Dental Plan - General Information

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Dental Plan - General Information

The following describes the principle features of your Dental Assistance Plan, which provides benefits for preventive, diagnostic, restorative, and orthodontia dental services. Enrollment in the Dental Assistance Plan is optional.

Who Is Eligible?

Active Employees - All regular employees who work at least 20 hours per week are eligible for Dental Assistance Plan coverage.

Eligible Employees - The following members of your family are also eligible for Dental Assistance Plan coverage:

Wife or husband.
Your unmarried children up to 19 years of age, including adopted children and stepchildren who reside with you and are dependent upon you for support.
An unmarried child is considered to be eligible for dependent coverage through the date in which they turn 19.
Dependent Student - Children under age 25 are also covered if they are unmarried, reside with you, are primarily supported by you, and attend an accredited college or university on a full-time basis. Coverage for students who are graduating from college and do not intend to continue their studies on a full-time basis will be continued up to three months after the date when all degree requirements are completed, provided the child qualifies as a dependent in all other respects.
Unmarried children who are mentally or physically incapable of earning their own living may be continued beyond age 19 if, within 31 days after they have reached the age limit, you submit proof of their incapacity.

Disabled Employees - Employees who qualify for Long Term Disability Insurance benefits may continue dental coverage for themselves and their eligible dependent(s) by payment of the appropriate contributions. This coverage will cease when Long Term Disability Insurance benefits are discontinued.

Employees on Leave of Absence - If you are on an approved leave of absence, your dental coverage may be continued by prepayment of the appropriate premiums.

Enrollment - Eligible employees must enroll in the Dental Assistance Plan within 30 days of their date of hire. Once you enroll, you must continue participation in the plan until the next enrollment period. If you do not enroll for coverage within 30 days of your date of hire, you will be required to wait until the next enrollment period to participate in the plan. Enrollment periods are held during December of each even numbered year, with coverage effective on January 1st of the following year.

To enroll, you must complete the enrollment form and list all dependents you want covered. By completing the form, you will authorize the necessary payroll deductions for the coverage you select.

The coverages available are:

Employee only
Employee and one dependent
Employee and two or more dependents

Coverage begins on your date of hire if you complete all enrollment forms promptly. If you have a change in your family and acquire a dependent or an additional dependent, you must notify the Human Resources Office within 30 days to include that dependent in your coverage. Dependent coverage is then effective the date you enroll.

What the Plan Covers

For covered non-orthodontic expenses, the AUI Group Dental Assistance Plan pays a maximum of $1500 in benefits over a calendar year for each covered individual. There is no maximum lifetime limit for non-orthodontic services.

Class I - Preventive and Diagnostic Services - The plan provides "first dollar" coverage for Class I dental services in accordance with a schedule. Class I expenses include the following:

Oral examinations, limited to two per calendar year.
Prophylaxis (cleaning and scaling of teeth), limited to twice per calendar year.
Fluoride treatments, excluding prophylaxis.
Sodium fluoride, limit once per year.
Stannous fluoride, limit of four times per year.
Acid fluoride phosphate, limit once per year.
Space maintainers, for insured children under age 19 only.
Installation of fixed or removable appliances.
Subsequent adjustment when required.
X-rays (dental x-rays, radiographs).
Full mouth, limit once every two years.
Supplementary bitewing, limit of twice per year.
Any dental x-ray required to diagnose a specific condition that needs treatment, except x-rays in conjunction with orthodontia

Class II - Basic and Major Dental Services - Class II services are reimbursed according to a schedule of allowances after each covered individual pays a deductible consisting of the first $25 in covered expenses during a calendar year. The maximum deductible for any family is $75 per calendar year. Any covered expenses used to meet the deductible during the last three months of one year may be carried over and applied toward the following year's deductible. Class II covered services include:

Restorations: fillings, inlays, onlays, and crowns.
Oral surgery: surgical procedures in and about the mouth.
Endodontics (such as root canal work): procedures used for the prevention and treatment of diseases of dental pulp.
Periodontics: surgical and nonsurgical procedures for treatment of the supporting area around the teeth.
Prosthodontics: services to replace one or more teeth extracted while the patient is covered under the Plan.

Class III - Orthodontic Services for Dependent Children to Age 19 - Our plan pays 50% of the reasonable and customary charges for orthodontic services, subject to a separate $1500 lifetime maximum benefit per eligible child. No deductible is required to claim these benefits. Typical services covered include:

Preliminary study (x-rays, diagnostic casts, and treatment plan).
Active Treatment.
Treatment for TMJ syndrome.

Schedule of Maximum Allowable Covered Dental Expenses - The maximum allowable amounts for services can be found here: Covered Procedures Payment Schedule. The amounts specified in the schedule are not intended to represent what your dentist's charges will be or should be. These are the maximum amounts that will be considered under the plan as covered dental expenses for specific dental services.

The claims administrator will pay benefits for dental services not listed, provided they are not specifically excluded from coverage. The claims administrator will determine benefits on the basis of the complexity and severity of the type of service in an amount consistent with the maximum allowance specified for other dental services.

How To File A Claim

In most cases you can present your Dental Coverage ID card to the provider and they will file claims for you. If the provider will not file the claim for you, claim forms can be obtained from the Human Resources website here: Dental Claim Form. You must fill out Part 1 of the claim form according to the instructions on the form. The dentist should provide you with information to submit for Part 2. Part 1 includes:

Authorization for the dentist to release necessary information to the claims administrator in order that your claim may be processed. This authorization must be signed as described on the form.
Authorization for the claims administrator to pay the dentist directly for work performed for you and members of your family. If you do not assign payment directly to your dentist, payment of benefits will be made to you.

Completed claim forms should be sent by you or your dentist to the Claims Administrator:

Medical Claim Service, Inc.
1 Wall Street, Suite 2A
Ravenwood, WV 26164

Questions on Claims - If you have a question about the claims administrator’s decision on your claim, you should contact them at 888-225-0522. When discussing your claim, please refer to the explanation of payment, the claim form, and any other correspondence that you may have received. Use the telephone number shown on the claim form to contact your claims administrator.

Coordination of Benefits

Coverage Under Non-AUI Plans If you or your covered dependents are eligible to receive benefits under another group dental plan, the benefits from that plan will be coordinated with the benefits from the AUI group plan so that up to 100% of the allowable expenses incurred during a calendar year will be paid jointly by the plans.

An allowable expense is any necessary, reasonable, and customary expense covered in full or in part under any one of the group plans involved.

A dental plan is considered to be any group insurance coverage or other arrangement of coverage for individuals in a group which provides dental services on an insured or an uninsured basis.

The rules for payment under the Coordination of Benefits provision are as follows:

Patient	Payment by AUI Plan	Payment by Other Plan
AUI Employee	Full Benefits	Balance of Cost Up to 100%
Employee's Spouse	Balance of Cost Up to 100%	Full Benefits

In the case of dependent children who are covered by more than one group plan, the insurance plan of the parent whose birthday occurs earlier in the calendar year will be the primary insurance plan for the children.

To obtain all the benefits available, you and your family members should file claims under each plan.

Husband and Wife Employed by AUI - When both spouses are employed by AUI, they may elect to be covered both as employees and as dependents under this plan, provided both pay the appropriate employee contribution. In such cases, dependent child(ren) can be covered by both spouses, again provided both spouses pay for dependent coverage. When claims are filed under such circumstances, benefits will be coordinated as outlined above, so that up to 100% of reasonable and customary expenses will be paid after each individual has satisfied the calendar year deductible.

AUI Group Medical Insurance - Coordination of Benefits - The AUI Group Medical Insurance Plan covers a very limited number of specific dental procedures, all of which are listed in the OAP Summary Plan Description. The AUI Group Medical Insurance Plan will only cover in cases of accidental injury or congenital defects. Whenever dental benefits are available under both the AUI Group Medical and Dental Assistance Plans, the benefits payable under the Dental Assistance Plan will be coordinated with the benefits payable under the AUI Group Medical Plan so that up to 100% of reasonable and customary expenses will be paid jointly by the plans. In all such cases the AUI medical plan is considered the primary policy and will provide benefit payments first.

Predetermination of Benefits

Before Treatment Begins - "Predetermination of Benefits" allows you to find out what services will be covered and what payments will be made before your dental treatment is performed. If you or one of your dependents is likely to incur dental expenses over $400, you should ask your dentist to file for Predetermination of Benefits. This feature of the Dental Assistance Plan assures that both you and your dentist will know in advance just what part of the dentist�s charges the plan will cover. Here is how it works:

The dentist informs the claims administrator of the proposed course of treatment by itemizing services and charges on the claim form which you provide.
The claims administrator then determines the amount the plan will pay and informs you and your dentist. You and your dentist should discuss the result before the work is done.

If a Predetermination of Benefits is not requested, the claims administrator will pay the claim based on whatever information he/she has on your case. Thus, a Predetermination of Benefits could save you considerable out-of-pocket expenses under certain circumstances (see next section on alternative procedures).

If your dentist submits a plan for Predetermination of Benefits and then changes the treatment plan, the claims administrator will adjust the payment accordingly. If any major changes in the treatment plan are made, your dentist should send in a revised plan.

Alternative Procedures - Sometimes there are several possible ways to treat a particular dental problem. For example, a filling can perform as well as a crown in certain situations. The same holds true in the decisions about the use of precious metals versus plastic. The claims administrator will base payment on the least costly scheduled amount, provided the result meets acceptable dental standards. Whenever the "Alternative Procedures" provision is used, the claims administrator�s dental consultant will be asked to review the claim.

The Predetermination of Benefits provision of the plan is important because, under this provision, the claims administrator has the right to pay the scheduled amount for the most economical method of treatment that does the job properly.

If you and your dentist decide to proceed with a more costly treatment, you will be responsible for the charges beyond those for the least costly appropriate treatment.

Exclusions and Limitations

The following dental expenses are not covered by this plan:

Cosmetic treatment, experimental treatment, dietary planning, plaque control, oral hygiene instructions, treatment for the correction of any congenital or developmental malformation.
Replacement of lost or stolen appliances, or extra appliances.
Replacement of a bridge or denture within five years of its original< installation unless this is necessary owing to installation of an original opposing full denture, the extraction of natural teeth, or irreparable damage as a result of an accident while the denture is in place.
Replacement of a dentally acceptable bridge or denture.
Appliance or restorations (other than full dentures) to alter vertical dimensions, stabilize teeth, or restore occlusion.
Installation of an initial appliance replacing teeth that were already missing when you or a dependent became insured.
Orthodontic services or supplies for anyone other than a dependent child.
Services covered by Workers� Compensation or similar laws.
Services performed in a U.S. Government hospital, unless you are required to pay for such services.
Charges in excess of reasonable and customary limits, charges for unnecessary services, or charges which would not have been made had no benefit existed.
Any dental treatment for which you are eligible for reimbursement under any government laws or regulations.
Services covered by benefits from no-fault automobile insurance.
Charges for broken appointments or completion of claim forms.
Charges for dental implants.
Any service rendered before coverage is effective.
Any service required as a result of an act of war, declared or undeclared.
Splinting for periodontal reasons where crowns, inlays, or onlays are being used for this purpose.

Termination of Coverage

Dental coverage for you and your dependents will stop when:

You terminate employment with AUI.
You die.
You fail to make contribution payments.

Individual dependent coverage will also cease whenever the dependent becomes ineligible.

Normally the plan will not pay for services or supplies beyond termination of your coverage, even if the claims administrator has predetermined the payments for a treatment plan submitted before your coverage ceases.

However, there are three exceptions for which benefits are payable, provided the work is completed within 60 days after coverage terminates:

A prosthetic device (such as full or partial dentures) if the dentist took the impressions and prepared the abutment teeth while the patient was covered.
A crown if the dentist prepared the tooth for the crown while the patient was covered by the plan.
Root canal therapy if the dentist opened the tooth while the patient was covered.

Continuation of Dental Assistance Plan Coverage after Termination of Employment or Dependent Eligibility Ceases

The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) provides that employees and their eligible dependents may continue their group dental coverage if the following qualifying events occur:

Termination or Reduction in Hours - If your employment with AUI terminates (for reasons other than for gross misconduct), or your work schedule is reduced to less than 20 hours per week, you are eligible to continue existing dental care coverage for you and your covered dependents up to 18 months. Divorce or Legal Separation: If you become divorced or legally separated, your covered spouse and dependent children living with your spouse are eligible to continue their existing group dental care coverage up to 36 months.

Loss of Dependent Status If your covered dependent child becomes ineligible under plan rules, existing dental care coverage may be continued up to 36 months.

Death - If you die, your covered spouse and dependent children are eligible to continue their group dental care coverage for up to 36 months beyond the time coverage would normally terminate.

Notification Requirements - If continued coverage is desired, you or your covered dependents are responsible for notifying the Human Resources Office in writing of the occurrence of divorce, legal separation, or loss of dependent status. In the event of termination of employment, reduction in work schedule, or death of the employee, information regarding enrollment procedures will be provided automatically by the Human Resources Office.

Election Period - An election to continue coverage must be made within 60 days of the date coverage would normally terminate because of one of the qualifying events described previously.

Premium Requirements - You or your dependents will be required to pay the full cost of the coverage continued under the provisions of COBRA. You or your dependents are responsible for ensuring that the premiums are paid on time.

Termination of Coverage Under COBRA - Coverage will end when any of the following events occur:

The applicable 18 or 36 months continuation period expires.
You drop coverage before the continuation period expires.
An individual becomes covered under another group plan.
Premiums are not paid on time.
The group health care plan is terminated for active employees.

Modified on Thursday, 06-Mar-2008 15:46:46 EST by Carolyn White