Dental Care Insurance

Transcription

1 Dental Care Insurance The Dental Care Insurance Plan covers a wide range of services and helps you pay for dental expenses incurred by you and your family. To your advantage... Basic coverage; Greater coverage; and Coverage for yourself only or for your entire family. The plan provided allows you to choose basic coverage (Option 1) or greater coverage (Option 2). These options are described in the table below: Option 1 Option 2 Annual deductible (*) (B) (C) - employee $40 $40 - dependents $40 $40 Percentage of reimbursement - Preventive and minor restorative 90% 90% - Endodontics and periodontics 90 % 90% - Major restorative services No 50% Maximum annual reimbursement per covered person $1,000 $1,500 (*) The deductible is the amount of eligible expenses you must pay during the calendar year (January 1 st to December 31 st ) before the plan begins to reimburse you for expenses incurred. If part or all of the deductible is paid during the last three months of a calendar year, the deductible that applies to the next calendar year will be reduced accordingly. If you decide to cover your dependents that are eligible, you must cover all of them under the option you have chosen for yourself. However, you may cover only your dependent children if: your spouse already has a dental care plan. Simply complete the "Request for Waiver of Dental Coverage" in Section 5 and submit a photocopy of your spouse's insurance certificate; or your spouse has no natural teeth. You must complete the appropriate form included in Section 5. Please note that your spouse will not be insured under the Dental Care Insurance Plan in the future if a waiver is requested. In addition, if your eligible dependent children are all covered under the comprehensive dental care coverage provided by the Quebec Health Insurance Plan because they are all under age 10, you may elect to cover your spouse only. Section 5 contains the appropriate form you need to complete in this case. 18

2 Different premium rates apply based on your spouse's age and your family status. Three levels of premiums have been established to recognize the three possible types of family coverage: you have a spouse but no dependent children; you do not have a spouse but you have one dependent child or more; you have a spouse and one dependent child or more. The monthly premium, effective until December 31, 2012, is as follows: Monthly premiums based on age (1) (2) as of January 1, 2011 Option 1 Option 2 Employee (B) (C) Under age 45 $28.57 $45.27 Age 45 or over $34.67 $54.82 Dependents Spouse only - under age 45 $30.07 $ age 45 or over $36.34 $57.54 Child(ren) only $19.48 $19.58 Spouse and child(ren) - under age 45 $49.55 $ age 45 or over $55.82 $77.12 (1) Does not include 9% provincial sales tax (2) Or at the time you join the plan, whichever is later Here's an example of how the premium is calculated: The monthly premium for a 42 years old female employee who requests the less generous coverage (Option 1) and decides to cover her dependents; i.e., her spouse aged 45 years old and one eligible child, would be calculated as follows: Employee : $28.57 Spouse and child : $55.82 Total monthly premium : $84.39 (1) calendar year. Therefore, the fee guide used from January 1, to December 31, 2011, will be the one in effect in 2010, and from January 1, to December 31, 2012, the one of If more than one type of treatment exists for the dental condition of the insured person, the insurer will limit reimbursement to the least expensive treatment that will produce a professionally adequate result with respect to the insured person s condition. What are eligible expenses? Eligible Dental Care expenses are divided in three (3) categories: Preventive and Minor Restorative Services (examinations, x-rays, extractions and restorations, etc.); Endodontic and Periodontic (root canal therapy and gums treatment); Major Restorative Services (crowns, dentures, repairs and replacement). Preventive and Minor Restorative Services (Options 1 and 2) Examinations and diagnoses Oral examination (once every 36 months) Oral routine examination for children under 10 years old (once every 24 months) Oral routine examination (once every 9 months) Emergency oral examination Specific oral examination X-rays Intra-oral -- periapical (one complete series every 9 months) Intra-oral bitewing Extra-oral Sialography Panoramic film (once every 36 months) Radiopaque dyes Tests and laboratory examinations Bacteriologic culture Biopsy of soft oral tissues Biopsy of hard oral tissues Cytological test (1) Does not include 9% provincial sales tax Regardless of the option chosen, reimbursement of eligible expenses incurred during a calendar year will be calculated based on the dental fee guide of the Quebec Dental Association of the previous 19

3 Preventive services Polishing of coronal portion of teeth (once every 9 months) Topical application of fluoride (once every 9 months ) Space maintainers (for persons under age 18) Restorative services Amalgam restoration Composite restoration Removable dentures Minor adjustments Rebasing and relining Repair with and/or without impression Oral surgery Closure oro-antral fistula Treatment of salivary glands Removal of erupted tooth (uncomplicated) Surgical removal (complex) Removal of tumors and cysts Alveoloplasty, alveolectomy and osteoplasty Repair of laceration Tuberoplasty Supplemental general services General anesthesia (in relation to surgery) Drugs Consultation Endodontic and Periodontic Treatments (Options 1 and 2) Endodontics Pulp capping Pulpotomy Emergency pulpectomy Endodontic traumatism Root canal therapy Endodontic surgery Apexification Periodontics (treatment of tissue surrounding teeth) Periodontal surgery Provisional splinting Periodontal scaling (3 units of time every 9 months; one unit of time equal to 15 minutes of treatment) Supplementary periodontal services Major Restorative Services (Option 2 only) Crowns Initial dentures (fixed or removable, partial, or complete) necessary as a result of the removal of one or several natural teeth after the employee is hired by his/her current employer Repair of fixed bridges Replacement of existing denture if : it is necessary as a result of the removal of one or several natural teeth after the employee is hired by his/her current employer and if the denture cannot be repaired it was installed at least five years ago and it cannot be repaired it was temporarily installed for a maximum period of 12 months while the insurance was in force it is necessary due to an accidental bodily injury suffered while the person was insured. Procedures requiring gold when an acceptable substitute would not be less expensive based on general dental practice. Are there any exclusions? The plan does not cover: dental treatments reimbursed under the Quebec Health Insurance and Hospital Insurance Acts as of January 1, 2011, except where an agreement exists between CADRE Assurances and the insurer to cover items which have ceased to be covered under government plans after that date; dental treatments carried out at no charge or paid directly or indirectly by any government, or for which the government does not allow the payment of benefits; orthodontic treatments; dental treatments carried out mainly for cosmetic purposes, including teeth whitening; treatments that are neither recommended nor approved by a dentist or physician; dental treatments required as a result of selfinflicted injury or as a result of war or participation in a riot; charges billed for a missed appointment or to complete claim forms required by the insurance company; charges for oral hygiene instructions; dental treatment for accidental injury to natural teeth when treatment is performed within 12 months of the accident; if the covered person is insured under a health insurance plan; charges billed in advance when treatment has not been completed; 20

4 sealants or athletic mouth guards; charges for self-curing or light-polymerized veneers, laminates or binders; laboratory charges higher than 60% of the fees for a procedure in the dental fee guide; procedures, appliances and restorations used to increase a vertical dimension or restore the occlusion; periodontics-related splinting when cast crowns, inlays or metal onlays are used; implants including all services, treatments and prothesis related to implants; root canal already done on the same tooth. How do I make a claim? If you incur dental expenses, ask the dentist to complete the standard form (available at the dentist s office) when treatment is provided and send the form to CADRE Assurances for reimbursement. Please note that direct payments from the insurer to the dentist (i.e., benefits assignments) are not permitted. Dental claims should be submitted no more than 12 months after expenses are incurred; otherwise, the insurance company will not reimburse them. What happens if I am covered under another Dental Plan? If you or any eligible dependent is insured under more than one group insurance plan, the benefits from all plans will be coordinated so that benefits from all sources do not exceed the actual expenses incurred. If your spouse is covered under another plan and the plan provided by CADRE, he/she must submit the claims to his/her insurance company. If there is still a balance payable, you may then submit a claim to the CADRE plan. When both parents are insured under separate plans, the person whose birthday is earlier in a civil year should submit claims for the dependent children to his/her insurance company. Any excess may be paid by the CADRE plan if the spouse's plan is the first payer (and vice versa). Can I find out in advance how much the Plan will pay? When the total cost of planned dental care is likely to exceed $300, we recommend that you submit a treatment plan so that you and your dentist will know in advance how much your insurance will cover. It is important to take note that if more than one type of treatment exists for the dental condition of the insured person, the insurer will limit reimbursement to the least expensive treatment that will produce a professionally adequate result with respect to the insured person's condition. What happens to coverage during a maternity leave or a parental leave? Coverage can continue if the premiums are paid and all plans in which you were participating before your leave are maintained. Does coverage continue during a disability? Coverage remains in force and you are required to continue paying the premiums. Does coverage continue during a leave with or without pay? You can continue your coverage if the premiums are paid and all plans in which you were participating before your leave are maintained. Does coverage continue in case of termination of employment, or if the CEGEP decides to no longer provide this insurance? Upon your request, dental care insurance can continue based on the terms and conditions described in Section 8 of this booklet. 21

5 What happens to my dependents' coverage if I die? The survivor clause states that coverage for your dependents covered at the time of your death remains in force for a maximum of 12 months at no cost, provided that your spouse is not covered under his/her employer plan at the time of your death or does not become covered afterwards. Can I change coverage? If you did not join the plan during your initial period of eligibility, you may do so on January 1 of any year. When does coverage end? Dental care insurance coverage ends on the earliest of: your termination of employment (unless you have requested that coverage continue based on the terms and conditions described in Section 8); your retirement; your 65th birthday; your death (subject to the survivor clause); the date on which you cease to participate in the plans provided by CADRE Assurances. If one of the above mentioned situations occurs, CADRE Assurances must be notified in writing without delay. If you have elected coverage under Option l, you must keep this coverage for at least three years. However, you may increase your coverage level and that of your dependents, if any, on January 1 of each year. If you do so, you must maintain Option 2 for a minimum of three years. You may also change your coverage within 31 days following the addition of a first dependent. If your spouse enters the workforce or changes jobs, you may increase or decrease your coverage and that of all your dependents within 31 days of the event, provided you submit the required proof. In this case, you may also decide whether or not you wish to cover your spouse. You may reduce coverage and at the same time your dependent coverage on any policy anniversary, provided you satisfy the three-year requirement described above. However, if you reduce your level of coverage or terminate voluntarily your coverage, you will have to wait another three years before becoming eligible to join again or to increase your level of coverage. Changes in coverage will be permitted only if you are actively at work when you apply for the change. 22