plan N Effective: Octber 1, BB PREML

2 Welcme t yur Delta Dental Premier plan, administered by Delta Dental f Washingtn, a funding member f the natinwide Delta Dental Plans Assciatin. Our missin is t supprt yur verall health by prviding excellent dental benefits and the advantages f access t care within the largest netwrk f dentists in Washingtn and natinwide. Supprting healthy smiles has been ur fcus fr ver 60 years. Yur Premier plan is a resurce t make it easy fr yu t care fr yur smile. This benefit bklet summarizes yur cverage and describes hw yur benefits may be used. Understanding yur benefits is the first step t getting the mst frm yur dental plan. Review this bklet befre yu visit yur dentist and keep it as a reference fr later n. Yu deserve a healthy smile. We re happy t help yu prtect it. Questins Regarding Yur Plan If yu have questins regarding yur dental benefits plan, yu may call: Delta Dental f Washingtn Custmer Service Written inquiries may be sent t: Delta Dental f Washingtn Custmer Service Department P.O. Bx Seattle, WA Yu can als us at CService@DeltaDentalWA.cm. Fr the mst current listing f Delta Dental Participating Dentists, visit ur nline directry at r call us at Cmmunicatin Access fr Individuals wh are Deaf, Hard f Hearing, Deaf, Blind r Speech-disabled Cmmunicatins with Delta Dental f Washingtn fr peple wh are deaf, hard f hearing, deaf-blind and/r speech disabled is available thrugh Washingtn Relay Service. This is a free telecmmunicatins relay service prvided by the Washingtn State Office f the Deaf and Hard f Hearing. The relay service allws individuals wh use a Teletypewriter (TTY) t cmmunicate with Delta Dental f Washingtn thrugh specially trained cmmunicatins assistants. Anyne wishing t use Washingtn Relay Service can simply dial 711 (the statewide telephne relay number) r t cnnect with a cmmunicatins assistant. Ask the cmmunicatins assistant t dial Delta Dental f Washingtn Custmer Service at The cmmunicatins assistant will then relay the cnversatin between yu and the Delta Dental f Washingtn custmer service representative. This service is free f charge in lcal calling areas. Calls can be made anywhere in the wrld, 24 hurs a day, 365 days a year, with n restrictins n the number, length r type f calls. All calls are cnfidential, and n recrds f any cnversatin are maintained BB ii PREML

3 Table f Cntents Summary f Benefits...1 Reimbursement Levels fr Allwable Benefits...1 Plan Maximum...1 Hw t Use Yur Plan...1 Claim Frms...2 Reimbursement Levels...2 Reimbursement Levels fr Other Prcedures...2 Cinsurance...2 Plan Maximum...2 Benefit Perid...3 Plan Deductible...3 Emplyee Eligibility, Enrllment, and Terminatin...3 Dependent Eligibility, Enrllment and Terminatin...3 Special Enrllment Perids...4 Extensin f Benefits...5 Hw t Reprt Suspicin f Fraud...5 Cnslidated Omnibus Budget Recnciliatin Act (COBRA)...6 Health Insurance Prtability and Accuntability Act (HIPAA)...6 Unifrmed Services Emplyment & Re-Emplyment Rights Act (USERRA)...6 Cnversin Optin...6 Necessary vs. Nt Cvered Treatment...6 Benefits Cvered By Yur Plan...6 Frequently Asked Questins abut Yur Dental Benefits Claim Review Appeals f Denied Claims Crdinatin f Benefits Subrgatin Yur Rights and Respnsibilities Glssary BB iii PREML

4 Reimbursement Levels fr Allwable Benefits Summary f Benefits Class I... Cnstant 80% Class II... Cnstant 80% Class III... Cnstant 50% TMJ prcedures... Cnstant 50% Annual Deductible per Persn... $25 Annual Deductible Family Maximum... $75 Plan Maximum Annual Plan Maximum per Persn... $2,000 Lifetime TMJ Maximum... $5,000 Annual TMJ Maximum... $1,000 The payment level fr cvered dental expenses arising as a direct result f an accidental injury is 100 percent up t the unused Plan maximum. All Enrlled Emplyees and Enrlled Dependents are eligible fr Class I, Class II, Class III cvered dental benefits, temprmandibular jint (TMJ) benefits and accidental injury benefits. The annual deductible is waived fr: Class I cvered dental benefits Accidental Injury benefits Hw t Use Yur Plan The best way t take full advantage f yur dental Plan is t understand its features. Yu can d this mst easily by reading this benefit bklet befre yu g t the dentist. This benefit bklet is designed t give yu a clear understanding f hw yur dental cverage wrks and hw t make it wrk fr yu. It als answers sme cmmn questins and defines a few technical terms. If this benefit bklet des nt answer all f yur questins, r if yu d nt understand smething, call a DDWA custmer service representative at Please be sure t cnsult yur prvider regarding any charges that may be yur respnsibility befre treatment begins. Chsing a Dentist With DDWA, yu may select any licensed dentist t prvide services under this Plan; hwever, if yu chse a dentist utside f the Delta Dental PPO Netwrk, yur csts may be higher than if yu were t chse a Delta Dental PPO Dentist. Dentists that d nt participate in the Delta Dental PPO Netwrk have nt cntracted with DDWA t charge ur established PPO fees fr cvered services. As a result, yur chice f dentists culd substantially impact yur ut-f-pcket csts. Once yu chse a dentist, tell them that yu are cvered by a DDWA dental plan and prvide them the name and number f yur grup and yur member identificatin number. Yur grup infrmatin can be fund n the identificatin card dcument prvided t yu at enrllment. Additinally, yu may btain yur grup infrmatin and yur member identificatin number by calling ur custmer service number at r thrugh ur website at Delta Dental f Washingtn assigns a randmly selected identificatin number t ensure the privacy f yur infrmatin and t address cncerns abut identify theft. Please nte that ID cards are nt required t see yur dentist, but are prvided fr yur cnvenience. Delta Dental Participating Dentists Dentists wh have agreed t prvide treatment t patients cvered by a DDWA plan are called Participating Dentists, because they participate in ur prgram f plans. Fr yur Plan, Participating Dentists are Delta Dental Premier Dentists, wh have agreed t prvide services fr their filed fee under ur standard agreement. Yu can find the mst current listing f Participating Dentists by ging nline t the Delta Dental f Washingtn website at Yu may als call us at BB 1 PREML

5 If yu select a Delta Dental Premier Dentist they will cmplete and submit claim frms, and receive payment directly frm DDWA n yur behalf. Payment will be based n the pre-apprved fees yur dentist has filed with their lcal Delta Dental plan. Yu will nt be charged mre than the Participating Dentist s apprved fee. Yu will be respnsible nly fr stated cinsurances, deductibles, any amunt ver the plan maximum and fr any elective care yu chse t receive utside the Cvered Dental Benefits. Nn-Participating Dentists If yu select a dentist wh is nt a Delta Dental Participating Dentist, yu are respnsible fr ensuring yur dentist cmplete and submit a claim frm. We accept any American Dental Assciatin-apprved claim frm that yur dentist may prvide. Yu can als dwnlad claim frms frm ur website at r btain a frm by calling us at Payment fr services perfrmed by a Nn-Participating Dentist will be based n their actual charges r DDWA s maximum allwable fees fr Nn-Participating Dentists, whichever is less. Yu will be respnsible t the dentist fr any balance remaining. Please be aware that DDWA has n cntrl ver Nn-Participating Dentist s charges r billing practices. Out-f-State Dentists If yu receive treatment frm a dentist utside Washingtn State, ther than a Delta Dental Participating Dentist, yu may be respnsible fr having the dentist cmplete and sign a claim frm. It may be up t yu t ensure that the claim is sent t DDWA. Payment will be based upn the lesser f either the actual charges r the allwed fees, at the percentage levels listed fr PPO Dentists. Claim Frms American Dental Assciatin-apprved claim frms may be btained frm yur dentist. Yu may als dwnlad claim frms frm ur website at r call us at t have frms sent t yu. DDWA is nt bligated t pay fr treatment perfrmed fr which claim frms are submitted fr payment mre than 6 mnths after the date f such treatment. Reimbursement Levels Yur dental Plan ffers 3 classes f cvered treatment. Each class als specifies limitatins and exclusins. Fr a summary f reimbursement levels fr yur plan, see the Summary f Benefits sectin in the frnt f this benefit bklet. Refer t the Benefits Cvered by Yur Plan sectin f this benefit bklet fr specific cvered dental benefits under this plan. Reimbursement Levels fr Other Prcedures The payment level fr cvered and allwable TMJ prcedures is 50 percent. The payment level fr cvered dental expenses arising as a direct result f an accidental injury is 100 percent, up t the unused Plan maximum. Cinsurance DDWA will pay a percentage f the cst f yur treatment and yu are respnsible fr paying the balance. The part yu pay is called the cinsurance. Cinsurance is payable even after yur deductible is met, if applicable. See the Reimbursement Levels fr Allwable Benefits sectin under the Summary f Benefits. Plan Maximum Fr yur plan, the maximum amunt payable by DDWA fr Class I, II and III cvered dental benefits (including Accidental Injury benefits) per Enrlled Persn is $2,000 each benefit perid. Charges fr dental prcedures requiring multiple treatment dates are cnsidered incurred n the date the services are cmpleted. Amunts paid fr such prcedures will be applied t the Plan maximum based n the incurred date. The lifetime maximum amunt payable by DDWA fr TMJ benefits is $5,000 per Enrlled Persn, with a calendar year maximum f $1,000 per Enrlled Persn BB 2 PREML

6 Benefit Perid Mst dental benefits are calculated within a benefit perid, which is typically fr ne year. Fr this plan, the benefit perid is the 12-mnth perid starting the first day f January and ending the last day f December. Plan Deductible Yur Plan has a $25 deductible per Enrlled Persn each benefit perid. This means that frm the first payment r payments DDWA makes fr cvered dental benefits, a deductin f $25 is taken. This deductin is wed t the prvider by yu. Once each Enrlled Persn has satisfied the deductible during the benefit perid, n further deductin will be taken fr that Enrlled Persn until the next benefit perid. The maximum deductible fr all members f a family (Enrlled Emplyee and 1 r mre Enrlled Dependents) each benefit perid is 3 times the individual deductible. This means that the maximum amunt that will be deducted fr all members f a family during a benefit perid will nt exceed $75. Once a family has satisfied the maximum deductible amunt during the benefit perid, n further deductin will apply t any member f that family until the next benefit perid. The annual deductible is waived fr: Class I cvered dental benefits Accidental Injury benefits Emplyee Eligibility, Enrllment, and Terminatin An Eligible Emplyee is an emplyee wh meets the qualificatin fr eligibility established by Grup. Eligible Emplyees becme Enrlled Emplyees nce they have fully cmpleted the enrllment prcess and DDWA has received the emplyer cntributins fr their enrllment. New emplyees are eligible t enrll in this Plan n the first day f the mnth after satisfying any waiting perid established by the Grup. Yu must cmplete the enrllment prcess in rder t receive benefits. DDWA must receive cmpleted enrllment infrmatin within 60 days f emplyee s Eligibility Date. If the enrllment infrmatin is nt received within 60 days, enrllment will nt be accepted until the next Open Enrllment Perid. Eligibility and Cverage terminates at the end f the mnth in which yu cease t be an emplyee, r at the end f the mnth fr which a timely payment f mnthly Premiums was made by Grup n yur behalf t DDWA, r upn terminatin f Grup s Cntract with DDWA, whichever ccurs first. In the event f a suspensin r terminatin f cmpensatin directly r indirectly as a result f a strike, lckut, r ther labr dispute, an Enrlled Emplyee may remain enrlled by paying the applicable Premium directly t the emplyer fr a perid nt t exceed 6 mnths. Payment f Premiums must be made when due, r DDWA may terminate the cverage. The benefits under yur DDWA dental Plan may be cntinued prvided yu are eligible fr Federal Family and Medical Leave Act (FMLA) and yu are n a leave f absence that meets the FMLA criteria. Fr further infrmatin, cntact yur emplyer. Dependent Eligibility, Enrllment and Terminatin Eligible Dependents are yur spuse r dmestic partner and children f yurs, yur spuse r yur dmestic partner, frm birth thrugh age 25. Children include bilgical children, stepchildren, fster children and adpted children. Spuses and children f Dependents are nt eligible fr cverage under this plan. Nn-registered dmestic partnership is a relatinship whereby 2 peple: a) Share the same regular and permanent residence; b) Have a clse persnal cmmitted relatinship; c) Are jintly respnsible fr basic living expenses such as fd, shelter and similar expenses; d) Are nt married t anyne; e) Are each 18 years f age r lder; f) Are nt related by bld clser than wuld bar marriage in their state f residence; g) Were mentally cmpetent t cnsent t cntract when the dmestic partnership began; and h) Are each ther's sle dmestic partner and are respnsible fr each ther's cmmn welfare BB 3 PREML

7 Eligible Dependents may nt enrll in this Plan unless the emplyee is an Enrlled Emplyee. A child will be cnsidered an Eligible Dependent as an adpted child if 1 f the fllwing cnditins are met: 1) the child has been placed with the eligible Enrlled Emplyee fr the purpse f adptin under the laws f the state in which the emplyee resides; r 2) the emplyee has assumed a legal bligatin fr ttal r partial supprt f the child in anticipatin f adptin. When additinal Premium is nt required, we encurage enrllment as sn as pssible t prevent delays in claims prcessing. See the Special Enrllment sectin fr additinal infrmatin. Cverage fr an enrlled dependent child wh attains the limiting age while cvered under this Plan will nt be terminated if the child is and cntinues t be bth 1) incapable f self-sustaining emplyment by reasns f a develpmental disability (attributable t intellectual disability r related cnditins which include cerebral palsy, epilepsy, autism, r anther neurlgical cnditin which is clsely related t intellectual disability r which requires treatment similar t that required fr intellectually disabled individuals) r physical handicap; and 2) chiefly dependent upn the Enrlled Persn fr supprt and maintenance. Cntinued cverage requires that prf f incapacity and dependency be furnished t DDWA within 31 days f the dependent s attainment f the limiting age. DDWA reserves the right t peridically verify the disability and dependency but nt mre frequently than annually after the first 2 years. The Plan als prvides cverage fr a child pursuant t the terms f a Qualified Medical Child Supprt Order (QMCSO), even if the parent des nt have legal custdy f the child r the child is nt dependent n the parent fr supprt. This applies regardless f any enrllment seasn restrictins that might therwise exist fr dependent cverage. A QMCSO may be either a Natinal Medical Child Supprt Ntice issued by a state child supprt agency r an rder r judgment frm a state curt r administrative bdy directing the cmpany t cver a child under the Plan. Federal law prvides that a QMCSO must meet certain frm and cntent requirements t be valid. If the parent is nt enrlled in this Plan, the parent must enrll fr cverage fr bth the parent and the child. If the plan receives a valid QMCSO and the parent des nt enrll the dependent child, the custdial parent r state agency may d s. A child wh is eligible fr cverage thrugh a QMCSO may nt enrll their spuse r dependents fr cverage under the plan. Unless therwise indicated, an Enrlled Dependent shall cease t be enrlled in this Plan n the last day f the mnth f the Enrlled Emplyees emplyment, r when the persn n lnger meets the definitin f an Eligible Dependent, r the end f the calendar mnth fr which Grup has made timely payment f the mnthly Premiums n behalf f the Enrlled Emplyee t DDWA, r upn terminatin f Grup s Cntract with DDWA, whichever ccurs first. An enrlled dependent may terminate cverage at the renewal r extensin f the dental plan r at pen enrllment nly, unless changes are allwed fllwing a qualifying event. Once an enrlled dependent s cverage is terminated, the cverage cannt be reinstated unless there is a qualifying event as defined in the Special Enrllment sectin. A new family member, with the exceptin f newbrns, adpted children and fster children, shuld be enrlled n the first day f the mnth fllwing the date he r she qualifies as an Eligible Dependent (see Special Enrllment ). A newbrn shall be cvered frm and after the mment f birth, and an adpted child r child placed in anticipatin f adptin shall be cvered frm the date f assumptin f a legal bligatin fr ttal r partial supprt r upn placement. A fster child is cvered frm the time f placement. When additinal Premium is nt required, we encurage enrllment as sn as pssible t prevent delays in claims prcessing but cverage will be prvided in any event. Dental cverage prvided includes, but is nt limited t, cverage fr cngenital anmalies f infant children. See the Special Enrllment sectin fr additinal infrmatin. Eligible Emplyees wh chse nt t enrll an Eligible Dependent during the initial enrllment perid f the dental Plan may enrll the Eligible Dependent nly during an pen enrllment, except under special enrllment. Special Enrllment Perids Enrllment is allwed at Open Enrllment times, and als during Special Enrllment Perids, which are triggered by the fllwing situatins: 1. Lss f Other Cverage If yu and/r yur Eligible Dependents invluntarily lse cverage under anther dental plan, yu may apply fr cverage under this Plan if the fllwing applies: Yu declined enrllment in this Plan. Yu lse eligibility in anther health Plan r yur cverage is terminated due t the fllwing: BB 4 PREML

8 Legal separatin r divrce Cessatin f dependent status Death f Emplyee Terminatin f emplyment r emplyer cntributins Reductin in hurs Lss f individual r grup market cverage because f mve frm Plan area r terminatin f benefit plan Exhaustin f COBRA cverage Yur applicatin t enrll in this Plan is received by DDWA within 31 days f lsing ther cverage. Cverage will be effective the first day f the mnth fllwing receipt f applicatin. If these cnditins are nt met, yu must wait until the next Open Enrllment Perid t apply fr cverage. DDWA r Grup may require cnfirmatin that when initially ffered cverage the Eligible Persn submitted a written statement declining because the Eligible Persn r Eligible Dependent has ther cverage. DDWA requests that applicatin fr cverage under this Plan must be made within 31 days f the terminatin f previus cverage. If an additinal Premium fr cverage is required and enrllment and payment is nt cmpleted within the 31 days, such Eligible Dependent may be enrlled during the next Open Enrllment. 2. Marriage, Birth r Adptin If yu declined enrllment in this Plan, yu may apply fr cverage fr yurself and yur Eligible Dependents in the event f marriage, birth f a child, r when yu r yur spuse assume legal bligatin fr ttal r partial supprt r upn placement f a child in anticipatin f adptin. Marriage r Dmestic Partner Registratin DDWA requests the applicatin fr cverage be made within 31 days f the date f marriage/registratin. If enrllment and payment are nt cmpleted within the 31 days, the Eligible Dependent may be enrlled during the next pen enrllment. DDWA cnsiders the terms spuse, marriage, marital, husband, wife, widw, widwer, next f kin and family t apply equally t dmestic partnerships r individuals in dmestic partnerships, as well as t marital relatinships and married persns. References t disslutin f marriage will apply equally t dmestic partnerships that have been terminated, disslved r invalidated. Where necessary, gender-specific terms such as husband and wife used in any part f this benefit bklet will be cnsidered as gender neutral and applicable t individuals in dmestic partnerships. DDWA and the grup will fllw all applicable state and federal requirements, including any applicable regulatins. Birth A newbrn shall be cvered frm and after the mment f birth. DDWA requests the applicatin fr cverage be made within 90 days f the date f birth. If an additinal Premium fr cverage is required and enrllment and payment is cmpleted after 90 days, the enrllment becmes effective n the first day f the mnth in which enrllment ccurs. Enrllment may be cmpleted at any time up t the 4th birthday. Enrllment after the 4th birthday must be cincident with an pen enrllment perid. Adptin DDWA requests the applicatin fr cverage be made within 90 days f the date f assumptin f a legal bligatin fr ttal r partial supprt r upn placement f the child in anticipatin f adptin. If an additinal Premium fr cverage is required and enrllment and payment is nt cmpleted within the 90 days, the Eligible Dependent may be enrlled during the next pen enrllment. Extensin f Benefits In the event a persn ceases t be eligible fr enrllment, r ceases t be enrlled, r in the event f terminatin f this Plan, DDWA shall nt be required t pay fr services beynd the terminatin date. An exceptin will be made fr the cmpletin f prcedures requiring multiple visits that were started while cverage was in effect, are cmpleted within 21 days f the terminatin date, and are therwise benefits under the terms f this Plan. Hw t Reprt Suspicin f Fraud If yu suspect a dental prvider, an insurance prducer r an individual might be cmmitting insurance fraud, please cntact DDWA at Yu may als want t alert any f the apprpriate law enfrcement authrities including: BB 5 PREML

9 The Natinal Insurance Crime Bureau (NICB). Yu can reach the NICB at (callers d nt have t disclse their names when reprting fraud t the NICB). The Office f the Insurance Cmmissiner (OIC) at r g t fr mre infrmatin. Cnslidated Omnibus Budget Recnciliatin Act (COBRA) Federal law requires that shuld certain qualifying events ccur which wuld have previusly terminated cverage, cverage may cntinue fr a perid f time n a self-pay basis. When yu terminate fr reasns ther than grss miscnduct, yu may cntinue yur dental benefits up t 18 mnths, r until yu are cvered under anther grup dental plan, by self-paying the required Premium. If a dependent n lnger meets the eligibility requirements due t the death r divrce f the emplyee, r des nt meet the age requirement fr children, cverage may cntinue up t 3 years, r until the dependent is cvered under anther grup dental plan, by self-paying the required Premium. Cntact yur emplyer fr further clarificatin and details f hw they plan t implement this cntinuatin f cverage fr eligible persns. Health Insurance Prtability and Accuntability Act (HIPAA) Delta Dental f Washingtn is cmmitted t prtecting the privacy f yur dental health infrmatin. The Health Insurance Prtability and Accuntability Act (HIPAA) requires DDWA t alert yu f the availability f ur Ntice f Privacy Practices, which yu may view and print by visiting Yu may als request a printed cpy by calling DDWA at Unifrmed Services Emplyment & Re-Emplyment Rights Act (USERRA) Emplyees wh jin a branch f military service have the right t cntinue dental cverage fr up t 24 mnths by paying the mnthly Premiums, even if they are emplyed by grups that are t small t cmply with COBRA. Fr further infrmatin n yur rights under this act, please cntact yur legal cunsel. Cnversin Optin If yur dental cverage stps because yur emplyment r eligibility ends, the grup plicy ends, r there is an extended strike, r lckut r labr dispute, yu may apply directly t DDWA t cnvert yur cverage t a Delta Dental Individual plan. Yu must apply within 31 days after terminatin f yur grup cverage r 31 days after yu receive ntice f terminatin f cverage, whichever is later. The benefits and premium csts f a Delta Dental Individual plan may be different frm thse available under yur current plan. Yu may learn abut ur Individual Plans and apply fr cverage nline at DeltaDentalCversMe.cm r by calling Necessary vs. Nt Cvered Treatment Yur dentist may recmmend a treatment plan that includes services which may nt be cvered by this Plan. Prir t treatment, yu and yur dentist shuld discuss which services may nt be cvered as well as any fees that are yur respnsibility. Fr further infrmatin see the Cnfirmatin f Treatment and Cst sectin. Benefits Cvered By Yur Plan The fllwing are the cvered dental benefits under this Plan and are subject t the limitatins and exclusins (refer als t General Exclusins sectin) cntained in this benefit bklet. Such benefits (as defined) are available nly when prvided by a licensed dentist r ther licensed prfessinal when apprpriate and necessary as determined by the standards f generally accepted dental practice and DDWA. Nte: Please be sure t cnsult yur prvider befre treatment begins regarding any charges that may be yur respnsibility. The amunts payable by DDWA fr cvered dental benefits are described n yur Summary f Benefits sectin f this benefit bklet BB 6 PREML

10 Class I Benefits Class I Diagnstic Cvered Dental Benefits Diagnstic evaluatin fr rutine r emergency purpses X-rays Limitatins Cmprehensive r detailed and extensive ral evaluatin is cvered nce in the patient s lifetime by the same dentist. Subsequent cmprehensive r detailed and extensive ral evaluatin frm the same dentist is paid as a peridic ral evaluatin. Rutine evaluatin is cvered twice in a benefit perid. Rutine evaluatin includes all evaluatins except limited, prblem-fcused evaluatins. Limited prblem-fcused evaluatins are cvered twice in a benefit perid. A cmplete series r a panramic X-ray is cvered nce in a 5 year perid frm the date f service. Any number r cmbinatin f X-rays, billed fr the same date f service, which equals r exceeds the allwed fee fr a cmplete series, is cnsidered a cmplete series fr payment purpses. Supplementary bitewing X-rays are cvered nce in a benefit perid. Diagnstic services and X-rays related t temprmandibular jints (jaw jints) are nt a paid cvered benefit under Class I benefits. See Temprmandibular Jint Benefits sectin. Exclusins Cnsultatins Study mdels Class I Preventive Cvered Dental Benefits Prphylaxis (cleaning) Peridntal maintenance Sealants Tpical applicatin f fluride including fluridated varnishes Space maintainers Preventive resin restratin Limitatins Any cmbinatin f prphylaxis and peridntal maintenance is cvered twice in a benefit perid. Peridntal maintenance prcedures are cvered nly if a patient has cmpleted active peridntal treatment. Under certain cnditins f ral health, prphylaxis r peridntal maintenance (but nt bth) may be cvered up t a ttal f 4 times in a benefit perid.* *Nte: These benefits are available nly under certain cnditins f ral health. It is strngly recmmended that yu have yur dentist submit a Cnfirmatin f Treatment and Cst request t determine if the treatment is a cvered dental benefit. A Cnfirmatin f Treatment and Cst is nt a guarantee f payment. See the Cnfirmatin f Treatment and Cst sectin fr additinal infrmatin BB 7 PREML

11 Tpical applicatin f fluride is limited t 2 cvered prcedures in a benefit perid. Sealants: Payment fr applicatin f sealants will be fr permanent mlars with n restratins (includes preventive resin restratins) n the cclusal (biting) surface. The applicatin f a sealant is a cvered dental benefit nce in a 2-year perid per tth frm the date f service. Space maintainers are cvered nce in a patient s lifetime fr the same missing tth r teeth thrugh age 17. Preventive resin restratins: Exclusins Payment fr a preventive resin restratin will be fr permanent mlars with n restratins n the cclusal (biting) surface. The applicatin f a preventive resin restratin is a cvered dental benefit nce in a 2-year perid per tth frm the date f service. The applicatin f preventive resin restratin is nt a paid cvered benefit fr 2 years after a sealant r preventive resin restratin n the same tth frm the date f service. The applicatin f preventive resin restratin is nt a paid cvered benefit after a sealant r preventive resin restratin n the same tth. Plaque cntrl prgram (ral hygiene instructin, dietary instructin and hme fluride kits) Class I Peridntics Cvered Dental Benefits Prescriptin-strength fluride tthpaste Antimicrbial rinse dispensed by the dental ffice Limitatins Prescriptin-strength fluride tthpaste and antimicrbial rinse are cvered dental benefits fllwing peridntal surgery r ther cvered peridntal prcedures when dispensed in a dental ffice. Prf f a peridntal prcedure must accmpany the claim r the patient s DDWA histry must shw a peridntal prcedure within the previus 180 days. Antimicrbial rinse may be dispensed nce per curse f peridntal treatment, which may include several visits. Antimicrbial rinse is available fr wmen during pregnancy withut any peridntal prcedure. Class II Sedatin Cvered Dental Benefits General Anesthesia Intravenus Sedatin Limitatins Class II Benefits General Anesthesia and Intravenus Sedatin is a Cvered Dental Benefit when administered by a licensed Dentist r ther Licensed Prfessinal wh meets the educatinal, credentialing and privileging guidelines established by the Dental Quality Assurance Cmmissin f the state f Washingtn r as determined by the state in which the services are prvided BB 8 PREML

12 General anesthesia is cvered in cnjunctin with certain cvered enddntic, peridntic and ral surgery prcedures, as determined by DDWA, r when medically necessary, fr children thrugh age 6, r a physically r develpmentally disabled persn, when in cnjunctin with Class I, II, III r TMJ cvered dental benefits.* Intravenus sedatin is cvered in cnjunctin with certain cvered enddntic, peridntic and ral surgery prcedures, as determined by DDWA. Either general anesthesia r intravenus sedatin (but nt bth) are cvered when perfrmed n the same day. General anesthesia r intravenus sedatin is nly a paid cvered benefit as specifically allwed abve. *Nte: These benefits are available nly under certain cnditins f ral health. It is strngly recmmended that yu have yur dentist submit a Cnfirmatin f Treatment and Cst request t determine if the treatment is a cvered dental benefit. A Cnfirmatin f Treatment and Cst is nt a guarantee f payment. See the Cnfirmatin f Treatment and Cst sectin fr additinal infrmatin. Class II Palliative Treatment Cvered Dental Benefits Palliative treatment fr pain Limitatins Pstperative care and treatment f rutine pst-surgical cmplicatins are included in the initial cst fr surgical treatment if perfrmed within 30 days. Class II Restrative Cvered Dental Benefits Restratins (fillings) Stainless steel crwns Limitatins Restratins n the same surface(s) f the same tth are cvered nce in a 2-year perid frm the date f service Restratins are cvered fr the fllwing reasns: Treatment f carius lesins (visible destructin f hard tth structure resulting frm the prcess f dental decay) Fracture resulting in significant lss f tth structure (missing cusp) Fracture resulting in significant damage t an existing restratin If a resin-based cmpsite r glass inmer restratin is placed in a psterir tth (except thse placed in the buccal (facial) surface f bicuspids), it will be cnsidered an elective prcedure and an amalgam allwance will be made, with any difference in cst being the respnsibility f the patient. Restratins necessary t crrect vertical dimensin r t alter the mrphlgy (shape) r cclusin are nt a paid cvered benefit. Stainless steel crwns are cvered nce in a 2-year perid frm the seat date. Exclusins Overhang remval Cpings Re-cnturing r plishing f restratin BB 9 PREML

13 Please als see: Crwns (ther than stainless steel), inlays, veneers r nlays are a Class III Restrative benefit. Refer t Class III Restrative fr mre infrmatin regarding cverage fr crwns (ther than stainless steel), inlays, veneers r nlays. Class II Oral Surgery Cvered Dental Benefits Remval f teeth Preparatin f the muth fr insertin f dentures Treatment f pathlgical cnditins and traumatic injuries f the muth Exclusins Bne replacement graft fr ridge preservatin Bne grafts, f any kind, t the upper r lwer jaws nt assciated with peridntal treatment f teeth Tth transplants Materials placed in tth extractin sckets fr the purpse f generating sseus filling Please als see: Class II Sedatin fr Sedatin infrmatin. Class II Peridntics Cvered Dental Benefits Surgical and nnsurgical prcedures fr treatment f the tissues supprting the teeth Services cvered include: Limitatins Peridntal scaling/rt planing Peridntal surgery Limited adjustments t cclusin (8 teeth r fewer) Lcalized delivery f antimicrbial agents* Gingivectmy Peridntal scaling/rt planing is cvered nce in a 36-mnth perid frm the date f service. Limited cclusal adjustments are cvered nce in a 12-mnth perid frm the date f service. Peridntal surgery (per site) is cvered nce in a 3-year perid frm the date f service. Peridntal surgery must be preceded by scaling/rt planing a minimum f 6 weeks and a maximum f 6 mnths, r the patient must have been in active supprtive peridntal therapy, prir t such treatment. Sft tissue grafts (per site) fr implants and natural teeth are cvered nce in a 3-year perid frm the date f service. Lcalized delivery f antimicrbial agents is a cvered dental benefit under certain cnditins f ral health such as peridntal Case Type III r IV, and 5mm (r greater) pcket depth readings.* Lcalized delivery f antimicrbial agents is limited t 2 teeth per quadrant and up t 2 times (per tth) in a benefit perid BB 10 PREML

14 Lcalized delivery f antimicrbial agents must be preceded by scaling and rt planing a minimum f 6 weeks and a maximum f 6 mnths, r the patient must have been in active supprtive peridntal therapy, prir t such treatment. *Nte: Sme benefits are available nly under certain cnditins f ral health. It is strngly recmmended that yu have yur dentist submit a Cnfirmatin f Treatment and Cst request t determine if the treatment is a cvered dental benefit. A Cnfirmatin f Treatment and Cst is nt a guarantee f payment. See the Cnfirmatin f Treatment and Cst (Frmerly called Predeterminatins) sectin fr additinal infrmatin. Please als see: Class I Preventive fr peridntal maintenance benefits. Class II Sedatin fr Sedatin infrmatin. Class III Peridntics fr cclusal equilibratin and cclusal guard. Class II Enddntics Cvered Dental Benefits Prcedures fr pulpal and rt canal treatment, services cvered include: Pulp expsure treatment Pulptmy Apicectmy Limitatins Rt canal treatment n the same tth is cvered nly nce in a 2-year perid frm the date f service. Re-treatment f the same tth is allwed when perfrmed by a dentist ther than the dentist wh perfrmed the riginal treatment and if the re-treatment is perfrmed in a dental ffice ther than the ffice where the riginal treatment was perfrmed. Exclusins Bleaching f teeth Please als see: Class II Sedatin fr Sedatin infrmatin. Class III Peridntics Class III Benefits These benefits are available fr patients with peridntal case type III r IV nly, as determined by yur Dentist. It is strngly recmmended that prir t treatment yu have yur dentist submit a Cnfirmatin f Treatment and Cst t determine if the planned treatment is a Cvered Dental Benefit. A Cnfirmatin f Treatment and Cst is nt a guarantee f payment. Cvered Dental Benefits Occlusal guard (nightguard) Repair and relines f cclusal guard Cmplete cclusal equilibratin Limitatins Occlusal guard (nightguard) is cvered nce in a 3-year perid frm the date f service BB 11 PREML

15 Repair and relines dne mre than 6 mnths after the date f initial placement are cvered. Cmplete cclusal equilibratin is cvered nce in a lifetime. Class III Restrative Cvered Dental Benefits Crwns, veneers, r nlays fr treatment f carius lesins (visible destructin f hard tth structure resulting frm the prcess f remving dental decay) r fracture resulting in significant lss f tth structure (e.g., missing cusps r brken incisal edge) Crwn buildups Pst and cre n enddntically treated teeth Limitatins A crwn veneer r nlay n the same tth is cvered nce in a 7-year perid frm the seat date. An implant-supprted crwn n the same tth is cvered nce in a 7-year perid frm the seat date f a previus crwn n that same tth. An inlay (as a single tth restratin) will be cnsidered as elective treatment and an amalgam allwance will be made nce in a 2-year perid, with any difference in cst being the respnsibility f the cvered persn. Payment fr a crwn, veneer, inlay, r nlay shall be paid based upn the date that the treatment r prcedure is cmpleted. A crwn buildup is a cvered dental benefit when mre than 50 percent f the natural crnal tth structure is missing and there is less than 2mm f vertical height remaining fr 180 degrees r mre f the tth circumference and there is evidence f decay r ther significant pathlgy. A crwn buildup r a pst and cre are cvered nce in a 7-year perid n the same tth frm the date f service. Crwn buildups r pst and cres are nt a paid cvered benefit within 2 years f a restratin n the same tth frm the date f service. A crwn used fr purpses f re-cnturing r repsitining a tth t prvide additinal retentin fr a remvable partial denture is nt a paid cvered benefit unless the tth is decayed t the extent that a crwn wuld be required t restre the tth whether r nt a remvable partial denture is part f the treatment. A crwn r nlay is nt a paid cvered benefit when used t repair micr-fractures f tth structure when the tth is asymptmatic (displays n symptms) r there is an existing restratin with n evidence f decay r ther significant pathlgy. A crwn r nlay placed because f weakened cusps r existing large restratins withut vert pathlgy is nt a paid cvered benefit. Exclusins Cpings Class III Prsthdntics Cvered Dental Benefits Full and immediate dentures Remvable and fixed partial dentures (fixed bridges) Inlays when used as a retainer fr a fixed partial denture (fixed bridge) Adjustment r repair f an existing prsthetic appliance BB 12 PREML

16 Surgical placement r remval f implants r attachments t implants Limitatins Replacement f an existing prsthetic appliance is cvered nce every 7 years frm the delivery date and nly then if it is unserviceable and cannt be made serviceable. Payment fr dentures, fixed partial dentures (fixed bridges); inlays (nly when used as a retainer fr a fixed bridge) and remvable partial dentures shall be paid upn the delivery date. Implants and superstructures are cvered nce every 7 years. Temprary dentures DDWA will allw the amunt f a reline tward the cst f an interim partial r full denture. After placement f the permanent prsthesis, an initial reline will be a benefit after 6 mnths. Denture adjustments and relines Denture adjustments, relines, repairs and rebases dne mre than 6 mnths after the initial placement are cvered. Exclusins Duplicate dentures Subsequent adjustments and repairs are cvered. Subsequent relines r rebases will be cvered nce in a 12-mnth perid. An adjustment r reline perfrmed mre than 6 mnths after a rebase will be cvered. Persnalized dentures Maintenance r cleaning f a prsthetic appliance Cpings Crwns in cnjunctin with verdentures are nt a paid cvered benefit Temprmandibular Jint Benefits Fr the purpse f this plan, Temprmandibular Jint (TMJ) treatment is defined as dental services prvided by a licensed dentist fr the treatment f disrders assciated with the temprmandibular jint. TMJ disrders shall include thse disrders that have 1 r mre f the fllwing characteristics: pain in the musculature assciated with the temprmandibular jint, internal derangements f the temprmandibular jint, arthritic prblems with the temprmandibular jint, r an abnrmal range f mtin r limitatin f mtin f the temprmandibular jint. Dental Services are thse that are: 1) Apprpriate, as determined by DDWA, fr the treatment f a disrder f the temprmandibular jint under all the factual circumstances f the case; 2) Effective fr the cntrl r eliminatin f 1 r mre f the fllwing, caused by a disrder f the temprmandibular jint: pain, infectin, disease, difficulty in speaking, r difficulty in chewing r swallwing fd; 3) Recgnized as effective, accrding t the prfessinal standards f gd dental practice; and 4) Nt experimental r primarily fr csmetic purpses. Services cvered will be bth surgical and nn-surgical. Nn-surgical prcedures shall include but are nt limited t: TMJ examinatin, X-rays (including TMJ film and arthrgram), temprary repsitining splint, cclusal rthtic device, remvable metal verlay stabilizing appliance, fixed stabilizing appliance, cclusal equilibratin, arthrcentesis, and manipulatin under anesthesia. The maximum amunt payable by DDWA fr dental services related t the treatment f TMJ disrders shall be $1,000 per cvered persn, after the applicatin f deductibles, if applicable and cinsurance, in any benefit perid, and a lifetime benefit f $5,000 per cvered individual. The amunts payable fr TMJ benefits during the benefit perid shall nt be applied t the cvered persn's annual Plan maximum BB 13 PREML

17 It is strngly suggested that a TMJ treatment Plan be submitted t, and a Cnfirmatin f Treatment and Cst request be made by, DDWA prir t cmmencement f treatment. A Cnfirmatin f Treatment and Cst is nt a guarantee f payment. See the Cnfirmatin f Treatment and Cst sectin fr additinal infrmatin. Well Baby Checkups Fr yur infant child, Delta Dental f Washingtn ffers access t ral evaluatin and fluride thrugh yur family physician. Please ensure yur infant child is enrlled in yur dental plan t receive these benefits. Many physicians are trained t ffer these evaluatins, s please inquire when scheduling an appintment t be sure yur physician ffers this type f service. When visiting a physician with yur infant (age 0-3), DDWA will reimburse the physician, as a Nn- Participating prvider, n yur behalf fr Oral Evaluatin and Tpical Applicatin f Fluride services perfrmed. Reimbursement will be based n 100 percent f the applicable Nn-Participating prvider fee fr either Oral Evaluatin r Tpical Applicatin f Fluride, r bth, depending n actual services prvided. Please see the Benefits Cvered by Yur Plan sectin f this bklet fr any ther limitatins. Als, please be aware that Delta Dental f Washingtn has n cntrl ver the charges r billing practices f nn-dentist prviders which may affect the amunt Delta Dental f Washingtn will pay and yur financial respnsibility. If yur prvider has received training regarding Well Baby Checkups frm DDWA they will have been prvided instructins n hw t submit a claim frm. If yur prvider has nt received training frm DDWA, r if any prvider has questins regarding hw t file a claim they may cntact us at fr infrmatin n submitting a standard claim frm fr this service. If yu have paid yur prvider directly and have a receipt fr these services, please call us at fr infrmatin n hw t btain reimbursement. Accidental Injury DDWA will pay 100 percent f the filed fee r the maximum allwable fee fr Class I, Class II and Class III Cvered Dental Benefit expenses arising as a direct result f an accidental bdily injury. Hwever, payment fr accidental injury claims will nt exceed the unused Plan maximum. A bdily injury des nt include teeth brken r damaged during the act f chewing r biting n freign bjects. Cverage is available during the benefit perid and includes necessary prcedures fr dental diagnsis and treatment rendered within 180 days fllwing the date f the accident. General Exclusins The benefits cvered under this plan are subject t limitatins and exclusin listed in the benefits sectins abve which affect the type r frequency f prcedures which will be reimbursed. Additinally, this Plan des nt cver every aspect f dental care. There are exclusins t the type f services cvered. These general exclusins are detailed in this General Exclusins sectin. All limitatins and exclusins warrant careful reading. 1. Dentistry fr csmetic reasns is nt a paid cvered benefit. 2. Restratins r appliances necessary t crrect vertical dimensin r t restre the cclusin. Such prcedures, which include restratin f tth structure lst frm attritin, abrasin r ersin and restratins fr malalignment f teeth, are nt a paid cvered benefit. 3. Services fr injuries r cnditins that are cmpensable under Wrker's Cmpensatin r Emplyers' Liability laws, and services that are prvided t the cvered persn by any federal r state r prvincial gvernment agency r prvided withut cst t the cvered persn by any municipality, cunty, r ther plitical subdivisin, ther than medical assistance in this state, under medical assistance RCW , r any ther state, under 42 U.S.C., Sectin 1396a, sectin 1902 f the Scial Security Act. 4. Applicatin f desensitizing agents (treatment fr sensitivity r adhesive resin applicatin). 5. Experimental services r supplies, which include: a. Prcedures, services r supplies are thse whse use and acceptance as a curse f dental treatment fr a specific cnditin is still under investigatin/bservatin. In determining whether services are experimental, DDWA, in cnjunctin with the American Dental Assciatin, will cnsider them if: i) The services are in general use in the dental cmmunity in the state f Washingtn; ii) The services are under cntinued scientific testing and research; iii) The services shw a demnstrable benefit fr a particular dental cnditin; and BB 14 PREML

18 iv) They are prven t be safe and effective. b. Any individual whse claim is denied due t this experimental exclusin clause will be ntified f the denial within 20 wrking days f receipt f a fully dcumented request. c. Any denial f benefits by DDWA n the grunds that a given prcedure is deemed experimental may be appealed t DDWA. DDWA will respnd t such appeal within 20 wrking days after receipt f all dcumentatin reasnably required t make a decisin. The 20-day perid may be extended nly with written cnsent f the cvered persn. d. Whenever DDWA makes an adverse determinatin and delay wuld jepardize the cvered persn's life r materially jepardize the cvered persn's health, DDWA shall expedite and prcess either a written r an ral appeal and issue a decisin n later than 72 hurs after receipt f the appeal. If the treating Licensed Prfessinal determines that delay culd jepardize the cvered persn's health r ability t regain maximum functin, DDWA shall presume the need fr expeditius review, including the need fr an expeditius determinatin in any independent review under WAC Analgesics such as nitrus xide, cnscius sedatin, euphric drugs r injectins f anesthetic nt in cnjunctin with a dental service; r injectin f any medicatin r drug nt assciated with the delivery f a cvered dental service. 7. Prescriptin drug. 8. Hspitalizatin charges and any additinal fees charged by the dentist fr hspital treatment. 9. Brken appintments. 10. Behavir management. 11. Cmpleting claim frms. 12. Habit-breaking appliances. 13. Orthdntic services r supplies. 14. This Plan des nt prvide benefits fr services r supplies t the extent that benefits are payable fr them under any mtr vehicle medical, mtr vehicle n-fault, uninsured mtrist, underinsured mtrist, persnal injury prtectin (PIP), cmmercial liability, hmewner's plicy, r ther similar type f cverage. 15. All ther services nt specifically included in this Plan as Cvered Dental Benefits. DDWA shall determine whether services are Cvered Dental Benefits in accrdance with standard dental practice and the Limitatins and Exclusins shwn in this benefits bklet. Shuld there be a disagreement regarding the interpretatin f such benefits, the subscriber shall have the right t appeal the determinatin in accrdance with the nn-binding appeals prcess in this benefits bklet and may seek judicial review f any denial f cverage f benefits. What is a Delta Dental Participating Dentist? Frequently Asked Questins abut Yur Dental Benefits A Delta Dental Participating Dentist is a dentist wh has signed an agreement with Delta Dental stipulating that he r she will prvide dental treatment t subscribers and their dependents cvered by DDWA s grup dental care plans. Delta Dental Participating Dentists submit claims directly t DDWA fr their patients. Can I chse my wn dentist? See Chsing a Dentist under the Hw t Use Yur Plan sectin in the frnt f this benefit bklet. Hw can I get claim frms? Yu can btain American Dental Assciatin-apprved claim frms frm yur dentist. Yu can als btain a cpy f the apprved claim frm frm ur website at Yu may als btain a claim frm by calling ur Custmer Service Number at Nte: If yur dentist is a Delta Dental participating prvider, he r she will cmplete and submit claim frms fr yu BB 15 PREML

19 What is the mailing address fr DDWA claim frms? If yu see a Delta Dental Participating Dentist, the dental ffice will submit yur claims fr yu. If yur dentist is nt a Participating Dentist, it will be up t yu t ensure that the dental ffice submits yur claims t Delta Dental f Washingtn at P.O. Bx 75983, Seattle, WA Wh d I call if I have questins abut my dental Plan benefits? If yu have questins abut yur dental benefits, call DDWA s custmer service department at Questins can als be addressed via at CService@DeltaDentalWa.cm. Des DDWA cver tth-clred fillings n my back teeth? It is yur grups chice t cver psterir cmpsite filling (tth-clred fillings n yur back teeth), r nly allw psterir amalgam fillings (silver filling n yur back teeth). Please see the Benefits Cvered by Yur Plan sectin t determine which electin yur grup has made. Yu may als lg n t the MySmile Persnal Benefits Center n ur website, r call us at fr assistance in determining whether r nt yur plan cvers psterir cmpsite fillings. D I have t get an estimate befre having dental treatment dne? Yu may ask yur dentist t cmplete and submit a request fr an estimate, called a Cnfirmatin f Treatment and Cst. The estimate will prvide yu with estimated cst and benefits fr yur prcedure, but are nt a guarantee f payment. What is Delta Dental? Delta Dental Plans Assciatin is a natinal rganizatin made up f lcal, nnprfit Delta Dental plans that prvide dental benefits cverage. DDWA is a member f the Delta Dental Plans Assciatin. Is this plan a Qualified Dental Plan? N, this plan has nt been certified t meet the state and federal pediatric dental cmpnent f the Essential Health Benefits required fr Qualified Health Plans. Claim Review Cnfirmatin f Treatment and Cst (Frmerly called Predeterminatins) A Cnfirmatin f Treatment and Cst is a request made by yur dentist t DDWA t determine yur benefits fr a particular service. This Cnfirmatin f Treatment and Cst will prvide yu and yur dentist with general cverage infrmatin regarding yur benefits and yur ptential ut-f-pcket cst fr services. A Cnfirmatin f Treatment and Cst is nt an authrizatin fr services but a ntificatin f Cvered Dental Benefits available at the time the Cnfirmatin f Treatment and Cst is made and is nt a guarantee f payment (please refer t the Initial Benefits Determinatin sectin regarding claims requirements). A standard Cnfirmatin f Treatment and Cst is prcessed within 15 days frm the date f receipt f all apprpriate infrmatin. If the infrmatin received is incmplete DDWA will ntify yu and yur Dentist in writing that additinal infrmatin is required in rder t prcess the Cnfirmatin f Treatment and Cst. Once the additinal infrmatin is available yur Dentist shuld submit a new request fr a Cnfirmatin f Treatment and Cst t DDWA. In the event yur benefits are changed, terminated, r yu are n lnger cvered under this Plan, the Cnfirmatin f Treatment and Cst is n lnger valid. DDWA will make payments based n yur cverage at the time treatment is prvided. Urgent Cnfirmatin f Treatment and Cst Requests Shuld a Cnfirmatin f Treatment and Cst request be f an urgent nature, whereby a delay in the standard prcess may seriusly jepardize life, health, the ability t regain maximum functin, r culd cause severe pain in the pinin f a physician r dentist wh has knwledge f the medical cnditin, DDWA will review the request within 72-hurs frm receipt f the request and all supprting dcumentatin. When practical, DDWA may prvide ntice f determinatin rally with written r electrnic cnfirmatin t fllw within 72 hurs BB 16 PREML