UFCW LOCAL 1776 and PARTICIPATING EMPLOYERS                                   HEALTH and WELFARE FUND

 

Dental Coverage

The Dental Plan is designed to promote optimum dental health by providing comprehensive coverage for diagnostic and preventive care. The Dental Plan also provides supplementary coverage for restorative care (fillings), periodontics (gum treatments), endodontics (root canal), orthodontics (braces), and oral surgery. Both you and your eligible dependents are entitled to dental benefits under the Dental Plan. If you or your eligible dependents are covered under any other dental plan, check the section titled "Coordination of Benefits" to see how to submit your dental claims. The Fund has retained Miquon, Inc. to develop a network of participating dentists and to provide consulting services for the Dental Plan. You may choose to use the network or you may use any dentist of your choice. Because the participating network dentists have agreed to provide services at contract rates and agreed not to balance bill for their services except as provided in their contract with the Fund, your costs will be lower if you elect to use a network dentist. The current list of participating dental providers and the dental fee schedule will be provided to you automatically without charge. How to Enroll You must complete a Dental Enrollment Form with the Fund office to participate in the network under the Dental Plan. If you elect to participate in the Dental Plan network, you and your eligible dependents must enroll with a participating dentist. Your election to participate in the Dental Plan network and your enrollment with a participating dentist will remain in effect for you and your eligible dependents for as long as you are eligible for benefits under the Fund, or until changed by you. You may change your election to participate in the Dental Plan network and your enrollment with a participating dentist only once every twelve months. You must first notify the Fund office of any change. Your enrollment selection as well as any change will be effective on the day of receipt of the appropriate form, except that enrollment changes cannot be approved if there are any unpaid balances with a participating dental office. Please read the following information carefully. After you make your selection, return your completed Dental Enrollment Form to the Fund office as soon as possible. Your election to participate in the network under the Dental Plan determines the way in which your dental benefits are paid. For example, if you elect to participate in the Dental Plan network but you receive care from a non-participating dentist, no benefits will be paid for these services. Alternatively, if you elect not to participate in the dental plan network and you receive services from a participating dentist, your benefits will still be paid at the non-participating level. How the Plan Works If you enroll with a participating dentist You will be required to choose a primary care dentist from a list of participating dentists who have agreed to provide services to the Fund's participants at reduced fees. This primary care care dentist will provide you and your eligible dependents with most dental services. If you need to see a specialist, your primary care dentist will refer you to another participating dentist who practices the appropriate specialty. You can also refer to the current list of Participating Dental Providers. If you do not enroll with a participating dentist If you do not enroll with a participating dentist, the Plan will pay benefits at a lower rate. What the Plan Pays If you enroll with a participating dentist The Fund has a contract with all of the participating dentists which guarantees the fees for the services the dentist performs. For most diagnostic, preventive, and basic restorative care, the participating dentist accepts the contracted rate as payment in full. Your participating dentist bills the Fund directly for the services and you make no payment. For some services, you and the Fund share the cost. The maximum amount your participating dentist can charge for any service is established in a fee schedule. When your dentist performs one of these services, the participating dentist bills the Fund for its portion (which is the majority of the cost), and bills you for the remaining balance of the contracted rate (called your co-payment). If you do not enroll with a participating dentist The Fund will reimburse you or pay your dentist directly for eligible services based on a schedule of allowances rather than a contracted rate. In most cases, the Fund allowance will be less than your dentist charges, and you will be responsible for paying the difference. Your out-of-pocket costs will be more than if you had enrolled with a participating dentist. The cost to you will vary depending on how much your dentist charges. Maximum payments Whether you use a participating dentist or a non-participating dentist, the maximum amount the Dental Plan will pay for dental benefits (except orthodontics) in any calendar year is $1,500 per person. (The lifetime allowance for orthodontic cases is a separate limitation and does not count toward the $1,500 per person calendar year maximum.) Pre-Authorization Whether you use a participating or non-participating dentist, the following procedures must be pre-authorized and the x-rays must accompany the claim form:    All crown and bridgework    Periodontics    Orthodontics    Extensive oral surgery    Dentures    Any other procedures that are expected to cost more than $500 Pre-authorization for the procedure is determined by the dental consultant retained by the Fund to determine the appropriateness and quality of the care you receive. Pre-authorization also determines the eligibility of the service and states your financial liability. If pre-authorization is not obtained, the claim may be denied. Orthodontics Both the participating and non-participating dental schedules have lifetime allowances per person for orthodontic cases. The Fund will pay its allowance in installments upon submission of a claim. The Fund prorates the allowance for partial banding or other special cases. Also, certain appliances are counted as part of the orthodontic benefit. Therefore, the amount paid for these appliances will be deducted from the total orthodontic benefit. Contact the Fund office for more information. The lifetime orthodontic allowance is not counted toward the $1,500 per person calendar year maximum under the Dental Plan; it is a separate benefit (see above under "Maximum Payments"). The Fund will pay its allowance in pre-set installments which are determined at the time the orthodontic service is pre-authorized. Pediatric dentistry If you enroll with a participating dentist and your child needs to be treated by a pediatric dentist, the Plan has participating pediatric dentists which your child may use, provided the following prerequisites are met:    Care must be performed on a patient under the age of four or on a develop- mentally disabled dependent child.    You must have a referral from your primary care dentist.    Care must be approved in advance by the dental consultant. In these cases, the participating pediatric dentist will charge the same amount as the primary care dentist. However, if the above conditions are not met, the services will not be covered. Filing Claims If you use a participating dentist The participating dentist will give you a claim form to sign when you receive treatment. Your dentist then bills the Fund directly. If any service you receive requires a co-payment, you will be responsible for paying that amount directly to the dentist. If you use a non-participating dentist You must submit a claim form to the Fund office in order to receive reimbursement according to the scheduled allowance for the procedure. Upon receipt of the completed claim form, the Plan will pay the allowance either to you or to your dentist, depending on the assignment of benefits presented with the claim. To obtain a claim form, contact the Fund office. Please note: the rules concerning pre-authorization (described above) still apply when you use a non-participating dentist. Whether you use a participating dentist or a non-participating dentist, all claims must be filed no later than one year from the date of service in order to be considered for payment. Special Provisions If you live more than 25 miles from a participating dentist If you live more than 25 miles from a participating primary care dentist or participating specialist, contact the Fund office. You may participate in the program and you may use a dentist of your choice. The Fund will determine the reasonable and customary fee charged by dentists (or specialists) in your geographic area for the services provided and will pay benefits for these services in accordance with the same percentages of payment by the Fund to participating dentists for similar services, as set forth in the dental fee schedule. However, the Fund cannot guarantee that your dentist will accept the payment by the Fund as payment in full. You may have to pay a balance since there is no contract with the non-participating dentist. Missed/cancelled appointments When you schedule an appointment with your dentist, that time is reserved for you. If you miss or cancel a dental appointment with less than 48 hours notice, the participating dentist may charge you a $10.00 fee for basic services, or a maximum $25.00 fee if supplemental services were scheduled for that missed appointment. This fee is your responsibility; it is not covered under the Plan. Any fee charged by a non-participating dentist for a missed/cancelled appointment is also not covered under the Plan. Dental emergencies If you are enrolled with a participating dentist and have a dental emergency, contact your primary care dentist. All of the primary care dentists have agreed to provide emergency care. If you require additional assistance, contact the Fund office. Limitations The following plan limitations are based on standard dental practice:    Periodic oral exams are allowed once every six months.    Full month x-rays are allowed once every 48 months.    Up to four bitewing x-rays are allowed every six months.    Prophylaxis (cleaning) is allowed once every six months.    Crowns, bridges and dentures may be replaced after five years from the date of insertion. Maryland Bridges may be replaced after three years.    Relines and rebases of complete dentures are allowed after one year from the date of insertion. Exclusions The Dental Plan does not cover expenses for the following services:    Cosmetic or aesthetic services including cosmetic bonding (other than Orthodontics as provided above).    Replacement of lost or stolen appliances within five years.    Replacement of a bridge or denture which meets commonly held dental standards of functional acceptability.    Appliances or restorations, other than full dentures, whose primary purpose is to alter vertical dimension, stabilize periodontally involved teeth or restore occlusion.    Treatment of Temporomandibular joint dysfunction (TMJ/TMD).    Extraction of wisdom teeth when not medically necessary.    Sealants for patients over age 16.    Services deemed necessary as a result of an accident when such services are payable under another insurance carrier.    Services payable under Workers' Compensation.    Services payable by a third party, such as another health plan, in accordance with established COB procedures.    Missed/cancelled appointments.