Federal Employee Dental Options

Transcription

1 Federal Employee Dental Options Offered to Lovelace FEHB Plan Members Option I What Is The Low Cost? Monthly Annual Subscriber Amount $6.00 $63.00 Subscriber Plus One Dependent $10.50 $ Family $15.50 $ DentalSource Sandia Dental Plan Advantages: No deductibles No claim forms No pre-enrollment exams No prior authorization required Pre-existing conditions covered No limits on the amount of benefits No waiting periods for dental benefits The DentalSource Sandia Dental Plan is a cost effective alternative to dental insurance that provides our members significant savings on their dental care. DentalSource, who administers this dental plan, is a membership dental organization involving New Mexico dentists and consumers who are dedicated to quality dental care services. DentalSource encourages proper dental hygiene by promoting early detection and regular dental health maintenance. What Dental Services Are Covered? As a member of the DentalSource Sandia Dental Plan, you receive special savings with DentalSource's guaranteed low, pre-set fees on virtually all types of dental work. You can save as much as 20% to 60% off most dental procedures. This dental plan provides reduced fees on preventive and comprehensive dental procedures and offers the complete care you deserve. Specialists are available for certain services. Members who have services performed by a participating specialist will receive a percentage reduction from the dentist's usual, customary and reasonable fees. DentalSource members are responsible for appropriate taxes (gross receipts tax varies by county) due for dental services provided. Who Is Eligible? You and your spouse are eligible, as are unmarried dependents up to age 26. Any child over age 26 will be covered if he or she is incapable of self-sustaining employment by reason of developmental or physical disability. Should you elect coverage for dependents with developmental or physical disabilities over the age of 26, please furnish proof of their disability status. Where Do I Obtain Services? You select your dentist from the *Sandia Participating Provider List. Every dentist selected to participate in our plan is a private practitioner who meets the strict qualification standards of DentalSource. Our participating dentists share our philosophy and join in our goal to assure members of the highest professional standards and best quality care possible. How Do I Receive Care? Upon enrollment, you will receive a DentalSource Dental Plan ID Card. To receive care, simply call your selected DentalSource dentist for an appointment and present your DentalSource ID Card. When you receive care, simply pay the DentalSource Dental Plan member fees listed on your schedule of benefits directly to the dental office. These fees are paid in full at each visit. In case of a dental emergency, you should contact your DentalSource dentist directly. If your Dental- Source dentist is unavailable for emergency care (palliative treatment to control pain, bleeding, or infection) within 24 hours of the onset of the dental emergency as verified by DentalSource, members may obtain emergency care from any licensed dentist to prevent dental health from being jeopardized. Please return to your DentalSource dentist for followup treatment. In order to receive up to a $20.00 reimbursement for emergency fees paid, a written request for reimbursement with an itemized receipt must be received by DentalSource within 30 days of the emergency visit. *For a Sandia Plan Provider Listing, Please Refer to Our Website: For more information, please contact: 1804 Juan Tabo NE, Ste. A, Albuquerque, New Mexico Phone: (888) Alb: (505) Web Site: These Benefits are neither offered nor guaranteed under contract with FEHB program, but are made available to all enrollees and family members who become members of the Lovelace Federal Health Plan.

2 Sandia Purple Plan - Option I 2 ADA Code / Procedure Name Member Pays Dentist ADA Code / Procedure Name Member Pays Dentist DIAGNOSTIC 0120 periodic oral evaluation...$ limited oral evaluation - problem focused...$ comprehensive oral evaluation (new/established)...$ comprehensive perio evaluation (new/established)...$ intraoral complete series including bitewings...$ intraoral periapical first film...$ intraoral periapical - each additional film...$ intraoral occlusal film...$ extraoral-first film...$ extraoral additional film...$ bitewing single film...$ bitewings two films...$ bitewings three films...$ bitewings four films...$ tomographic survey...$ panoramic film...$ cephalometric film...$ oral/facial photographic images...$ caries susceptibility tests... $ pulp vitality tests... $ diagnostic casts...$ accession of tissue exam & prep... $ accession of tissue micro exam... $ accession of tissue micro exam, surgical margins... $ processing/inter cyto smears... $ other oral pathology, by report... $0 PREVENTIVE 1110 prophylaxis adult (cleaning)...$ prophylaxis child (cleaning)...$ topical application of fluoride-child...$ topical application of fluoride-adult...$ topical fluoride varnish...$ nutritional counseling... $ tobacco counseling... $ oral hygiene instruction... $ sealant per tooth...$ space maintainer - fixed unilateral...$ space maintainer - fixed bilateral...$ space maintainer - removable unilateral...$ space maintainer - removable bilateral...$ recementation of space maintainer...$ additional prophylaxis - adult/child... $65/$46 RESTORATIVE 2140 amalgam 1 surface primary or permanent...$ amalgam 2 surfaces primary or permanent...$ amalgam 3 surfaces primary or permanent...$ amalgam 4 or more surfaces primary or permanent...$ resin 1 surface - anterior...$ resin 2 surfaces - anterior...$ resin 3 surfaces - anterior...$ resin 4 or more surfaces incl incisal angle...$ resin based composite crown, anterior...$ resin 1 surface - posterior...$ resin 2 surfaces - posterior...$ resin 3 surfaces - posterior...$ resin 4 or more surfaces-posterior...$ inlay metallic 1 surface...$ inlay metallic 2 surfaces...$ inlay metallic 3 surfaces...$ onlay metallic 2 surfaces...$ onlay metallic 3 surfaces...$ onlay metallic 4 or more surfaces...$ inlay porcelain/ceramic 1 surface...$ inlay porcelain/ceramic 2 surfaces...$ inlay porcelain/ceramic 3 surfaces...$ onlay porcelain/ceramic 2 surfaces...$ onlay porcelain/ceramic 3 surfaces...$ onlay porcelain/ceramic 4 or more surfaces...$ inlay composite/resin 1 surface...$ inlay composite/resin 2 surfaces...$ inlay composite/resin 3 or more surfaces...$ onlay composite/resin 2 surfaces...$ onlay composite/resin 3 surfaces...$ onlay composite/resin 4 or more surfaces...$ crown porcelain ceramic substrate...$ crown porcelain fused high noble metal...$ crown porcelain fused to predominantly base metal...$ crown porcelain fused to noble metal...$ /4 cast high noble metal...$ crown - 3/4 porcelain/ceramic...$ crown full cast high noble metal...$ crown full cast predominantly base metal...$ crown full cast noble metal...$ recement inlay...$ recement crown...$ prefabricated stainless steel crown primary...$ prefabricated stainless steel crown permanent...$ prefabricated resin crown...$ prefabricated stainless steel crown resin face...$ protective restoration...$ core build-up including any pins...$ pin retention per tooth in addition to restoration...$ cast post and core in addition to crown...$ prefabricated post & core in addition to crown...$ labial veneer (resin laminate) chairside...$ labial veneer (porcelain laminate) laboratory...$ temporary crown (fractured tooth)...$ repair crown by report...$104 *ENDODONTICS 3110 pulp cap direct (excluding final restoration)...$ pulp cap indirect (excluding final restoration)...$ pulpotomy (excluding final restoration)...$ pulpal debridement primary or permanent...$ pulpal therapy anterior primary tooth...$ pulpal therapy posterior primary tooth...$ root canal anterior (excluding final restoration)...$ root canal bicuspid (excluding final restoration)...$ root canal molar (excluding final restoration)...$ apicoectomy/periradicular surgery - anterior...$ apicoectomy/periradicular surgery bicuspid 1st root...$ apicoectomy/periradicular surgery molar 1st root...$ apicoectomy/periradicular each additional root...$ retrograde filling - per root...$ root amputation - per root...$ hemisection incl root removal-excl root canal...$ tooth bleaching (discolored)...$56 *PERIODONTICS 4210 gingivoplasty/gingivectomy 4 or more contiguous teeth...$ gingivoplasty/gingivectomy 1 to 3 teeth per quad...$ gingival flap incl root planing 4 or more contiguous teeth...$ gingival flap incl root planing 1 to 3 teeth per quad...$ clinical crown lengthening, hard & soft tissue...$ osseous surg incl flap entry & clos 4 or more contiguous teeth...$ osseous surg incl flap entry & clos 1 to 3 teeth per quad...$ bone replacement graft - first site in quad...$ pedicle soft tissue graft procedure...$ free soft tissue graft includes donor site...$ provisional splinting - intracoronal...$ provisional splinting - extracoronal...$272 pho fax toll sales@dentalsource.com 1804 Juan Tabo NE, Ste. A, Albuquerque, New Mexico /1/12

3 ADA Code / Procedure Name Member Pays Dentist ADA Code / Procedure Name Member Pays Dentist 4341 root planing/perio scaling - 4 or more teeth per quad...$ root planing/perio scaling - 1 to 3 teeth per quad...$98 *PERIODONTICS 4355 full mouth debridement to enable evaluation...$ periodontal maintenance...$ general procedures by report...$18 *REMOVABLE PROSTHODONTICS 5110 complete denture, upper... $ complete denture, lower... $ immediate denture, upper... $ immediate denture, lower... $ upper partial denture, resin w clasps rests teeth...$ lower partial denture, resin w clasps rests & teeth...$ maxillary partial denture - cast metal framework w resin denture bases (incl any conventional clasps, rests & teeth...$ mandibular partial denture - cast metal framework w resin denture bases (incl any conventional clasps, rests & teeth...$ maxillary partial denture-flexible base...$958 (incl. any clasps, rests, & teeth) 5226 mandibular partial denture-flexible base...$958 (incl. any clasps, rests, & teeth) removable unilateral partial denture, w pontic (nesbit)...$ adjust complete denture upper...$ adjust complete denture lower...$ adjust partial denture upper...$ adjust partial denture lower...$ repair broken complete denture base...$ replace missing/broken teeth, comp dent per tooth...$ repair resin denture base...$ repair cast framework...$ repair or replace broken clasp...$ replace broken teeth - per tooth...$ add tooth to existing partial denture...$ add clasp to existing partial denture...$ rebase complete upper or lower denture...$ rebase complete upper or lower partial denture...$ reline complete upper or lower denture, chairside...$ reline upper or lower partial denture chairside...$ reline complete upper or lower denture, laboratory...$ reline upper or lower partial denture laboratory...$ temporary complete denture upper or lower...$ temporary partial stayplate dent upper or lower (flipper)...$ tissue conditioning upper or lower denture...$77 *FIXED PROSTHODONTICS 6210 pontic cast high noble metal...$ pontic cast predominantly base metal...$ pontic cast noble metal...$ pontic porcelain fused to high noble metal...$ pontic porcelain fused to predom base metal...$ pontic porcelain fused to noble metal...$ pontic porcelain substrate...$ pontic resin with high noble metal...$ pontic resin with predominantly base metal...$ pontic resin with noble metal...$ retainer cast metal for resin bonded fix prosthesis...$ inlay porcelain/ceramic 2 surfaces...$ inlay procelain/ceramic 3 surfaces...$ inlay cast high noble metal 2 surfaces...$ inlay cast high noble metal 3 or more surfaces...$ inlay cast predominantly base metal 2 surfaces...$ inlay cast predominantly base metal 3 or more surfaces...$ inlay cast noble metal 2 surfaces...$ inlay cast noble metal 3 or more surfaces...$ onlay porcelain/ceramic 2 surfaces...$ onlay porcelain/ceramic 3 or more surfaces...$ onlay cast high noble metal 2 surfaces...$ onlay cast high noble metal 3 or more surfaces...$ onlay cast predominantly base metal 2 surfaces...$ onlay cast predominantly base metal 3 or more surfaces...$ onlay cast noble metal 2 surfaces...$ onlay cast noble metal 3 or more surfaces...$ crown resin with high noble metal...$ crown resin with predominantly base metal...$ crown resin with noble metal...$ crown porcelain fused to high noble metal...$ crown porcelain fused to predom base metal...$ crown porcelain fused to noble metal...$ crown 3/4 cast high noble metal...$ crown full cast high noble metal...$ crown full cast predominantly base metal...$ crown full cast noble metal...$ recement bridge...$ stress breaker...$ precision attachment...$ cast post & core in addition bridge retainer...$ prefabricated post & core in addition bridge retainer...$ core build up for retainer incl pins...$ bridge repair, by report...$199 *ORAL SURGERY 7111 coronal remnants, deciduous tooth...$ extraction erupted tooth or exposed root...$ surgical extraction of tooth - erupted...$ removal of impacted tooth - soft tissue...$ removal of impacted tooth - partial bony...$ removal of impacted tooth - complete bony...$ removal of impacted complete bony w complications...$ surgical removal of residual root, cutting procedure...$ tooth replantation &/or stabiliz. of evulsed/displaced...$ surgical access of an unerupted tooth...$ biopsy of oral tissue - hard (bone/tooth)...$ biopsy of oral tissue - soft (all others)...$ transseptal fiberotomy...$ alveoplasty in conjuntion w extractions-quad...$ alveoplasty not in conjuntion w extractions-quad...$ incision & drainage of abscess, intraoral soft tissue...$ incision & drainage of abscess, extraoral soft tissue...$ suture of recent small wound up to 5 cm...$ frenulectomy (frenectomy/frenotomy) - sep. procedure...$ excision of hyperplastic tissue, per arch...$202 ORTHODONTICS 8010 limited orthodontic treatment of the primary dentition... $ limited orthodontic treatment of the transitional dentition... $ limited orthodontic treatment of the adolescent dentition... $ limited orthodontic treatment of the adult dentition... $ interceptive orthodontic treatment of the primary dentition... $ interceptive orthodontic treatment of the transitional dentition... $ comprehensive orthodontic treatment of the transitional dentition... $ comprehensive orthodontic treatment of the adolescent dentition... $ comprehensive orthodontic treatment of the adult dentition... $ removable appliance therapy...$ fixed appliance therapy...$ periodic orthodontic treatment visit (as part of contract)...$ orthodontic retention removal of appliances, construction & place...$ orthodontic treatment (alternative billing to a contract fee)...$ repair of ortho appliances...$ lost or broken retainer...$ rebonding or recementing and/or repair, as required, of fixed retainer...$150 OTHER SERVICES 6010 Implants - refer to Sandia Provider List for Percentage of Savings 9110 palliative emergency treatment of pain, minor...$ local anesthesia...$ deep sedation/general anesthesia first 30 minutes...$ deep sedation/general anesthesia each add 15 minutes...$ inhalation of nitrous oxide/analegesia, anxiolysis...$ intravenous conscious sedation/analgesia - 1st 30 min....$ intravenous conscious sedation/analgesia - each add. 15 min...$ consultation... $ office visit after regular hours...$ application of desensitizing medication... $ occlusal night guard...$ occlusal adjustment limited...$ occlusal adjustment complete...$ bleaching (including trays) per arch...$ missed appt. w/o 24 hr. notice - per hr. scheduled...$30 *If services of a specialist are required (for Oral Surgery, Endodontics, Periodontics, Pedodontics or Prosthodontics) these co-payments do not apply. Members will receive a significant percentage reduction of the usual specialist fee. See provider list. Taxes not included. 3

4 Federal Employee Indemnity Dental Option Offered to Lovelace FEHB Plan Members Option II Indemnity Dental Option The Indemnity Dental Option is a comprehensive dental indemnity plan with the Freedom of Choice to see any licensed dentist. You can SAVE additional out of pocket expenses by seeing a DentalSource "In- Network" participating dentist under the Indemnity Option. When you use a Preferred dentist, you save because these dentists have agreed to charge from a reduced fee schedule. This means lower expenses and no balance billing for you. Co-payments are guaranteed and the dentists may only charge you the amount DentalSource determines to be your share of the treatment cost. This Indemnity Dental Option is exclusively designed and offered to Lovelace FEHB Plan members. What is the low Monthly cost? Monthly Subscriber Amount $34.85 Subscriber Plus One Dependent $75.33 Family $ Preferred dental Option Advantages: Freedom to see any licensed dentist Over 475 Preferred (PPO) Dentists $1200 Annual Maximum Per Person $1000 Lifetime Orthodontic Benefit Local Customer Service Underwritten by Companion Life Insurance Company A.M. Best Rated A+ Superior Dental Services "In-Network" Co-insurance "Out-of-Network" Co-insurance Class I: (Diagnostic/Preventive) 100% 100% Class II: (Basic) 50% 50% Class III: (Major) 35% 35% Class IV: (Ortho)* 50% 50% * Class IV services have a 12-month waiting period from date of enrollment. Send Dental Claims To: Total Dental Administrators, Inc. Claims Processing Dept. P.O. Box Phoenix, AZ For more information, please contact: 1804 Juan Tabo NE, Ste. A, Albuquerque, New Mexico Phone: (888) Alb: (505) Web Site: 4

5 DentalSource Indemnity Option Preventive Services - Covered at 100% (In-Network) Covered at 100% (Out-of-Network) No waiting period Routine Exams Prophylaxis (cleanings - one every 6 months) Emergency Exams for dental pain (minor procedures) Fluoride Treatments for dependent children under age 19 (one per 12 months) Bitewing X-rays (one every 6 months) Sealants Basic Services - Covered at 50% (In-Network) Covered at 50% (Out-of-Network) No waiting period Periapical X-rays Full mouth or panorex X-rays (one per 36 months) Simple restorative services (Fillings) Simple extractions Palliative treatment for dental pain, local anesthesia Major Services - Covered at 35% (In-Network) Covered at 35% (Out-of-Network) No waiting period Major restorative services (crowns and inlays) Prosthetics (bridges, dentures) Replacement of prosthodontics, dentures, crowns and inlays Denture relines Endodontics (Root Canals) Periodontics Space maintainers Oral surgery General anesthesia (for services dentally necessary) * Orthodontic Services - Covered at 50% (In-Network) Covered at 50% (Out-of-Network) *12 month waiting period from date of enrollment Up to age 19 Deductible and Maximums A $50.00 annual deductible will be applied per enrolled person and is limited to a maximum deductible of $150 per family per calendar year. The calendar year benefit maximum is $1,200 per person. Payment is based upon Maximum Allowable Charge of In-Network providers. Predetermination of Benefits For your protection, a predetermination of benefits is recommended for treatment plans that exceed $300. This benefit helps members better understand their coverage. It explains which recommended procedures will be covered and at what amount. Members should submit the treatment plan for review and a predetermination of benefits before receiving the service. Who Is Eligible? You and your spouse are eligible, as are unmarried dependents up to age 26. Any child over age 26 will be covered if he or she is incapable of self-sustaining employment by reason of developmental or physical disability. Should you elect coverage for dependents with developmental or physical disabilities over the age of 26, please furnish proof of their disability status. How Do I Receive Care? Upon enrollment, you will receive a dental ID card. This will be a separate card from your health plan member ID Card. To receive care, simply call your dentist for an appointment and present your dental plan ID card. For The Most Current Preferred Provider Listing, Please Refer to Our Website: * Class IV services have a 12-month waiting period from date of enrollment. This is a general outline of covered benefits and does not include all benefits, limitations, and exclusions of the policy. Please see your certificate for details. 5

6 How Do I Join? How Do I Join Option I? 1. Simply review the entire brochure. Complete and sign the attached Enrollment/Authorization Form. 2. If your Enrollment/Authorization Form and payment are received at DentalSource by the 23rd of the month, your coverage will be effective the 1st day of the following month. Forms received after the 23rd of the month will be effective on the 1st day of the 2nd following month. 3. Mail your completed Enrollment/Authorization Form with the correct payment to DentalSource. 4. We require that you maintain your coverage for a full twelve (12) month period. Please note, as with all coverages, membership fees are non-refundable. By electing coverage through DentalSource you are agreeing to maintain coverage for a full 12 months. If your health plan coverage should terminate mid-year, your dental policy still remains under the 12 month contract and cannot be terminated until your contract year has been met. Payment Options-Option I Annual Payment You may pay the entire annual membership fee by check, money order, MasterCard, Visa or Discover Cards. Monthly Bank Draft If you wish to pay the membership fee on a monthly basis, payment must be made by Monthly Electronic Fund Transfer. To initiate the Monthly Bank Draft option, complete the attached Enrollment/Authorization Form and provide a check made out to DentalSource for the 1st months payment. In addition, please include a voided check from the bank you wish to have the membership fees drafted. Each month your premium will be automatically drafted from your bank account typically between the 23rd and 28th of the month for the next month's coverage. No monthly checks, no postage, no statements. The Monthly Bank Draft option is reliable and automatic! DentalSource will make reasonable efforts to collect unpaid premiums by sending written notice after the date that delinquent charges are due. Failure to pay any delinquent premiums will result in termination of coverage. The 12 month contract period is continuous and therefore does not allow for any lapse in coverage. Any additional charges to your account due to insufficient funds or overdraft fees will be the members responsibility and will not be refunded by DentalSource. How Do I Join Option II? 1. Review the entire brochure, complete and sign the attached Enrollment/Authorization Form. Return your Enrollment/Authorization Form with payment for the appropriate amount to DentalSource Dental Plan. 2. Enrollment Forms must be received by December 31 st to begin coverage January 1st. The next opportunity to enroll in the DentalSource Indemnity Option will not be until the next open enrollment season. Only new Lovelace FEHB members may enroll after open enrollment has ended and must do so within the first sixty days of enrollment in the health plan. Payment Option Monthly Bank Draft Payment must be made by Monthly Electronic Fund Transfer. To initiate the Monthly Bank Draft, complete the attached Enrollment/Authorization Form and provide a check made out to DentalSource for the 1st month's payment. In addition, please include a voided check from the bank you wish to have the membership fees drafted. Each month your premium will be automatically drafted from your bank account between the 23rd and 28th of the month for the next month's coverage. No monthly checks, no postage, no statements. The Monthly Bank Draft option is reliable and automatic! DentalSource will make reasonable efforts to collect unpaid premiums by sending written notice after the date that delinquent charges are due. Failure to pay any delinquent premiums will result in termination of coverage. The 12 month benefit period is continuous and therefore does not allow for any lapse in coverage. Any additional charges to your account due to insufficient funds or overdraft fees will be the members responsibility and will not be refunded by DentalSource. Termination of Coverage If you would like to cancel your coverage, you must submit a written cancellation request. If you cancel your membership as a Lovelace FEHB member and you want to terminate your dental coverage, you must also notify DentalSource Dental Plan in writing. All written cancellation requests received by the 23rd of the month will become effective the first day of the following month. Any cancellation requests received after the 23rd will take effect on the 1st of the 2nd following month. Any Bank Draft member who elects to terminate their dental coverage will not be refunded any drafted premium. Any Indemnity Option Plan members who terminate their dental plan coverage mid year will be permanently restricted from re-enrolling in the Indemnity Option Plan. 6

7 Please Print Clearly Federal Employee Dental Enrollment/Authorization Form For Lovelace FEHB Plan Members Social Security Number Coverage Effective Date Date Employed Full Time Dental Office Selected (Option I Only) Last Name First Name MI Date of Birth Sex Home Address Street City State zip Home Phone Work Phone Address Do you have other Dental Coverage? Do any of your dependents have other coverage? If YES, List Carrier Below Spouse Name - Last First Name MI c h i l d r e n Dental Options o Option I Sandia Dental Plan Monthly Bank Draft o $6.00 o $10.50 o $15.50 Annual Premium (To initiate this Bank Draft Option, please include the1st months payment.) o $63.00 o $ o $ Sex Date of Birth Name of Other Carrier o Option II Indemnity Dental Plan Monthly Bank Draft Annual Payment Choice: Please check one o Check o Visa o MasterCard o Discover (To initiate this Bank Draft Option, please include the1st months payment.) o $34.85 o $75.33 o $ Credit Card #: Expiration Date 3 Digit CVV# Draft Authorization/Membership Agreement Unless I have elected annual payment, I hereby authorize DDP to charge my account each month the applicable membership fee to be credited to my account with DDP. This authority is to remain in full force and effect until I notify DDP in writing of its termination (My Bank is authorized to make corrections should any be necessary). I have read and understand the terms and conditions of this authorization. I hereby authorize the release of my dental records to DDP for use in a quality review program. X o Surepay Electronic Funds Transfer Payment. Please charge my account monthly. o Checking o Savings Routing # Account # Dentist NOMINATION FORM If the dentist of your choice is not listed in our directory, you may complete this form to nominate the dentist to participate in the Dental- Source Dental Network. An application packet will be sent to eligible providers. The normal time frame for credentialing of dentists takes approximately 60 days after this application has been received. Dentist Information Name: City: Member Information Name: Please Mail Form to the Following Address: DentalSource Dental Plan, Inc., 1804 Juan Tabo NE, Ste. A, Albuquerque, New Mexico 87112, Attn: Provider Services Or Fax to Provider Services at Thank you for your interest in the DentalSource Dental Network 1/12 7

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