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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
Covered Benefits in the Indemnity Dental Plan
Diagnostic and Preventive Care
Oral Surgery
Restorative Dentistry
Endodontics
Periodontics
Prosthodontics
General Limitations and Exclusions on PPO Dental Plan Benefits
Orthodontic Care under the PPO Dental Plan
Exclusions and Limitations on Orthodontics

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.