DENTAL PLAN INFORMATION

Transcription

1 County of Kern DENTAL PLAN INFORMATION FOR PERMANENT EMPLOYEES Independence PPO Dental LIBERTY Cobalt Plus DHMO Dental Administered by LIBERTY Dental Plan of California 1(888)

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3 Table of Contents LIBERTY Dental Plans Comparison of Dental Plans (Chart)... 3 Tips for choosing a dental plan... 4 Independence PPO Dental Plan Summary... 5 Benefit Description... 6 Liberty DHMO Dental ~ Cobalt Plus Summary... 7 Benefit Description... 8 Kern County Human Resources Health Benefits 1115 Truxtun Ave, 1 st Floor Bakersfield, California Phone: (661)

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5 COMPARISON OF DENTAL PLANS LIBERTY Independence PPO LIBERTY DHMO Cobalt Plus Benefits PPO Dentist Non-PPO Dentist DHMO Dentist Any other Dentist Annual Maximum (per person) $1, $1, None N/A Deductible (per calendar year) Individual Family Coinsurance (plan pays) Preventive Exams (prophylaxis) X-Rays Other Services - Restorative (Amalgam, plastic, acrylic filling of cavities) $50.00 $ % 90% $50.00 $ % 70% $0.00 $ % 100% 90% 70% 100% Endodontic (Pulpal therapy and root canals) 90% 70% 100% Periodontics (Ttreatment of gums and bones supporting teeth) 90% 70% 100% N/A N/A Prosthodontics (partial and complete dentures) 90% 70% Patient pays: $ dentures $25.00 partial Crowns 90% 70% Patient pays: $45.00 to $90.00 Orthodontia Contact Customer Service Of negotiated fees Of reasonable and customary charge Procedure must be listed in the schedule of s to be covered at 100%. Many other services are offered with a specified co-payment. Deductible waived Dental plans administered by: LIBERTY Dental Plan Call Liberty Dental for provider information or visit their website at 3

6 TIPS FOR CHOOSING A DENTAL PLAN There are several things to consider when choosing between the two dental plans offered by the County. We suggest that you read the preceding summaries of each plan and consider the following. Service: Benefits are payable under Independence PPO Dental plan for services provided by any dentist. (If you use an Independence dentist, the plan pays higher s than if you used a non-contracted dentist.) With the Liberty DHMO dental plan, contact any Liberty DHMO provider to schedule an appointment. (If you use a Non-Liberty DHMO dentist, the plan pays no s.) Cost: The employee payroll contribution is slightly more for Independence PPO that Liberty DHMO Dental. The Liberty DHMO plan offers basic services at no charge. Many other services are offered with a specified copayment due from the patient. However, any service not specifically listed in their schedule will cost the patient 50% of the dentist s normal fee. The Independence PPO plan has some out-of-pocket cost for all services. Using an Independence PPO dentist limits the patient cost to 10% of the contracted rate for covered services. Also, the deductible is waived for preventive services. Plan Annual Maximum: Independence PPO Dental has a $1,500 calendar year maximum per member. Once the plan has paid $1,500, there is no more available to that member for the remainder of the calendar year. Liberty DHMO has no annual maximum. Orthodontia: The Independence PPO Dental plan offers NO orthodontia coverage. Liberty DHMO offers a discounted rate if you are referred to a Liberty DHMO orthodontist by your Liberty DHMO dentist. Contracted Providers: Contracted providers for the Independence PPO Dental plan and the Liberty Cobalt Plus DHMO Dental plan can be located at 4

7 LIBERTY Dental Plan INDEPENDENCE PPO DENTAL PLAN Independence PPO Dental Plan The Independence PPO Plan for Kern County Employees is a preferred provider dental plan administered by Liberty Dental. A preferred provider dental plan is a system of dental care under which services are provided to insured persons at a negotiated rate. Employees and their family members save money and avoid paperwork when they use contracting or Anetwork@ dentists. These network dentists@ have agreed to participate in UHC=s preferred dentist organization program (PPO). They have agreed to provide insured persons with dental care at a negotiated fee, and take responsibility for obtaining any treatment authorizations required under the plan. Independence PPO Plan Advantages: Extensive Network - Dentists throughout California participate in the network. Freedom of Choice - Employees and their family members are given the freedom of choice to select virtually any licensed dentist; however, when they choose a non-network dentist they will pay more for their care. Cost Savings - Network dentists have agreed not to charge you more than the A dental negotiated rate.@ When you choose a network dentist, you will not be responsible for any amount in excess of the dental negotiated rate for the covered services of a network dentist. Preventive Care - Through preventive features, such as oral examinations, x-rays and prophylaxis, minor dental problems can often be treated before they become major problems. When you use a network dentist, your annual deductible will be waived for Diagnostic and Preventive Services. No Claim Forms - When you use a network dentist, you do not need to submit a claim form for covered dental expenses. Your network dentist will complete and submit the claim form to Liberty Dental. And Liberty Dental will pay the s of the plan directly to the dentist. How the Program Works The Independence PPO Plan provides you with the freedom of choice to select virtually any licensed dentist, but if you choose to use a network dentist, you also take advantage of negotiated discounts and a more generous reimbursement schedule. If you use a dentist who does not participate in the Independence PPO Dental network, you may pay a lot more for dental care. Whenever you need dental care, simply call and make an appointment. You will be responsible for your annual deductible and for your portion of the covered services. When you use the Independence PPO Dental Plan network, your dentist will submit claims for the covered expense to Liberty Dental and Liberty Dental will reimburse the dentist directly. Use Network Providers and Make Efficient Use of Network Resources If you have a particular dentist in mind and he or she is not on the Preferred Provider List, you may call the customer service telephone number on your identification card to see if the dentist has recently joined the network. It is your responsibility to verify that the dentists you use are members of the Independence PPO Dental Plan provider network. To maximize your s when you require specialist care, ask your attending dentist to refer you to a specialist who is a member of the Independence PPO Dental network. Customer Service A dedicated customer service unit is available to handle all dental inquires at 1(888) Contracted PPO Providers For contacted Independence PPO providers visit Liberty Dental s website at 5

8 COUNTY OF KERN HEALTH BENEFITS DIVISION INDEPENDENCE PPO PLAN BENEFIT SCHEDULE DENTAL DEDUCTIBLES (per calendar year) DENTAL BENEFITS Individual Deductible...$50 Family Deductible...$150 Exception: The Dental Deductible does not apply to Diagnostic and Preventive Services. PAYMENT RATES After the Dental Deductible has been satisfied, the plan will pay the percentage of covered dental expenses shown below, for the type of services received, up to the Dental Benefit Maximum: PPO Participating Dentists Diagnostic & Preventative Services...90% Restorative Services...90% Prosthodontic Services (Fixed & Removable)...90% Endodontic Services...90% Periodontic Services...90% Oral Surgery...90% Non-Participating Dentists Diagnostic & Preventative Services...70% Restorative Services...70% Prosthodontic Services (Fixed & Removable)...70% Endodontic Services...70% Periodontic Services...70% Oral Surgery...70% DENTAL BENEFIT MAXIMUM Calendar Year Maximum...$1,500

9 LIBERTY Dental Plan Cobalt Plus DHMO Dental Plan This managed care dental plan is similar in nature to an HMO medical program. When you enroll in this plan, you must seek services from a contracted Liberty Cobalt Plus dentist for all your dental care. If you do not use a Liberty Cobalt Plus dentist, your dental care will not be covered. You will be required in some situations to pay a co-payment at the time you receive your treatment. HOW LIBERTY DENTAL COBALT PLUS WOKS When you or your covered dependent(s) need dental care, you must go to a contracted dentist with Liberty Cobalt Plus. If you require specialized care beyond the expertise of the general dentist, you will be referred to a member of the contracted specialized dental panel. If you go to a dental office that is not contracted with Liberty Dental Cobalt Plus, your dental care will not be covered. However, if you have an emergency and you are out of the area (more than 30 miles from a contracted dental office), you may see a licensed dentist in an emergency for the relief of pain only. You will need to send Liberty Dental a copy of the bill showing the treatment you received and the fee charged. Liberty Dental will reimburse you up to $50.00 for each dental emergency. Contracted Cobalt Plus DHMO Dental Providers For contacted Cobalt plus providers visit Liberty Dental s website at Annual Maximum None Deductible (per calendar year) Preventive Other None None 7

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15 LIMITATIONS: 1. Prophylaxis are covered once every six consecutive months. Additional prophylaxis are available at the listed member co-payment amount; 2. Full Mouth X-rays are limited to once every 36 consecutive months; 3. Fluoride Treatments are covered once every 6 consecutive months. Additional fluoride treatments, up to the 18 th birth date, are available at the listed member co-payment amount; 4. Sealants are covered only on the first and second permanent molars and up to the 14 th birth date; 5. Crowns, Jackets, Inlays and Onlays are s on the same tooth only once every five years, and consistent with professionally recognized standards of dental practice; 6. Replacement of existing Full and Partial Dentures are covered once per arch every 5 years, except when they cannot be made functional through reline or repairs; 7. Denture Relines are covered twice per year, and only when consistent with professionally recognized standards of dental practice; 8. Any routine dental services performed by a Primary Care Dentist or Specialist in an inpatient/outpatient hospital setting, under certain circumstances, will be considered for coverage. EXCLUSIONS: 1. Any procedure not specifically listed as a Covered Benefit; 2. Replacement of lost or stolen prosthetics or appliances including crowns, bridges, partial dentures, full dentures, and orthodontic appliances; 3. Any treatment requested, or appliances made, which are either not necessary for maintaining or improving dental health, or are for cosmetic purposes unless otherwise covered as a ; 4. Procedures considered experimental, treatment involving implants or pharmacological regimens other than listed as Covered Benefit (See Independent Medical Review in the Group Evidence of Coverage and Disclosure Form); 5. Oral surgery requiring the setting of bone fractures or bone dislocations; 6. Hospitalization; 7. Out-patient services; 8. Ambulance services; 9. Durable Medical Equipment; 10. Mental Health services; 11. Chemical Dependency services; 12. Home Health services; 13. General anesthesia, analgesia, intravenous/intramuscular sedation or the services of an anesthesiologist other than listed as Covered Benefit; 14. Treatment started before the member was eligible, or after the member was no longer eligible 15. Procedures, appliances, or restorations to correct congenital, developmental or medically induced dental disorder, including but not limited to: myofunctional(e.g. speech therapy), myoskeletal, or temporomandibular joint dysfunctions (e.g. adjustments/corrections to the facial bones) unless otherwise covered as an orthodontic ; 16. Procedures which are determined not to be dentally necessary consistent with professionally recognized standards of dental practice; 17. Treatment of malignancies, cysts, or neoplasms; 18. Orthodontic treatment started prior to member s effective date of coverage; 19. Appliances needed to increase vertical dimension or restore occlusion; 20. Any services performed outside of your assigned dental office, unless expressly authorized by Liberty Dental Plan, or unless as outlined and covered in Emergency Dental Care section. Members with Questions, please call: Member Services (888) LIBERTY Dental Plan of California, Inc. P.O. Box Providers with Questions, please call: Santa Ana, CA Professional Services (800) Website: Cobalt Plus

16 PERMANENT TEETH Upper Right: Upper Left: 1: 2: 3: 4: 5: 6: 7: 8: 9: 10: 11: 12: 13: 14: 15: 16: 3rd Molar posterior tooth 2nd Molar posterior tooth 1st Molar posterior tooth 2nd Bicuspid posterior tooth 1st Bicuspid posterior tooth Cuspid anterior tooth Lateral incisor anterior tooth Central incisor anterior tooth Central incisor anterior tooth Lateral incisor anterior tooth Cuspid anterior tooth 1st Bicuspid posterior tooth 2nd Bicuspid posterior tooth 1st Molar posterior tooth 2nd Molar posterior tooth 3rd Molar posterior tooth Lower Right: Lower Left: 25: 26: 27: 28: 29: 30: 31: 32: 17: 18: 19: 20: 21: 22: 23: 24: Central incisor anterior tooth Lateral incisor anterior tooth Cuspid anterior tooth 1st Bicuspid posterior tooth 2nd Bicuspid posterior tooth 1st Molar posterior tooth 2nd Molar posterior tooth 3rd Molar posterior tooth 3rd Molar posterior tooth 2nd Molar posterior tooth 1st Molar posterior tooth 2nd Bicuspid posterior tooth 1st Bicuspid posterior tooth Cuspid anterior tooth Lateral incisor anterior tooth Central incisor anterior tooth PRIMARY TEETH Upper Right: Upper Left: A: 2nd primary molar posterior tooth B: 1st primary molar posterior tooth C: Cuspid anterior tooth F: Central incisor anterior tooth D: Lateral incisor anterior tooth I: 1st primary molar posterior tooth J: 2nd primary molar posterior tooth Lower Left: G: Lateral incisor anterior tooth H: Cuspid anterior tooth E: Central incisor anterior tooth Lower Right: T: 2nd primary molar posterior tooth S: 1st primary molar posterior tooth R: Cuspid anterior tooth K: 2nd primary molar posterior tooth L: 1st primary molar - posterior Q: Lateral incisor anterior tooth N: Lateral incisor anterior tooth P: Central incisor anterior tooth O: Central incisor anterior tooth M: Cuspid anterior tooth 14 Cobalt Plus

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