Dental Options 2018 BALTIMORE CITY PUBLIC SCHOOLS

Dental Options 2018 BALTIMORE CITY PUBLIC SCHOOLS

Contents Important Information for 2018... 1 Dental HMO (DHMO) Dental Plan... 2 Preferred Dental PPO (DPPO) Dental Plan... 3 Summary of Dental PPO Benefits... 4 Comparison of Benefits... 5 Notice of Nondiscrimination and Availability of Language Assistance Services... 6

Important Information for 2018 Phone numbers DHMO Customer Service 844-495-0653 PPO Dental Customer Service 866-891-2802 Dental mailing address CareFirst BlueCross BlueShield Dental Claims, Appeals and Correspondence P.O. Box 14114 Lexington, KY 40512-4114 Dental plan options Baltimore City Public Schools offers its employees and their dependents the choice of two dental plans. Your first option is a Dental HMO (DHMO) plan, which is available at no cost to you and no annual maximum. Your second option is a dental-buy up, PPO plan (DPPO). This means that, for an additional premium, which is shared between you and your employer, you can buy-up to the CareFirst BlueCross BlueShield Preferred dental plan. Baltimore City Public Schools Dental Plan Options 2018 1

Dental HMO (DHMO) Dental Plan Advantages of the DHMO plan When you receive in-network care, you enjoy the following: No claim forms. No deductibles. Unlimited maximum benefit amount. Braces covered for children and adults. Things to remember You can change your dentist at any time (if no balance exists). You can choose a different dentist for each family member. You must get a referral to see a specialist. Frequently asked questions Do I need to select a dentist? Yes. Before you can receive benefits under this plan, you must first select a dentist within the provider directory. Must family members go to the same dentist? No. Each family member may select a different participating general dental office. What about orthodontia for adults and children? Orthodontia is covered for both adults and children. Do I have to fill out claim forms after each routine visit? There are no claim forms to complete. Over 100 general dentists and specialists in over 50 locations in Baltimore City. Are there any benefit maximums? There are no benefit maximums. What happens in a dental emergency away from home? The dental program will cover the cost of diagnostic and therapeutic procedures delivered by any general dentist up to a maximum of $50 per emergency occurrence greater than 50 miles from home. How do I find a participating DHMO dentist? To find a DHMO dentist, visit carefirst.com and select Find a Provider; select Dental from the options; select your search (by name or specialty); for network select Dental HMO; then your plan DHMO 5000S. 2 Baltimore City Public Schools Dental Plan Options 2018

Preferred Dental PPO (DPPO) Dental Plan Baltimore City Public Schools is giving you the option to purchase an enhanced dental plan, called the CareFirst Preferred Dental PPO (DPPO), which provides a larger network of dentists. Advantages of the DPPO plan Freedom of choice, freedom to save With Preferred Dental coverage, you have the freedom to see any dentist. This plan also gives you the option to reduce your out-ofpocket expenses by visiting a dentist who participates in our network of Preferred providers. It s your choice! Preventive care and more Benefits for you and your family include regular preventive care, X-rays, dental surgery and more. A summary of your benefits is available on page 5 of this guide. Large network Over 2,300 general and pediatric dentists in Maryland participate in CareFirst s Preferred Dental Network. There are over 500 network dentists in Baltimore City and 95% of participating dentists are accepting new patients. You may already be seeing a dentist who is part of our network. There are 77,000 dentists in the national network. Out-of-network care For a higher out-ofpocket cost, the Preferred plan allows you to go outside the network for care and still receive valuable dental coverage. Easy to use If you see a Preferred dentist, you will incur lower out-of-pocket costs for all dental services and you will have no claim forms to file. Preferred dentists have agreed to accept CareFirst s Allowed Benefit as payment in full for covered services. Once you meet your deductible and coinsurance, you won t be faced with additional expenses. Nationwide emergency coverage Emergency dental coverage is there when you need it, no matter where you are using your out-of-network coverage. Frequently asked questions Who is eligible to enroll? All Baltimore City Public Schools Employees and their dependents. Eligible dependents are covered until the end of the month in which they turn age 26 regardless of student status. How do I find a preferred dentist? You can access an online directory of dentists 24 hours a day at carefirst.com. Under the Solution Center click on Find a Doctor. Then choose Dental under provider type and select Preferred Dental (PPO). Once you are on this page, you can find all the dentists in your area by putting in a zip code, city and state, or you can check to see if your dentist is in our network by typing their last name under option 3. How much will I have to pay for dental services? The chart on page 4 gives you an overview of many of the covered services along with the percentage you will pay for each class of services, both in and out-of-network. Is there a lot of paperwork? There is no paperwork when you use a dentist in our Preferred Dental Network. If you see a non-participating dentist, you may be required to pay all costs at the time of care, and then submit a claim form in order to be reimbursed for covered services. Who can I call with questions about my dental plan? Call CareFirst BlueCross BlueShield toll free at 866-891 2802. Baltimore City Public Schools Dental Plan Options 2018 3

Summary of Dental PPO Benefits Benefits PREVENTIVE & DIAGNOSTIC SERVICES (CLASS I) Oral Exams (two per benefit period) Cleanings (two per benefit period) Bitewing X-rays (two procedures per benefit period) Full mouth X-ray or panoramic and bitewing X-ray combination and one cephalometric X-ray (once per 36 months) Fluoride treatments (two per benefit period per member, up to age 19) Sealants on permanent molars (once per tooth per 36 months per member, up to age 19) Space maintainers for prematurely lost posterior baby teeth (once per 60 months) Emergency oral exam and palliative treatment BASIC SERVICES (CLASS II) Fillings using approved materials (one filling per surface per 12 months) Oral surgery (treatment for cysts, tumor and abscesses) General anesthesia rendered for a covered dental service Tooth extractions MAJOR SERVICES (CLASS III) Tooth scaling and root planing (once per 24 months, one full mouth treatment) Gum surgery including bone surgery, tissue surgery and bite adjustments (once per 60 months) Root canal treatment Full and/or partial dentures (once per 60 months) Fixed bridges, crowns, implants, inlays and onlays (once per 60 months) Denture adjustments and relining (limits apply for regular and immediate dentures) Recementation of crowns, inlays and/or bridges (once per 12 months) Repair of prosthetic appliances as required (once in any 12 month period per specific area of appliance) ORTHODONTIC SERVICES (CLASS IV) Benefits for orthodontic services (braces) are available for covered members who meet treatment criteria. Covered services are limited to 36 consecutive months of covered services. ANNUAL DEDUCTIBLE AND MAXIMUM (IN- AND OUT-OF-NETWORK) You Pay In-Network No charge 20% of Allowed Benefit after deductible 1 40% of Allowed Benefit after deductible 50% of Allowed Benefit 1 You Pay Out-of-Network Difference between CareFirst s payment and the Non-Participating Dentist s charges 2 20% of Allowed Benefit after deductible 2 40% of Allowed Benefit after deductible 50% of Allowed Benefit 2 $50 Individual / $150 Family Deductible (applies to classes II and III) $1,500 Orthodontic Lifetime Maximum $1,500 Annual Maximum 1 For in-network providers, plan payment is based on dental plan s negotiated fee schedule. After the deductible is met, Preferred dentists accept 100% of the Allowed Benefit as payment in full for covered dental services. 2 If you use an out-of-network provider, you will need to pay the provider and will be reimbursed by the plan using an out-of-network plan allowance schedule. Your out-of-pocket costs will most likely be higher. Non-Participating Dentists may bill the Member for the difference (if any) between the Allowed Benefit and the Non-Participating Dentist s actual charge for Covered Dental Services. Summary of Exclusions Not all services and procedures are covered by your benefits contract. This plan summary is for comparison purposes only and does not create rights not given through the benefit plan. 4 Baltimore City Public Schools Dental Plan Options 2018

Comparison of Benefits This chart shows key differences between the DHMO 5000S Plan and the DPPO Plan Estimated Out-of- Pocket expenses for the most commonly used services. For a complete listing of the DHMO 5000S Plan: Procedures, copayments and limitations, visit the Schools benefits website at www.baltimorecityschools.org. ADA procedure code Description 120 Periodic Oral Evaluations (once per 6 months) DHMO 1 5000s DPPO You Pay In-Network 2 Out-Network 3 You Pay You Pay $0.00 $0.00 $0.00 272 Bitewings Two Films $0.00 $0.00 $0.00 330 Panoramic Film $0.00 $0.00 $0.00 1110 Prophylaxis (cleaning) Adult (once per 6 months) 1120 Prophylaxis (cleaning) Child (once per 6 months) $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2140 Amalgam One Surface, Permanent $0.00 $9.90 $20.40 2160 Amalgam Three Surface, Permanent $0.00 $15.12 $32.40 2330 Resin Based Composite, One Surface, Anterior $0.00 $14.40 $24.80 2332 Resin Based Composite, Three Surface, Anterior $0.00 $20.80 $37.60 2750 Crown Porcelain/High Noble Metal $245.00 $248.00 $354.80 2751 Crown Porcelain/Noble Metal $235.00 $238.00 $325.60 3330 Molar Root Canal $185.00/$490.00 5 $238.00 $332.00 4260 Osseous Surgery $196.00/$495.00 5 $239.00 $340.00 4341 Periodontal Scaling and Root Planing Quad $40.00/$86.00 5 $48.00 $81.60 5110 Complete Denture Upper $249.00 $267.48 $522.00 7140 Extraction, Erupted Tooth or Exposed Root $40.00/$73.00 5 $15.40 $25.20 7210 Surgical Extraction of Erupted Tooth $40.00/$80.00 5 $26.80 $43.40 7240 Removal of Impacted Tooth Completely Bony $85.00/$155.00 5 $45.18 $78.40 8080 Comprehensive Orthodontic Treatment Adolescent $1,850.00 $1,480.50 $3,198.00 4 9110 Palliative Treatment $15.00 $0.00 $0.00 1 Benefits are available in-network only. 2 Member estimated out-of-pocket expense when services are rendered by a CareFirst Preferred Participating Dentist without consideration of deductible or annual benefit maximum. 3 Member estimated out-of-pocket expense based upon dentist fee at 50th percentile of 2007 NDAS schedule without consideration of deductible or annual benefit maximum. Member subject to balance billing over and above this amount. 4 Allowed Benefit ($4,698) minus the $1,500 Ortho Lifetime Maximum. 5 Member copayment when service rendered by Participating Specialist. This document is for comparison purposes only and does not create rights not given through the benefit plan. Baltimore City Public Schools Dental Plan Options 2018 5

Notice of Nondiscrimination and Availability of Language Assistance Services CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. CareFirst: Provides free aid and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, please call 855-258-6518. If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinator by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you. To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinator as indicated below. Please do not send payments, claims issues, or other documentation to this office. Civil Rights Coordinator, Corporate Office of Civil Rights Mailing Address P.O. Box 8894 Baltimore, Maryland 21224 Email Address civilrightscoordinator@carefirst.com Telephone Number 410-528-7820 Fax Number 410-505-2011 You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. NDLA (6/17) CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc. NDLA (6/17) 6 Baltimore City Public Schools Dental Plan Options 2018

Notice of Nondiscrimination and Availability of Language Assistance Services Foreign Language Assistance Baltimore City Public Schools Dental Plan Options 2018 7

Notice of Nondiscrimination and Availability of Language Assistance Services 8 Baltimore City Public Schools Dental Plan Options 2018

Notice of Nondiscrimination and Availability of Language Assistance Services Baltimore City Public Schools Dental Plan Options 2018 9

CareFirst BlueCross BlueShield CareFirst BlueChoice, Inc. 10455 Mill Run Circle Owings Mills, MD 21117-5559 carefirst.com Health benefits administered by: CONNECT WITH US: CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. which are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst or Maryland, Inc. BOK5182-1S (9/17)