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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