NEW
York
DISTRICT
COUNCI OF CARPENTERS WELFARE FUND
DENTAL
SCHEDULE
FOR
MEMBERS
AND
THEIR
ELIGIBLE
DEPENDENT
Administered
By
Self-Insured
Dental Services
JANUARY
1,1999
ELIGIBILITY:
Your eligibility and the eligibility of your dependents is defined in your NYDCC Summary Plan Description.
ELIGIBLE
DEPENDENTS:
include the lawful spouse and each unmarried child from birth until the last day of the
calendar year in which the child reaches age 19.
Dependent
children attending an accredited school or college on a full-time basis are eligible until
the end of the year in which the child reaches age 25 or graduates, whichever comes first
ANNUAL
DEDUCTIBLE:
The annual deductible will be waived for diagnostic and preventive services and
orthodontic treatment.
Active Carpenters: $100
Retired Carpenters: $50
Carpenters employed by the
City of New York Active/Retiree: $100
Building Contractors Association: $50
ANNUAL
MAXIMUM:
$1,500 annual maximum per covered individual.
ORTHODONTIC
BENEFIT:
For eligible dependent children only. There is a maximum of 24 months of active treatment
and 18 months passive. Orthodontic benefits are not subject to the annual maximum.
Deductibles are not applied to orthodontic services.
COVERED
EXPENSES:
Covered Expenses include charges incurred for the performance of Dental Services provided
for in the Schedule of Covered Dental Expenses,
when the Dental Service is performed by or under the direction of a duly licensed Dentist,
is essential dental care, and begins and is completed while the individual is covered for
benefits.
A
Dental Service is deemed to start when the actual performance of the service starts except
that:
·
for fixed bridgework and removable dentures, it starts
when
the first impressions are taken and/or abutment
teeth
are prepared;
·
for a crown, it starts on the first date of preparation of
the
tooth involved;
·
for root canal therapy, it starts when the pulp chamber
of
the tooth is opened.
HOW
TO FILE A CLAIM:
After dental work is performed, have your Dentist complete all items in the Dentist
Information portion of the Claim Form and list the procedures, dates of services and
charges and sign in the space provided for Dentist signature. You should then complete all
items in the Member Information portion. Be sure to include spouse and dependent
information.
Completed
claim forms, with x-rays and other attachments, should be sent to:
Self
Insured Dental Services
P0
Box 9095 Dept. 95
Valley
Stream, NY 11582-9095
516-396-55001718-204-7172
800-537-1238
Claim
Forms are available from the fund office. Dental claims must be filed within 12 months
after the date of service. Claims filed later than 12 months from the date of service will
not be reimbursed. If you would like the payment
made directly to your Dentist, you may do so by signing the Authorization to Assign
Benefits” box on the claim form.
PRE-TREATMENT
REVIEW:
This process is intended to inform you and your dentist, in advance of treatment, what
benefits are provided by the Dental Program. It enables you to obtain knowledge of the
operation of your dental plan prior to undertaking treatment and incurring expenses.
A
Claim Form for Pre-Treatment Review should be filed by your Dentist if the course of
treatment prescribed for you is expected to cost more than $300 in a 90 day period and/or
includes any of the following services: crowns, bridges, dentures, orthodontics, inlays or
periodontal surgery. The Dentist should complete the claim form describing the planned
treatment and the intended charges before starting treatment. Complete your part of the
form and mail it together with the necessary x-rays and other supporting documentation.
S.l.D.S.
will review the proposed treatment and apply the appropriate Plan provisions. You and your
Dentist will receive a report showing the amount the Plan will pay for each procedure. If
there is a disallowance, it will be indicated and an explanation will be provided. Discuss
the treatment plan and the benefits payable with your Dentist.
If
you receive a pre-treatment authorization for a proposed course of treatment that was
submitted by one Dentist, that preauthorization will remain valid if you elect to have
some or all of the work done by another Dentist. The pre-authorization will be honored for
one year after issuance.
Please
be aware that a pre-treatment authorization is not a promise of payment.
Work must be done while you are still covered by the Fund for benefits (except where there
is an Extension of Benefits) and no significant change occurred in the condition of your
mouth after the pre-estimate was issued. Payment will be made in accordance with plan
allowances and limitations in effect at the time services are provided.
EXTENSION
OF BENEFITS:
An expense incurred in connection with a Dental Service that is completed after a
person’s benefits cease will be deemed to be incurred while that person was eligible
if:
·
for crowns, fixed bridgework and full or partial dentures a pre-treatment authorization
was issued and impressions were taken and/or teeth were prepared while that person was an
eligible beneficiary and the device was installed or delivered within three months after
that person’s eligibility terminated.
· for orthodontic appliances a pre-treatment
authorization was issued and impressions were taken while the individual was an eligible
dependent and the device was installed within three months after eligibility terminated.
There is no extension of benefits for active or passive months of treatment.
· for root canal therapy, the pulp chamber
of the tooth was opened while that person was eligible for benefits and the treatment was
completed within three months after that person’s eligibility terminated.
There
is no extension for any dental service not shown above.
COORDINATION OF DENTAL BENEFITS: If you or your
family members are eligible to receive dental benefits under another group plan in
addition to the NYDCC Welfare Fund Dental Plan, benefits will be coordinated with the
benefits from your other group plan so that up to 100% of the allowable expenses will be
paid jointly by the plans. The allowable expense for a procedure is defined as the average
usual and customary charge for a specific geographic area. Members should file with the
primary plan first and then the secondary plan. The plan that covers an individual as an
employee, or union member pays first, and the plan that covers an individual as a family
member pays second. Be certain to enclose a’ copy of the payment voucher from the
primary plan when filing a claim with the secondary plan.
BIRTHDAY
RULE:
The Birthday Rule is applied for determining the primary carrier for payment of dental
benefits for dependent children. The plan of the parent whose birthday, month and day,
falls first in the calendar year is the primary carrier. For example, if your birthday is
May 9 and your spouse’s birthday is July 27, your dental plan will be primary.
ALTERNATE BENEFIT PROVISION: Due to the element of
choice available in the treatment of some dental conditions, there may be more than one
course of treatment that could produce a suitable result based on accepted dental
standards. When the pre-treatment review or claim analysis is performed and there is
another procedure that could address the problem, S.l.D.S will advise you of the
determination. In these instances, although you may
elect to proceed with the original treatment plan, reimbursement allowances will be based
on a less expensive Alternate Course of Treatment. This should in no way be considered
a reflection on your treating dentist’s recommendations. By using the pre-treatment
review and authorization procedures you and your Dentist can determine, in advance, what
benefits are available for a given course of treatment. If the course of treatment has
already begun, or has been completed without a pretreatment authorization estimate, the
benefits paid by the Dental Plan may be based on the less expensive treatment.
GUARDED PROGNOSIS LIMITATION: If, in the opinion
of the claims administrator, the longevity of the proposed or rendered treatment is
limited, payment may be made in accordance with Plan provisions. However, any future
benefits for additional services may be affected.
COSMETIC
LIMITATION:
Where there is more then one method of restoring a decayed or fractured tooth, one of
which may result in a more esthetic restoration than others, payment will be based on the
least costly professionally acceptable treatment option.
EXPENSES
NOT COVERED:
Covered Expenses will not include, and no payment will be made for, expenses incurred for:
1. treatment
for the purpose of cosmetic improvement.
2. replacement
of a lost or stolen appliance.
3. replacement
of a bridge, crown, inlay or denture within five years after the date it was originally
installed.
4. replacement
of a bridge, crown, inlay or denture which is or can be made usable according to common
dental standards.
5. procedures,
appliances or restorations (except full dentures) whose main purpose is to:
a) change vertical dimension; or
b) diagnose or treat conditions or dysfunctions of the
temporomandibular joint; or
c) stabilize periodontally involved teeth.
6. multiple
bridge abutments.
7. a
surgical implant of any type, including any prosthetic device attached to it.
8. for
general anesthesia/conscious sedation, intravenous sedation or analgesia.
9. dental
services that do not meet common dental standards.
10. services
not included as Covered Dental Expenses in the Dental Schedule.
11. services
for which benefits are not payable according to the “General Limitations”
section.
GENERAL
LIMITATIONS:
No payment will be made for expenses incurred for you or any one of your dependents:
1. for
or in connection with services or supplies resulting from an accidental injury and which
are deemed to be the responsibility of a third party.
2. for
or in connection with an injury arising out of, or in the course of, any employment for
wage or profit.
3. for
or in connection with a sickness which is covered under any workers compensation or
similar law.
4. for
charges made by a hospital owned or run by the United States Government unless there is a
legal obligation to pay such charges whether or not there is any insurance.
5. to
the extent that payment is unlawful where the person resides when the expenses are
incurred.
6. for
charges which would not have been made if the person had no insurance, including services
provided by a member of the patient’s immediate family.
7. to
the extent that they are more than Reasonable and Customary Charges.
8. for
charges for unnecessary care, treatment or surgery.
9. to
the extent that you or any of your Dependents is in any way paid or entitled to payment
for those expenses by or through a public program.
10.
for
or in connection with experimental procedures or treatment methods not accepted.
NEW
York
DISTRICT
COUNCI OF CARPENTERS WELFARE FUND
Participating
Dentist Program
This
feature of your dental program is designed to provide you with comprehensive dental
services while reducing or eliminating your out-of-pocket expenses.
When
you use a NYDCC participating dentist you will be provided with the services covered by
your dental plan without any out-of-pocket expense except as noted below. Since usual and
customary dentist charges generally exceed the Maximum Charges listed in the Schedule,
this represents an overall savings to you in the cost of your dental services.
When
you use a participating provider you will not incur any out-of-pocket expenses except in
the following instances:
1. To satisfy the annual deductible. If all or
part of the
deductible
has already been met, your dentist will refund that portion to you when the claim is
settled.
2. For services that are listed in the Schedule
but for which the Plan will not pay, e.g.:
a)
cosmetic restorations
b)
where the Alternate Benefit provision is applied
c)
where frequency limitations and/or plan maximums have been met
In
these Instances, the participating dentist’s charges may not exceed the Maximum
Charges as stated in the Schedule
3. For
non-covered services (there are a few procedures not covered by the Plan), you are not to
pay more than the dentist’s usual and customary charge for that service.
If
you are a beneficiary under more than one dental plan, the dentist is entitled to the
benefits available from bath plans. The combined payment for any procedure, however, may
not exceed the usual and customary fee for that procedure and payment from the second plan
must be applied first toward any applicable deductibles.
SELECTING
A DENTIST:
It is important to understand that the NYDCC Welfare Fund does not recommend any
particular dentist. You are responsible to select the dentist of your choice, and should
exercise the same care and apply the same criteria in selecting a participating dentist
that you would in selecting a non-participating dentist. If you use a participating
dentist you will be expected to assign benefits on the claim form so that the
participating dentist can be paid by the Fund. If you use a nonparticipating dentist,
the Fund will pay up to the maximum allowance set forth in the dental schedule and you
will be responsible for the difference between that allowance and your dentist’s
charge.
SCHEDULING
AN APPOINTMENT:
To take advantage of II program, select a dentist from the List of Participating Dentist
and call for an appointment. Be sure to identify yourself as eligible member of the New
York District Council Carpenter Welfare Fund. Please
note that identification cards are not required or issued for the dental benefits program.
The
panel of participating dentists was developed in cooperation with our dental consultants,
SIDS. Should you need a assistance with the program, have any specific complain’
suggestions or comments, or if you need an updated List Participating Dentists (occasional
changes are anticipate please contact:
Self-Insured
Dental Services
P.O.
Box 9095
Valley
Stream N.Y. 11582-9095
516-396-5500
/ 718-204-7172
800-537-1238
SIDS
will monitor the performance of participating dentists insure that appointments are freely
given and honored and that treatment is rendered in a professional manner and no improper
charges are levied.
We
urge you to use participating dentists. We want your input and we want to hear from you
concerning your reaction to your use of a participating dentist. If you have any problems
complaints or require an explanation of charges please feel free to write or call
Self-Insured Dental Services.
Schedule of
Covered Dental Allowances
DIAGNOSTIC & PREVENTIVE
Plan
Pays
ORAL
EXAMINATION
12.00
maximum-one
in 6 consecutive months
FULL
MOUTH SERIES X-RAYS
10
to 14 periapical /bitewing films
28.00
PANORAMIC FILM
28.00
periapical or bitewing, per film
4.00
OCCLUSAL FILM
13.00
CEPHALOMETRIC FILM
32.00
POSTERIOR-ANTERIOR film
29.00
LATERAL FILM
32.00
TEMPOROMANDIBULAR FILM
40.00
maximum-$48
in 12 consecutive months
PROPHYLAXIS,
including scaling and polishing
adult
22.00
child
22.00
maximum-one
in 6 consecutive mths
FLUORIDE
TREATMENT
excluding prophylaxis
16.00
to
age 15, 2 in any 12 consecutive months
SPACE
MAINTAINER
acrylic
98.00
metal
135.00
BASIC
RESTORATIVE
SILVER
AMALGAM FILLINGS
one surface
20.00
two surfaces
32.00
three or more surfaces
48.00
PLASTIC FILLING
27.00
COMPOSITE RESIN
one surface
28.00
two surface
40.00
three surfaces
60.00
four or more and incisal angle
44.00
SILICATE CEMENT FILLING
25.00
METALLIC INLAY
one surface
190.00
two surfaces
250.00
three surfaces
300.00
MAJOR
RESTORATIVE
Pre-operative
periapical x-ray required. There is a 5
year
frequency limitation on replacements.
‘CROWNS
plastic
120.00
porcelain jacket
300.00
plastic with metal
310.00
porcelain with metal
325.00
full cast
300.00
3/4 cast
210.00
Plan
Pays
STAINLESS
STEEL CROWN, primary tooth ....
100.00
CAST
POST & CORE
86.00
PREFAB POST AND CORE
86.00
ENDODONTICS
x-ray
evidence of satisfactory completion required
PULPOTOMY
36.00
ROOT THERAPY
one canal
145.00
two canals
180.00
three canals
232.00
four or more canals
232.00
APICOECTOMY
126.00
PROSTHODONTICS
Pre-operative
X-rays are required when filing a claim for pretreatment review or payment on all
prosthetics. X-rays of the full arch must be included for all bridgework. There is a five
year frequency limitation from date of installation on all prosthetics.
COMPLETE
DENTURE
immediate or permanent
335.00
PARTIAL DENTURE-unilateral
240.00
each additional tooth
100.00
PARTIAL DENTURE-bilateral
acrylic base with clasps and rests 280.00
cast metal base
360.00
OBTURATOR
250.00
BRIDGE PONTIC
full cast
235.00
plastic with metal
235.00
porcelain with metal
265.00
ABUTMENT-INLAY 2 SURFACE
200.00
ABUTMENT-INLAY 3 SURFACE
250.00
CAST
METL RETNR-ACID ETCH BRIDGE ....
175.00
BRIDGE
ABUTMENT
crown-plastic with metal
310.00
crown-porcelain fused to metal
325.00
crown-full cast
300.00
DENTURE RELINE-chair
80.00
DENTURE RELINE-laboratory
94.00
DENTURE REPAIRS
denture adjustment
20.00
repair complete denture base
43.00
replace tooth in denture
first tooth
35.00
each additional
14.00
replace broken facing
63.00
add tooth to existing partial denture
first tooth
35.00
each additional
14.00
RECEMENTATION
crown
22.00
inlay
18.00
PERIODONTIC
SERVICES
Although
eight teeth constitute the anatomic compliment of a quadrant, for purposes of settling
claims for periodontal treatment, payment will be based on five teeth per quadrant.
Accordingly, if at least five teeth are treated in a quadrant, payment will be based on
the allowance for a full quadrant. If fewer than five teeth are treated, payment will be
pro-rated on the basis of five teeth per quadrant. When more than one
Periodontal Procedure is performed on the same day.
claims for services will be combined and payment
will be based on the most costly procedure.
Plan
Pays
ROOT
SCALING, GINGIVAL CURETTAGE & BITE CORRECTION, including prophylaxis,
per visit
40.00
entire mouth
40.00
periodontal
maintenance
40.00
maximum
allowance on any combination of the above services Is $160 in a calendar year
PERIODONTAL
SURGERY
confirmation
by charting and/or x-rays required per quadrant of at least 5
teeth
gingivectomy,
gingivoplasty and mucogingival surgery
per quadrant
150.00
osseous surgery,
including
gingivectomy-per quad
300.00
ORAL
SURGERY
ROUTINE
EXTRACTION
32.00
SURGICAL EXTRACTION
must
be demonstrated by x-ray
erupted
tooth
48.00
impaction-soft tissue
75.00
impaction-partial bony
94.00
impaction-complete bony
130.00
ALVEOLOPLASTY-per jaw
72.00
BIOPSY OF ORAL TISSUE
84.00
REMOVAL OF CYST OR TUMOR
72.00
FRENULECTOMY
85.00
ORTHODONTICS
eligible
dependent children only
INITIAL
FIXED APPLIANCE
400.00
ACTIVE TREATMENT-per month
50.00
maximum
of 24 mths
PASSIVE
TREATMENT-per 6 Th
40.00
maximum
of 18 mths
MINOR
TOOTH MOVEMENT
removable acrylic appliance
80.00
removable metal appliance
110.00
fixed acrylic appliance
70.00
fixed metal appliance
80.00
ADJUNCTIVE
SERVICES
PALLIATIVE
TREATMENT
22.00