(800) 922-9902 dc16info@hsba.com

Dental Expense Coverage

Important note to Retirees: Retirees who elect to enroll in a dental Plan must pay the full cost of the coverage. The Trust Fund Office will provide you with information on the cost of each plan. If you do not enroll in a dental Plan when you retire, you will not be able to enroll at a later date.

You have a choice between the Dental PPO Plan or one of two Pre-Paid Dental Plans.  If you choose one of the Pre-Paid Dental Plans, you and your eligible Dependents must receive your dental care from the dental office(s) in which you enroll.

Choice of Dental Plans

The Trust Fund offers active Employees and their eligible Dependents a choice between three dental plans: a self-funded Dental PPO Plan and two prepaid Dental Plans.

Summary of BenefitsFiling ClaimsQuick Reference Chart

Prepaid Dental Plan Options

This section provides a brief summary of the fully insured dental Plan coverage available under the Fund. However, where this chapter deviates from the certificate of coverage and summary of benefits produced by the Dental Plan Insurance Company, the Insurance Company documents will prevail.

Please note that the two Pre-Paid Dental Plans are fully insured and are not subject to the requirements of Health Care Reform. Therefore, the calendar year and lifetime maximums will apply to all Plan Participants.  In addition, Dependent Children are only eligible for dental coverage until the end of the month that they turn age 19 (or age 24 if a fulltime student).

Dental PPO Plan

This Plan works like the Blue Cross Network (PPO) Plan. When you receive services, the Plan pays a percentage of covered costs; you pay the remaining percentage and any costs that aren’t covered. The Plan is self-funded by the Trust Fund and administered by the Dental Plan listed on the Quick Reference Chart.

You may use any dentist you choose, but you will generally pay less out of pocket if you use a PPO dentist.

Delta Dental

Contracted Dentist

Non-PPO Premier or

Non-Delta Dental Dentist

Calendar Year Maximum Active Plan $2,000

(does not apply to Dependent Children of Active Employees up to age 19)

Calendar Year Maximum Retiree Plan $2,000
Calendar Year Deductible $50 per individual

$100 per family

Plan Paid Coinsurance Based on Delta Contracted Rates Based on the Allowed Charges as determined by the Dental Plan
  • Diagnostic & Preventive
100%, No Deductible 80%,  No deductible
  • Restorative
80% 60%
  • Oral Surgery
80% 60%
  • Periodontal
80% 60%
  • Endodontics
80% 60%
  • Prosthodontic
80% 60%
Orthodontics

  • provided only to Dependent Children
  • Limitations apply
50% of Allowed Charges up to a Lifetime Maximum of $2,500 Benefits are payable in 3 installments automatically issued over the course of 12 months, beginning with the date of banding. The first installment is 50% of the orthodontic benefit and the remaining two installments of 25% are issued at 6 months and 12 months. If orthodontic treatment began before you become eligible, the Dental Plan’s payments will begin with the first payment due to the dentist following your eligibility date.
Covered Benefits in the Indemnity Dental Plan

Payment of Allowed Charges is based on the Dental Plan’s contract with their network provider or the Dental Plan’s determination of the Allowed Charges for non-PPO dentist.  Non-PPO dentists may balance bill you for any billed charges that exceed that amount.

The Plan covers “Dentally Necessary” treatment that meets all of the following conditions:

  • The care and treatment is appropriate given the symptoms, and is consistent with the diagnosis, if any. “Appropriate” means that the type, level, and length of service and setting are needed to provide safe and adequate care and treatment;
  • It is rendered in accordance with generally accepted dental practice and professionally recognized standards;
  • It is not treatment that is generally regarded as experimental or unproven; and
  • It is specifically allowed by the licensing statutes which apply to the provider who renders the service.

In instances where there are optional methods of treatment, the allowance for the least expensive procedure will be paid.

Diagnostic and Preventive Care

The Dental Plan provides benefits for all necessary procedures to assist the dentist in evaluating the existing condition and the dental care needed by the patient. The following limitations apply:

  • Diagnostic and preventive services are not subject to the annual Deductible.
  • Charges for examinations and consultations are covered twice in a calendar year.
  • Full mouth x-rays are covered once in each five year period while covered under any Dental Plan.
  • Bitewing x-rays are covered twice in a calendar year for children under age 18 and once in a calendar year for adults, and are not payable as a separate benefit in the same year as a full-mouth series.
  • Dental prophylaxis is covered twice per calendar year.
  • Fluoride treatment is covered twice in a calendar year while covered under any Dental Plan.
  • Space maintainers are covered through age 12 and not more than once every five years.
  • Oral pathology charges for the examination of oral tissue are covered.
  • Diagnostic casts are covered only as an orthodontic benefit.
Oral Surgery

The Plan provides benefits for extractions and other oral surgery including the following:

  • Benefits for extractions include local anesthesia, x-rays and postoperative care.
  • Benefits for the removal of tumors, cysts and neoplasms when a copy of the histopathological report is submitted.
Restorative Dentistry

The Dental Plan provides amalgam, synthetic porcelain and plastic restorations. The following services and limitations apply:

  • Composite (resin) restorations are covered on anterior teeth and the facial surface of bicuspids. Posterior composite restorations are an optional benefit and payment is limited to the cost of the equivalent amalgam restoration.
  • Sealants are covered for permanent non-restored teeth every 2 years. Restorations in teeth where sealants have been applied are covered after 12 months have elapsed since the application of the sealants. Replacement of sealants on non-carious teeth is covered only after two years.
  • Replacement of an existing filling is covered after the previous filling has been in place for 24 months.
  • Multiple fillings on a single tooth surface are covered as a single surface filling.
  • Benefits for crowns, inlays, onlays and cast restorations are provided only when the tooth shows extensive coronal destruction, as documented by x-rays or study models, and the tooth cannot be restored with an amalgam or composite filling.
  • Replacement of a cast restoration is limited to once every five years while covered under any Dental Plan unless the Dental Plan determines that the replacement is required because the restoration is unsatisfactory as a result of poor quality of care, or because the tooth involved has experienced extensive loss or changes to tooth structure or supporting tissue since the original placement.
  • Benefits will be paid for repair or re-cementation of an inlay, onlay, bridge or crown after 12 months or more have elapsed since the initial placement or previous re-cementation or repair.
Endodontics

The Plan provides for pulpal therapy and root canal filling subject to the following:

  • Endodontic therapy includes initial treatment, interim and final x-rays, temporary fillings and follow-up care.
  • Pulpotomies are provided when performed on primary teeth that have not begun to exfoliate.
  • Root canal therapy is covered once in a 12-month period.
Periodontics

The Plan provides benefits for procedures necessary for the treatment of diseases of the gums and bones supporting the teeth with the following limitations:

  • If full quadrants do not require treatment, the benefit payable for root planing and gingival curettage is determined by the number of teeth that require treatment.
  • Benefits for periodontal surgery are payable when need is documented following visits for non-surgical periodontal therapy and a subsequent re-evaluation.
  • Covered non-surgical periodontal therapies include root planing and gingival curettage are covered no more frequently than every 24 months in each quadrant.
Prosthodontics

The Plan provides benefits for bridges, partial dentures and complete dentures. The Plan provides for replacement of missing teeth using standard techniques. The following are limitations on prosthodontic benefits:

  • Prosthodontic appliances are covered only once every five years while eligible under any Dental Plan unless the Dental Plan determines that there has been such an extensive loss of remaining teeth or change in supporting tissues that the existing appliance cannot be made satisfactory.
  • Replacement of a second molar is covered only as part of a prosthesis that replaces adjacent missing teeth.
  • The allowance for a removable partial denture includes all teeth and clasps.
  • For patients under age 16, the Plan covers interim dentures.
  • The Plan provides for a rebase once every two years.
  • The Plan provides for a reline 12 months after a rebase or a previous reline.
  • The Plan provides for a reline six months after the placement of a denture.
  • The Plan provides for an office reline three months following placement of an immediate denture.

The following are excluded from prosthodontic benefits:

  • Specialized techniques, personalization and characterization.
  • Precision attachments.
  • Experimental procedures.
  • Surgical correction by grafts for denture retention purposes.
  • Inter-occlusal recording or analysis.
  • Unusual diagnostic techniques.
  • Procedures associated with overdentures.
  • Stress-breakers
  • Appliances to alter vertical dimension.
General Limitations and Exclusions on PPO Dental Plan Benefits
  • Charges for services with respect to congenital or developmental malformations, jaw repositioning, cosmetic surgery, or dentistry for solely cosmetic reasons except as specifically provided for under Orthodontic Care below.
  • Services and supplies for which patients are not required to pay, or which are furnished by a hospital or facility operated by the federal government or any authorized agency thereof, or furnished at the expense of such government agency except to the extent that such services are reimbursable to the Veterans Administration for non-service connected conditions under 38 U.S.C. 629.
  • Services and supplies which are furnished by any person, hospital or organization who or which, regardless of the patient’s financial ability, normally makes no charge therefore in the absence of eligibility for dental benefits.
  • Dental expenses incurred which may be paid under any other benefit provided by this Trust Fund.
  • Any hospital costs or any fees charged by the dentist for hospital treatment.
  • Charges for anesthesia, other than general anesthesia administered by a licensed dentist in connection with covered oral surgery.
  • Charges made by a relative of the Participant, except for Allowed Charges which constitute out-of-pocket expenses to such providers.
  • Services or supplies received as a result of accidental bodily injury or sickness arising out of, or in the course of, employment, including self-employment.
  • Services not performed by a Dentist, except x-rays ordered by a Dentist and services by a licensed dental hygienist under the Dentist’s supervision.
  • Services or supplies which are not Dentally Necessary, not customarily provided for dental care, or that are primarily for cosmetic purposes.
  • Dietary planning or oral hygiene instruction.
  • Surgical Implants (materials implanted into or on bone or soft tissue) or the removal of implants. However, the Dental Plan will make an allowance for the appliance actually placed on the implant(s), i.e. crowns, bridges, partial or full dentures. Single crowns will be paid as a pontic. The Plan would then not pay for any replacement for at least 5 years.
  • Athletic mouthpieces.
  • Appliances, surgical procedures or restorations to restore tooth structure lost due to abrasion, erosion or attrition or to alter vertical dimension or for rebuilding or maintaining chewing surfaces due to teeth being out of alignment or occlusion, or for stabilizing teeth (such services include but are not limited to equilibration and periodontal splinting)
  • Full mouth reconstruction and treatment of congenital malformations.
  • Extra-oral grafts (grafting of tissues from outside the mouth to oral tissue).
  • Prosthodontic services or any single procedure started prior to the date you became eligible for services under this Trust Fund.
  • Replacement of lost or stolen appliances which are less than five years old.
  • Diagnosis or treatment by any method of any condition related to the temporomandibular (jaw) joint or associated musculature, nerves, and other tissues.
  • Replacement of existing restorations for any purpose other than restoring structure damaged by active tooth decay.
  • Laminate veneers.
  • Outpatient prescription medication related to dental or orthodontic treatment (except for fluoride for children up to age 6 with a prescription).
  • Charges for completion of claim forms.
Orthodontic Care under the PPO Dental Plan

The Plan provides benefits for orthodontic services for Dependent children only when rendered by a licensed dentist.

If care is terminated for any reason during the course of treatment, the obligation of the Plan will cease with payment to the date of termination. If, in the combined judgment of the attending orthodontist and the orthodontic consultant, the reason for termination of treatment was because of the failure of the patient to cooperate with the treatment plan, the patient would not be eligible for any further orthodontic benefits under the Indemnity Dental Plan.

The Plan provides benefits for corrective, interceptive and preventive orthodontic treatment to realign natural teeth, to correct malocclusion, to provide pre-orthodontic guidance and to provide growth and development evaluation.

Exclusions and Limitations on Orthodontics

Orthodontic treatment will not be provided for the following:

  • Replacement of lost or broken appliances or retainers.
  • Treatment rendered by an orthodontist who is not licensed.
  • Orthodontic expenses incurred which may be paid under any other benefit provided by this Trust Fund.
  • Orthodontic treatment arising out of, or in the course of, employment, including self-employment.
  • Extended orthodontic treatment due to the Participant’s failure to comply with treatment instructions.

How to File a Claim for PPO Dental Plan Benefits

You can obtain dental claim forms from the Dental Plan. Your dentist’s office should also have standard claim forms that can be used.

If the treatment plan proposed by your dentist is extensive and involves crowns or bridges, or if the services will cost more than $300, you are encouraged to ask your dentist to request a predetermination, which will provide you with an estimate of the amount the Dental Plan will pay, assuming you are eligible at the time the services are actually provided.

If you go to a participating dentist and show your Delta Dental I.D. card, the dentist’s office will complete the claim for you and send it directly to the Dental Plan. The Dental Plan will directly reimburse the dentist for the portion of covered expenses provided under the Plan.

If you use a non-participating dentist, you will usually need to file a claim yourself. Fill out your part of the claim form. Have the dentist’s office complete its part of the claim form. Check the claim form to be certain that all applicable parts of the form are completed and that you are submitting all itemized bills.  Your completed claim must be mailed to the Dental Plan at the address on the Quick Reference Chart.

You will be reimbursed directly from the Dental Plan for the percentage of Allowed Charges payable under the Plan. You will be responsible for your portion of the coinsurance and any billed charges that exceed the allowance made by Delta.

You must submit your claim to the Dental Plan within 6 months of the date services were provided.

For information on what to do if you disagree with the decision made in regard to your claim, see Claims Review Procedures section of this website.

Indemnity Dental Plan

(for all Active and Retired Employees and eligible Dependents not enrolled in a Prepaid Dental Plan)

  • Dental Network Provider Directory
  • Dental Claims and Appeals
  • Prior authorization for dental services
Delta Dental (Group # 0308)

P.O. Box 7736
San Francisco, CA 94120

Toll Free: 1-800-765-6003
Web Site: www.deltadentalins.org

Important note to Retirees: Retirees who elect to enroll in a dental Plan must pay the full cost of the coverage.

Summary of BenefitsQuick Reference Chart

Prepaid Dental Plan Options

This section provides a brief summary of the fully insured dental Plan coverage available under the Fund. However, where this chapter deviates from the certificate of coverage and summary of benefits produced by the Dental Plan Insurance Company, the Insurance Company documents will prevail.

Please note that the two Pre-Paid Dental Plans are fully insured and are not subject to the requirements of Health Care Reform. Therefore, the calendar year and lifetime maximums will apply to all Plan Participants.  In addition, Dependent Children are only eligible for dental coverage until the end of the month that they turn age 19 (or age 24 if a fulltime student).

 

Prepaid Dental Plan #1 (California Only)

This Plan works like an HMO, which means that it is a “pre-paid” plan.  There are no Deductibles, no claims forms to file, no annual maximums (except for accidental injury). The program provides the benefits described in the Description of Benefits and Copayments, subject to the limitation and exclusions.

You must receive all of your services from your selected panel dentist. Services are covered as follows when you use a panel dentist:

  • Diagnostic and preventive care, basic fillings, and endodontics are covered at no cost.
  • You will be charged a copayment for a partial bony extraction or a completely bony extraction. Other oral surgery procedures are covered at no cost.
  • You will be charged a copayment for a gingiovectomy, osseous or mucogingival surgery, and a visit for emergency periodontic treatment. Other than these costs, periodontic care is covered at no cost.
  • You must pay the actual lab costs of precious metals used in prosthodontics. Other prosthodontic procedures are covered at no cost.
  • You will be charged a copayment for orthodontia benefits plus a start-up fee. Both adults and children are eligible for benefits for orthodontia.
  • You will be charged a copayment for emergency visits after hours and for failure to cancel an appointment.

The Group Dental Service Contract must be consulted to determine the exact terms and condition of coverage. An Evidence of Coverage will be sent to you upon enrollment.

No claim forms are necessary.  Appeal procedures are provided in the Evidence of Coverage booklet provided by the Prepaid Dental Plan.

Fully Insured Prepaid Dental Plan #1 for California residents only

(for all Active and Retired Employees and eligible Dependents not enrolled in the indemnity dental plan)

  • Dental Network Provider Directory
  • Dental Claims and Appeals
  • Prior authorization for dental services
DeltaCare USA (Group #6123)

Department 64936
El Monte, CA 91735

Toll Free: 1- 800-422-4234
Web Site: www.deltadentalins.com

Important note to Retirees: Retirees who elect to enroll in a dental Plan must pay the full cost of the coverage.

Summary of BenefitsQuick Reference Chart

Prepaid Dental Plan Options

This section provides a brief summary of the fully insured dental Plan coverage available under the Fund. However, where this chapter deviates from the certificate of coverage and summary of benefits produced by the Dental Plan Insurance Company, the Insurance Company documents will prevail.

Please note that the two Pre-Paid Dental Plans are fully insured and are not subject to the requirements of Health Care Reform. Therefore, the calendar year and lifetime maximums will apply to all Plan Participants.  In addition, Dependent Children are only eligible for dental coverage until the end of the month that they turn age 19 (or age 24 if a fulltime student).

Prepaid Dental Plan #2

If you enroll in this Prepaid Dental Plan, you must complete an Enrollment Card. You do not need to select a specific dental clinic. However, services are only available from dentists who are contracted with Dental Insurance company listed on the Quick Reference Chart.  Each time you receive services, it is your responsibility to confirm that the dentist providing the services is currently in the network.  Call the Customer Service number on your ID card for up-to-date directory information.  You must also show your ID card at the time of service.

You have no out-of-pocket cost for most covered services except for orthodontic care.  There is also a fee for after-hours visits. No benefits are paid for services received from any dentist who is not a contracted dentist at the time the services are received.  No claim forms are required.

Appeal procedures are provided in the Evidence of Coverage booklet provided by the Prepaid Dental Plan.

Fully Insured Prepaid Dental Plan #2

(for all Active and Retired Employees and eligible Dependents not enrolled in the indemnity dental plan)

  • Dental Network Provider Directory
  • Dental Claims and Appeals
  • Prior authorization for dental services
UHC Dental (Group # 712019)

Toll Free: 1- 877-816-3596

Web Site: www.myuhcdental.com

Important note to Retirees: Retirees who elect to enroll in a dental Plan must pay the full cost of the coverage.