DENTAL BENEFIT MATRIX. TERI, Inc. HSB Customer Service: EFFECTIVE DATE: BULLETIN PAGE

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Barnard Day
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1 Date Plan Change Fillings Plan Change Family Deductible DENTAL BENEFIT MATRIX TERI, Inc. HSB Customer Service: EFFECTIVE DATE: BULLETIN PAGE Description Effective Addition to dental coverage white posterior resin fillings Please add the following billing codes to the dental plan for white posterior resin fillings: Effective Family deductible is 2x s the Individual, $ New group; HSB will not process Run-In 1

2 CONSIDERATIONS PLAN FEATURES Benefit Options Dental with Network providers through First Dental Health Benefit Period Plan Year July 1 June 30 COB Dependent Child Limiting Age Normal COB with Birthday rule All eligible children covered through age 25. Coverage will terminate at the end of the month of the 26 th birthday. Dependent Eligibility Incapacitated children certification begins at age 19. Recertify every 2 years Covered Spouse, child, Domestic partner (same or opposite gender) Not Covered Common law spouse, grandchild Subrogation Pay and Pursue; administered by LNL, $500 threshold Claim Address UCR EOB Claim Filing Timeframe Claim Check Payment Cycle ID Cards COBRA Network First Dental Health HealthSCOPE Benefits PO Box Lubbock, TX EDI th percentile Monthly statements 12 months from the date of service Friday HSB prints; request duplicates via Self Service Administered by HSB; refer questions in regards to COBRA premiums to Benefits Administration at extension

3 DENTAL BENEFITS COVERED SERVICE/PLAN CATEGORY SCHEDULE OF BENEFITS DENTAL BENEFITS BENEFIT FREQUENCY/LIMITATION Payment for in-network services is based on provider s negotiated amount. Provider cannot balance bill charges in excess of negotiated amount. Payment for out-of-network services is based on provider s customary & reasonable amount. Provider can balance bill charges in excess of C & R amount. Benefits are paid the same whether the patient uses an In or Out of Network provider. When an Out of Network provider is used, the patient will be responsible for any amount over UCR in addition to any deductible or coinsurance responsibility. Pre-Treatment Estimate Missing Tooth Clause Deductible Plan Year: July 1 June 30 GENERAL INFORMATION Does not apply; teeth missing prior to the participant s effective date with this plan are covered Individual - $50 Family - $ Deductible waived for Preventive services 2. Deductible Carry forward does not apply 3. Family accumulation Eligible expenses incurred by all family members combined will be used to satisfy the family deductible (aggregate) Coinsurance Preventive 100% Basic 80% Periodontal 80% Major 50% after a 6 month waiting period for new hires Orthodontia 50% after a 12 month waiting period for new hires Annual Maximum Benefit $1,000 Excludes Preventive services; includes only Basic, Periodontal and Major services Lifetime Orthodontia Max $1,000 PREVENTIVE SERVICES OE Routine Oral Exam 100% no deductible Twice per plan year PY Prophylaxis 100% no deductible Twice per plan year One additional visit is allowed for participants under the care of a physician during pregnancy BW Bitewing X-rays 100% no deductible Participants under age 14: 1 set every 6 months Participants age 14 and older: 1 set every 12 months FL Fluoride 100% no deductible Twice per plan year Participants under age 19 SN Sealants 100% no deductible Participants under age 16 Once per tooth every 3 years Permanent 1 st and 2 nd molars only FX Full mouth X-ray 100% no deductible Once every 5 years PM Panoramic Film 100% no deductible Once every 5 years XR Cephalometric film 100% no deductible No limitations OX Occlusal X-rays 100% no deductible No limitations PX Periapical X-rays 100% no deductible No limitations H7 Harmful Habit Appliance 3

4 EC Palliative (Emergency treatment of pain) Minor procedures only to relieve pain 100% no deductible No limitations LB Labs 100% no deductible No limitations BASIC SERVICES SQ Space Maintainers 80% after deductible Participants under age 19 1 every 3 years OV Office Visits 80% after deductible No limitations CW - Consultations 80% after deductible 1 per dentist per participant every 12 months HM House/Extended Care Facility Call 4 HV Hospital Call XR Other x-rays: Extraoral Sialography Tomographic Oral/Facial images Cone Beam 80% after deductible No limitations IJ Injections Therapeutic Antibiotics Anti-inflammatory agents CQ Caries Susceptibility Test DT Pulp Vitality Test DF Diagnostic Casts RE Fillings Includes silicate, sedative fillings, white posterior resin fillings RK Recementation Includes space maintainers, inlays, onlays, dentures, partial dentures and crowns RF Repairs Includes crowns, dentures and partial dentures DJ Adjustments Includes dentures and partial dentures DQ Rebasing Includes dentures and partial dentures DU Relining Includes dentures and partial dentures 80% after deductible No limitations 80% after deductible Limited to once every 12 months EN Endodontic Treatment 80% after deductible 1 per tooth per lifetime TC - Tissue Conditioning 80% after deductible No limitations OS Oral Surgery 80% after deductible Simple and Surgical extractions, including wisdom teeth Only treatment related to accident/injury covered under Medical plan

5 MS Occlusal Adjustments MS Occlusal Guard AN - Anesthesia 80% after deductible General anesthesia covered for related covered Oral Surgery SJ Prefabricated Stainless Steel Crowns MAJOR SERVICES 6 MONTH WAITING PERIOD FOR MAJOR SERVICES FOR NEW HIRES 50% after deductible 1 per tooth per lifetime for participants under age 14 GF Gold Foil Restorations 50% after deductible Replacement covered if more than 5 years IY Inlay and Onlay Restorations 50% after deductible Replacement covered if more than 5 years CN Crowns 50% after deductible Replacement covered if more than 5 years DB Bridges 50% after deductible Replacement covered if more than 5 years PJ Pontics 50% after deductible Replacement covered if more than 5 years DR - Dentures 50% after deductible Replacement covered if more than 5 years PD Partial Dentures 50% after deductible Repair or replacement covered if more than 5 years have elapsed since original placement PD - Prosthodontics 50% after deductible Repair or replacement covered if more than 5 years have elapsed since original placement PO Maxillofacial Prosthetics IP - Implants Labial Veneers (Laminates) D0296 D2962 PERIODONTIC BENEFITS Periodontics 80% after deductible See below Full mouth debridement 1 per lifetime Periodontal maintenance 2 per 12 months in addition to Routine cleaning Scaling and Root Planing 1 per 24 months Surgical Periodontal procedures 1 per 24 months Guided Tissue Regeneration 1 per tooth per lifetime ORTHODOTIA BENEFITS 12 MONTH WAITING PERIOD FOR ORTHODONTIC SERVICES FOR NEW HIRES Orthodontics 50% no deductible Dependent children under age 19 5

6 EXCLUSIONS D0431 adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures D1310 nutritional counseling for control of dental disease D1320 tobacco counseling for the control and prevention of oral disease D1330 oral hygiene instruction D8692 Replacement of lost or broken retainer D2970 temporary crown (fractured tooth) D9941 Fabrication of athletic mouth guard D9970 Enamel microabrasion D9972 D9974 Bleaching internal or external D Sterilization 6

HealthPartners Dental Distinctions Benefits Chart

HealthPartners Dental Distinctions Benefits Chart Effective Date: The later of the effective date, or most recent anniversary date, of the Master Group Contract and your effective date of coverage under