DISTRICT COUNCI OF CARPENTERS WELFARE FUND
Self-Insured Dental Services
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
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 persons 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 persons 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 persons 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 spouses 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 dentists 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 patients 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.
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 dentists 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 dentists 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 dentists 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
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
ORAL EXAMINATION 12.00
maximum-one in 6 consecutive months
FULL MOUTH SERIES X-RAYS
to 14 periapical /bitewing films
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
maximum-one in 6 consecutive mths
excluding prophylaxis 16.00
to age 15, 2 in any 12 consecutive months
SILVER AMALGAM FILLINGS
two surfaces 32.00
three or more surfaces 48.00
PLASTIC FILLING 27.00
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
one surface 190.00
two surfaces 250.00
three surfaces 300.00
Pre-operative periapical x-ray required. There is a 5 year frequency limitation on replacements.
porcelain jacket 300.00
plastic with metal 310.00
porcelain with metal 325.00
full cast 300.00
3/4 cast 210.00
STAINLESS STEEL CROWN, primary tooth .... 100.00
POST & CORE
PREFAB POST AND CORE 86.00
x-ray evidence of satisfactory completion required
one canal 145.00
two canals 180.00
three canals 232.00
four or more canals 232.00
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.
immediate or permanent
PARTIAL DENTURE-unilateral 240.00
each additional tooth 100.00
acrylic base with clasps and rests 280.00
cast metal base 360.00
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
crown-plastic with metal
crown-porcelain fused to metal 325.00
crown-full cast 300.00
DENTURE RELINE-chair 80.00
DENTURE RELINE-laboratory 94.00
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
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.
ROOT SCALING, GINGIVAL CURETTAGE & BITE CORRECTION, including prophylaxis,
entire mouth 40.00
periodontal maintenance 40.00
maximum allowance on any combination of the above services Is $160 in a calendar year
confirmation by charting and/or x-rays required per quadrant of at least 5 teeth
gingivectomy, gingivoplasty and mucogingival surgery
including gingivectomy-per quad 300.00
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
eligible dependent children only
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
PALLIATIVE TREATMENT 22.00