DENTAL PLAN QUICK FACTS AND QUICK LINKS

Transcription

1 DENTAL PLAN QUICK FACTS AND QUICK LINKS A Quick Look at the Dental Plan Dental Service TakeCare Network Dentists Only Annual Maximum Benefit $1,500 per covered person per calendar year Diagnostic & Preventive You pay nothing. Restorative You pay 20% Simple Extractions You pay 20% Endodontics You pay 50% Periodontics You pay 50% Prosthodontics You pay 50% Orthodontics Plan pays a lifetime benefit up to $1,000 per covered person. Coverage is limited to the active phase (Phase II) of the treatment plan and is only available to covered children up to age 17. Dental Plan Details Dental Plan Contacts When Do I Enroll in Dental Coverage? New Associates Enrolling for the First Time: Before your 91st day of employment. All Other Associates: During annual enrollment and when you have a life event. Quick Links to Frequently Used Dental Plan Info I want to find a TakeCare network dentist My child needs braces What s covered under the plan? What s not covered under the plan? GUAM SALARIED & FULL-TIME HOURLY ASSOCIATES 58

2 DENTAL Guam Salaried & Full-Time Hourly Associates CHAPTER CONTENTS 60 How the Dental Plan Works 60 Finding In-Network Dentists 60 Emergency Care 60 In-Area Emergency Care 61 Out-of-Area Emergency Care 61 What is Covered 61 Diagnostic and Preventive Services 61 Restorative Services 61 Simple Extractions 61 Endodontics 61 Periodontics 61 Prosthodontics 61 Orthodontics 61 What is Not Covered 62 Plan Limitations 62 Plan Exclusions 63 Appealing a Claim 63 Right to Recover Payment 63 COBRA (Continuing Coverage After Termination) GUAM SALARIED & FULL-TIME HOURLY ASSOCIATES 59

3 GET THE MOST VALUE FROM YOUR PLAN What do you need? Find it here... Find a TakeCare participating dentist Call the Customer Service Department on Guam at , 24/7 How the Dental Plan Works When you receive care from a TakeCare network dentist, the Dental Plan pays 100%, 80%, or 50% of the cost, depending on the type of service that you receive. No benefits are payable for services received from a non-network dental provider. The services and supplies that the plan covers must be prescribed by a dentist, or provided by a TakeCare network dentist, dental hygienist, or other licensed practitioner, who is acting under the parameters of his or her license. The maximum annual benefit each calendar year is $1,500 per covered person. This includes diagnostic/ preventive services, restorative services, simple extractions, and endodontic, periodontic, and prosthodontic services. There is a separate lifetime maximum benefit of $1,000 for orthodontic services. Finding In-Network Dentists To get a TakeCare Provider Directory, call the Customer Service Department at Emergency Care In-Area Emergency Care Emergency treatment for acute infection, pain and bleeding or for accidental injury to the teeth and adjacent soft tissues is covered. Treatment is limited to care that will alleviate acute symptoms and does not include any definitive restorative treatment whether temporary or permanent. TakeCare must be notified within 48 hours of the treatment or as soon as reasonably possible, not to exceed 72 hours. In-area emergency care is limited to $100 of billed charges per emergency occurrence DENTAL PLAN COVERAGE Dental Service Annual Maximum Benefit Diagnostic & Preventive TakeCare Network Dentists Only $1,500 per covered person per calendar year You pay nothing. Restorative You pay 20% Simple Extractions You pay 20% Endodontics You pay 50% Periodontics You pay 50% Prosthodontics You pay 50% Orthodontics Plan pays a lifetime benefit up to $1,000 per covered person. Coverage is limited to the active phase (Phase II) of the treatment plan and is only available to covered children up to age 17. GUAM SALARIED & FULL-TIME HOURLY ASSOCIATES 60

4 Out-of-Area Emergency Care Dental services to members requiring emergency treatment while temporarily outside the service area are covered. Emergency treatment is limited to treatment that will alleviate acute symptoms only and does not include definitive restorative treatment such as root canal treatment, crowns, etc. Treatment is intended to stabilize the traumatic injury and should be performed within 48 hours of the event. You must notify TakeCare within 48 hours of treatment, or as soon as reasonably possible, not to exceed 72 hours. Out-of-area emergency care is limited to $100 of eligible charges per emergency occurrence. What is Covered Diagnostic and Preventive Services Diagnostic and preventive services are covered at 100%. Diagnostic services include routine x-rays (full mouth series are limited to once every three years and include eighteen x-rays or four bitewings, two periapicals and a panograph), clinical examinations and diagnostic treatment planning (exams are limited to one per benefit year for members twelve years and older). Preventive services are routine teeth cleaning and fluoride treatment (prophylaxis is limited to once every six months). Sealants for children only up to the age of twelve. Restorative Services General restorative services such as routine fillings (silver amalgam and anterior composite) are covered at 80%. Posterior composites are not covered, however, an allowance for a comparable silver amalgam restoration will be made. The difference in fees is your responsibility. Simple Extractions Simple non-surgical extractions of fully erupted teeth, including local anesthesia, suturing, if needed, and routine follow-up care are covered at 80%. Note: Extractions solely for the purposes of orthodontic treatment are not covered. Surgical extractions of unerupted or impacted teeth and general anesthesia are not covered. Endodontics Complete root canal therapy (includes pulpectomy and intra-operative radiographs), pulpotomy and pulpal therapy are covered at 50%. Periodontics The plan covers periodontics at 50%, including consultation, evaluation and treatment of the soft tissue and bones supporting the teeth, supragingival subgingival gross scaling(excessive calculus removal), subgingival curretage, root planing, periodontal maintenance (applicable only to those undergoing or who have completed periodontal treatment) and periodontal surgery. Prosthodontics The following prosthodontic services are covered at 50%: full and partial dentures; denture retainers and repairs, relining and/or reconstruction of dentures. Porcelain, ceramic and/or resin/resin metal and/or gold crowns and bridges, plastic/stainless steel crowns, space maintainers. Occlusal guards are not covered. Orthodontics The orthodontic benefit is limited to only the active orthodontic treatment phase after banding has occurred and applies only to children up to the age of 17 years who become new orthodontic patients under the TakeCare plan. A lifetime maximum benefit of $1,000 per individual applies to orthodontic treatment. The orthodontic benefit cannot be applied to the records and diagnostic fees, nor can it be applied to members whose appliances were installed while under another plan. What is Not Covered The following services are not covered by TakeCare: All services not specifically included in this chapter. Emergency services where TakeCare was not informed within 48 hours. Services prior to your start date of coverage or after the time coverage ends. TakeCare is not responsible for the cost of services rendered by a non-participating dentist when you have refused treatment provided or authorized through a member s primary dentist. GUAM SALARIED & FULL-TIME HOURLY ASSOCIATES 61

5 TakeCare is not responsible for the cost of services which are not necessary or not required in accordance with professionally recognized standards of dental practice. Plan Limitations Complete mouth x-rays are covered only once in a three-year period unless special need is shown and authorized by TakeCare. Panograph and four bitewing x-rays will be considered a full mouth series. Supplementary bitewing x-rays are provided upon request but no more than one every six months. Prophylaxis (routine teeth cleaning) is covered as required but not more often than once every six months. Crowns, jackets and gold restorations are covered only when other restorative material will not result in an adequate restoration. Replacement will be made only after five years have elapsed following any prior provision of crowns, jackets or gold restorations under the plan. Prosthodontic appliances (including, but not limited to fixed bridges, partial or complete dentures) will be replaced only after five years have elapsed following any prior provisions of such appliances under any program, except when the plan determines that there is such extensive loss of remaining teeth or change in supporting tissues that the existing appliance cannot be made satisfactory. In all cases in which you select a more expensive plan of treatment than is customarily provided, the plan will pay the applicable percentage of the lesser fee. You are responsible for the remainder of the dentist s fees. Posterior resin restorations are not a covered benefit. An allowance for a comparable amalgam restoration will be made. The difference in fees is your responsibility. Resin restorations on the facial/cervical surface of any posterior teeth are payable as one surface anterior restoration. In the event that more than one dentist furnishes services for one dental procedure, the plan shall pay not more than its liability has one dentist furnished all of the services. Treatment of dental emergencies is limited to treatment that will alleviate acute symptoms only and does not include definitive restorative treatment such as root canal treatment, crowns, etc. TakeCare must be notified within 48 hours of treatment. The orthodontic benefit is limited to the active orthodontic treatment phase only and applies only to children up to age 17 years who become new orthodontic patients under the TakeCare plan. The benefit does not apply to appliances that were installed while under another plan. Plan Exclusions All hospital cost and additional fees charged by the dentist for hospital treatment Cultures and/or histoligic tests Dental services which are provided to the eligible patient by any federal, local or state government agency or program Experimental procedures Extraction, study models and X-rays solely for orthodontic purposes Extra-oral grafts, implants of any kind including component parts (including but not limited to abutment attachments and special or additional screws) Implant related restorative services, procedures and supplies General anesthetic, conscious sedation and other forms of relative analgesia including, but not limited to, IV sedation and oral pre-medication Oral surgical procedures including, but not limited to, surgical extraction of erupted teeth, impacted teeth and unerupted teeth (including third molars (wisdom teeth) Prescription and over-the-counter drugs Fees for missed appointments and for copies of or transfer of dental records (including x-rays) Procedures, appliances or restorations necessary to increase vertical dimensions and/or restore or maintain the occlusion. Such procedures include, but are not limited to, full mouth rehabilitation, equilibration, periodontal splinting, restoration of tooth structure lost from attrition and restoration for malalignment of the teeth Prosthodontic services or devices (including crowns and bridges) of any single procedure started prior to the date the patient became eligible for such services under this Policy Replacement of lost or stolen dentures, bridges or other dental appliances GUAM SALARIED & FULL-TIME HOURLY ASSOCIATES 62

6 Services with respect to congenital or developmental malformations or cosmetic surgery or dentistry for purely cosmetic reasons including, but not limited to, cleft palate, maxillary and mandibular malformation, and enamel hypoplasia, flurosis and anodontia Cosmetic dentistry including, but not limited to, bleaching, veneers and posterior composites Temporomandibular joint (jaw) dysfunction and other related diseases Orthognathic surgery and other related services Treatment and/or removal of oral tumors, treatment of traumatic injuries except of the teeth and adjacent soft tissues as provided in covered benefits Treatment received any place other than your selected primary dentist s dental facility, except as provided in the out-of-area emergency benefit Appealing a Claim Please refer to the Claims and Appeals chapter regarding appealing claims. Right to Recover Payment If the Dental Plan makes a payment by mistake, the plan has the right to recover the amount of overpayment from any person, insurance company, or other organization to whom the payment was made. COBRA (Continuing Coverage After Termination) Federal law requires that you and your eligible dependents be offered the opportunity to purchase a temporary extension of coverage under the Dental Plan at group rates in certain instances where coverage under the Dental Plan would otherwise end. This coverage is referred to as COBRA. For more information, see the COBRA Coverage chapter. Work-related injuries Benefits and services not specified as covered. GUAM SALARIED & FULL-TIME HOURLY ASSOCIATES 63