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Service Employees 32BJ North Health Fund
Tri-State Preferred North Summary Plan Description (SPD)
>> Dental Benefits
How the Plan Works
The Plan provides coverage for necessary dental care received through:
Necessary dental care is a service or supply that is required to identify
or treat a dental condition, disease or injury. The fact that a dentist
prescribes or approves a service or supply or a court orders a service or
supply to be rendered does not make it dentally necessary. The service or
supply must be all of the following:
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provided by a dentist, or solely in the case of cleaning or scaling of
teeth, performed by a licensed, registered dental hygienist under the
supervision and direction of a dentist
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consistent with the symptoms, diagnosis or treatment of the condition,
disease or injury
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consistent with standards of good dental practice
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not solely for the patient’s or the dentist’s convenience, and
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the most appropriate supply or level of service that can safely be
provided to the patient.
Covered services are listed in the “Schedule of Covered Dental Services” subject to frequency limitations that are
stated in that Schedule. The Plan pays no benefits for procedures that
are not on the Schedule, but may provide an alternate benefit if approved
by the Fund. Whether you have to pay for those services and, if so, how
much, depends on whether you choose to receive your dental care from a
participating dental provider or from a non-participating dentist.
Participating Dental Providers
The Plan’s dental benefits include a “participating dentist” feature.
Dentists who are in the Plan’s participating dental provider network have
agreed to accept the amount that the Plan pays as payment in full for their
dental services. If you choose to receive your care from a participating
dental provider, you will not have to pay anything for covered dental care
you receive, except for osseous surgery, for which you will have to make
a $125 co-payment for each quadrant, and periodontal scaling and root
planning for which there is a 100% co-payment.
Non-Participating Dentists
The Plan will pay for dental work performed by any properly accredited
dentist, but the Plan will pay no more than the amount listed on its
Schedule of Allowed Amounts. (Contact Member Services at 1-212-388-3333
for a copy of the Schedule of Allowed Amounts.) If the dentist charges more
than those amounts for your dental care, you will be responsible to pay the
difference between what the dentist charges and what the Plan pays. Be
sure to ask the dentist before you start treatment what the charges will be,
so that you will know what your out-of-pocket expenses may be.
The Fund will pay the smaller of the dentist’s actual charge for a
covered dental service or the allowed amount for that procedure, as
indicated in the Schedule of Allowed Amounts.
Prior Approval
 ALERT:
06/10/10 NEW
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Prior approval must be obtained for the following:
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major restorative procedures for prefabricated stainless steel/resin
crown (deciduous teeth only) and crowns
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periodontics for osseous surgery
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removable prosthodontics
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fixed prosthodontics
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oral and maxillofacial surgery for removal of impacted tooth
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orthodontics, and
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all treatment plans that exceed $1,500.
Prior approval is necessary even if your dentist is a participating
dental provider.
An approved treatment plan submitted by a dentist can be used only
by that dentist and only within one year of the approval.
Changes to your current approved treatment plan require submitting a
new treatment plan for review and approval.
In order to submit a proposed treatment plan for review, your dentist
should send all the information, including diagnostic quality X-rays, to:
Daniel H. Cook Associates, Inc.
C/o Building Service 32BJ Health Fund
Dental Claims
P.O. Box 676
New York, NY 10013-0819
What Dental Services Are Covered
The Plan covers a wide range of dental services, including:
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preventive and diagnostic services such as routine oral exams,
cleanings, X-rays, topical fluoride applications and sealants
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basic therapeutic services such as extractions and oral surgery,
intravenous conscious sedation when medically necessary for oral
surgery, gum treatment, fillings and root canal therapy
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major services such as fixed bridgework, crowns, dentures, and gum
surgery, and
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orthodontic services such as diagnostic procedures and appliances to
realign teeth. There is a separate lifetime maximum on orthodontic
services of $2,500.
See the "Schedule of Covered Dental Services" section below for details.
Frequency Limitations
Benefits are subject to the frequency limits shown in the "Schedule of Covered Dental Services" section.
Schedule of Covered Dental Services
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| Procedure |
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Limits |
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Diagnostic |
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| Oral exam, periodic, limited (problem-focused),
comprehensive or detailed and extensive
(problem-focused) |
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Once every six months |
| |
|
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| X-rays: |
|
|
| |
|
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| • full mouth, complete series, including bitewings
or panoramic film |
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Once in any 36 consecutive months |
| |
|
|
| • bitewings, back teeth |
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Four films every six months |
| |
|
|
| • periapicals, single tooth |
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As necessary, up to yearly combined maximum
of $28 |
| |
|
|
| • occlusal film |
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As necessary, up to yearly combined maximum
of $28 |
| |
|
|
| • cephalometric film (orthodontic coverage
only) |
|
Once in a lifetime |
| |
| Preventive |
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Dental prophylaxis (cleaning and polishing)
|
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Once every six months |
| |
|
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| Topical fluoride treatment |
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Once in any calendar year for patients under
age 16 |
| |
|
|
Sealants (on the occlusal surface of a permanent
non-restored molar and pre-molar tooth)
|
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Once per tooth in any 24 consecutive months
for patients under age 16 |
| |
|
|
| Space maintenance (passive-removable or fixed
devices made for children to maintain the gap
created by a missing tooth until a permanent
tooth emerges) |
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Once per tooth for patients under age 16 |
| |
|
|
| Simple Restorative |
|
Amalgam (metal) fillings
|
|
Once per tooth surface in any 24 consecutive
months |
| |
|
|
| Resin (composite, tooth-colored) fillings |
|
Once per tooth surface in any 24 consecutive
months |
| |
|
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| Major Restorative |
|
Recementation of crown
|
|
Once per tooth in any calendar year |
| |
|
|
Prefabricated stainless steel/resin crown*
(deciduous teeth only)
|
|
Once per tooth in any 60 consecutive months |
| |
|
|
| Crowns,* when tooth cannot be restored with
regular filling(s) due to excessive decay or
fracture |
|
Once per tooth in any 60 consecutive months |
| |
|
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| Endodontics |
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| Root canal therapy |
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Once per tooth in a lifetime |
| |
|
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| Retreatment of root canal |
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Once per tooth in a lifetime |
| |
|
|
Apicoectomy (a post-operative film showing
completed apicoectomy and retrograde, if
placed, is required for payment)
|
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Once per tooth in a lifetime |
| |
|
|
| Pulpotomy |
|
Once per tooth in a lifetime |
| |
|
|
| Periodontics |
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| Gingivectomy or gingivoplasty |
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Once per quadrant in a lifetime |
| |
|
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Osseous surgery* (prior approval is required
with a full-mouth series of X-rays and periodontal
charting). In all cases, a participating
periodontal specialist may require you to make
a co-payment of $125 per quadrant.
|
|
Once per quadrant in a lifetime |
| |
|
|
Periodontal scaling and root planing
|
|
100% co-payment |
| |
|
|
| Periodontal maintenance (covered only if the
Plan also covered periodontal surgery and
the maintenance procedure is performed by a
periodontist) |
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Twice in any calendar year |
| |
|
|
| Removable Prosthodontics* |
|
| Complete or immediate (full) upper and
lower dentures or partial dentures, including 6
months of routine post-delivery care |
|
One denture per arch in any 60 consecutive
months |
| |
|
|
| Denture rebase or reline procedures, including
6 months of routine post-delivery care |
|
Once per appliance in any 36 consecutive
months |
| |
|
|
| Interim maxillary and mandibular partial denture
(anterior teeth only); no other temporary
or transitional denture is covered by the Dental
Plan |
|
Once per tooth in any 60 consecutive months |
| |
|
|
| Fixed Prosthodontics* |
|
| Fixed partial dentures and individual crowns |
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Once per tooth in any 60 consecutive months |
| |
|
|
| Prefabricated post and core procedures related
to fixed partial denture (X-ray showing
completed endodontic procedure is required) |
|
Once per tooth in any 60 consecutive months |
| |
|
|
| Simple Extractions |
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Non-surgical removal of tooth or exposed roots
(includes local anesthesia, necessary suturing and routine post-operative care)
|
|
Once per tooth |
| |
|
|
| Oral and Maxillofacial Surgery |
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Removal of impacted tooth*
|
|
Once per tooth in a lifetime |
| |
|
|
Alveoplasty (surgical preparation of ridge for
dentures, with or without extractions)
|
|
Once per quadrant in a lifetime |
Frenulectomy
|
|
Once per arch in a lifetime |
| |
|
|
| Removal of exostosis (removal of overgrowth
of bone) |
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Once per site in a lifetime |
| |
|
|
| Oral surgery is limited to removal of teeth, preparation of the mouth for dentures, removal
of tooth-generated cysts up to 1.25cm and incision and drainage of an intraoral or extraoral
abscess. |
| |
|
|
| Emergency Treatment |
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| Palliative treatment to alleviate immediate
discomfort (minor procedure only) |
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Twice in any calendar year |
| |
|
|
| Repairs |
|
| Temporary crown (fractured tooth) |
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Once per tooth in a lifetime |
| |
|
|
| Crown repair |
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Once per tooth in any 36 consecutive months |
| |
|
|
| Overcrown |
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Once per tooth in any 60 consecutive months |
| |
|
|
| Repairs to complete or partial dentures |
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Once per appliance in any calendar year |
| |
|
|
| Recement fixed or partial dentures |
|
Once per appliance in any calendar year |
| |
|
|
| Additions to partial dentures |
|
Two procedures in a calendar year |
| |
|
|
| Orthodontics* |
|
Course of Treatment
|
|
One course of treatment in a lifetime, up to
$2,500.
Initial diagnosis is a separate coverage. |
| |
|
|
| Benefits are payable only for treatment by orthodontists who are graduates of an advanced
education program in orthodontics accredited by the American Dental Association. A “course of
treatment” is defined as 30 consecutive months of active orthodontic treatment including braces,
monthly visits and retainers. |
| |
|
|
| Miscellaneous |
|
| |
|
|
| Occlusal guard |
|
One appliance in any 60 consecutive months |
 |
|
|
* Prior approval required.
Alternate Benefits
There is often more than one way to treat a given dental problem.
For example, a tooth could be repaired with an amalgam filling, a resin
composite or a crown. If this is the case, the Plan will generally limit
benefits to the least expensive method of treatment that is appropriate and
that meets acceptable dental standards. For example, if your tooth can be
filled with amalgam and you or your dentist decide to use a crown instead,
the Plan pays benefits based on the amalgam. You will have to pay the
difference.
What Is Not Covered
The Plan's dental coverage will not reimburse or make payments for the following:
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any services performed before a patient becomes eligible for benefits
or after a patient’s eligibility terminates, even if a treatment plan has
been approved
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reimbursement for any services in excess of the frequency limitations
specified in the Schedule of Covered Dental Services
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charges in excess of the Allowed Amounts – contact Member Services
for the Schedule of Allowed Amounts for dental care
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services that required prior approval, but are initiated without
approval, with the exception of emergency treatment
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treatment for accidental injury to natural teeth that is provided more
than 12 months after the date of the accident
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services or supplies that the Plan determines are experimental or
investigative in nature
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services or treatments that the Plan determines do not have a
reasonably favorable prognosis
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any treatment performed principally for cosmetic reasons, including,
but not limited to, laminate, veneers and tooth bleaching
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special techniques, including precision dentures, overdenture,
characterization or personalization of crowns, dentures, fillings or
any other service. This includes, but is not limited to, precision
attachments and stress-breakers. Full or partial dentures that require
special techniques and time due to special problems, such as loss of
supporting bone structure, are also excluded.
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any procedures, appliances or restorations that alter the “bite,” or
the way the teeth meet (also referred to as occlusion and vertical
dimension) and/or restore or maintain the bite, except as provided
under orthodontic benefits. Such procedures include, but are
not limited to, equilibration, periodontal splinting, full-mouth
rehabilitation, restoration of tooth structure lost from attrition, and
restoration for misalignment of teeth.
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any procedures involving full-mouth reconstruction, or any services
related to dental implants, including any surgical implant with a
prosthetic device attached to it
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diagnosis and/or treatment of jaw joint problems, including
temporomandibular joint disorder (TMJ) syndrome, craniomandibular
disorders, or other conditions of the joint linking the jaw bone and skull or
the complex of muscles, nerves, and other tissue related to that joint
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double or multiple abutments
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treatment for self-inflicted injury or illness
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treatment to correct harmful habits, including, but not limited to,
smoking and myofunctional therapy
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habit-breaking appliances, except under the orthodontics benefit
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services for plaque-control programs, oral hygiene instruction, and
dietary counseling
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services related to the replacement or repair of appliances or devices,
including:
- duplicate dentures, appliances or devices
- the replacement of lost, missing or stolen dentures and appliances
less than five years from the date of insertion or the payment date
- replacement of existing dentures, bridges or appliances that can be
made useable according to dental standards
- adjustments to a prosthetic device within the first six months of its
placement that were not included in the device’s original price, and
- replacement or repair of orthodontic appliances.
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drugs or medications used or dispensed in the dentist’s office
(any prescriptions that are required may be covered by the Plan's
prescription drug benefits – see the "Prescription Drug Benefits" section)
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charges for novocaine, xylocaine or any similar local anesthetic when
the charge is made separately from a covered dental expense
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additional fees charged by a dentist for hospital treatment
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services for which a participant has contractual rights to recover cost,
whether a claim is asserted or not, under Workers’ Compensation, or
automobile, medical, personal injury protection, homeowners or other
no-fault insurance
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treatment of conditions caused by war or any act of war, whether
declared or undeclared, or a condition contracted or accident occurring
while on full-time active duty in the armed forces of any country or
combination of countries
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any portion of the charges for which benefits are payable under any
other part of the Plan
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if a participant transfers from the care of one dentist to another
dentist during the course of treatment, or if more than one dentist
renders services for the same procedure, the Plan will not pay benefits
greater than what it would have paid if the service had been rendered
by one dentist
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transportation to or from treatment
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expenses incurred for broken appointments
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fees for completing reports or for providing records, or
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any procedures not listed under the Schedule of Covered Dental Services.
Coordination of Dental Benefits
If you have dental coverage through another carrier, which serves as
your primary dental insurer, prior approval is not required if you secured
this approval through your primary dental insurer. See the "Coordination of Benefits" section for
the rules that determine which carrier is primary.
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