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Group
Dental Care |
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This
summary of benefits is provided for
illustrative purposes only and may
not be used to bind coverage and /
or as asummary of benefits to any
prospective empolyer . For specific
details of your dental plan, please
contact your employer, benefits
advisor or agent |
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Category |
Benefit Highlights |
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Eligible Individuals
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May
include, but is not limited to all
active full and part-time
Individuals, and / or a specified
class or classes of individuals as
determined by the employer, subject
to a Insurance carrier approval.
Each of these classes maybe provided
a selection of benefits, limits and
/ or contributions independent of
the other. |
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Waiting Period |
Coverage may begin on the date of
hire, or a period of 30, 60, 90 or
more consecutive days of employment
from the date of hire. |
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Minimum Hours |
A
minimum of 20 to 40 hours per week
maybe required by the employer,
subject to underwriting approval by
the selected carrier. |
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Contribution |
Employer may elect to pay 100% of
all premiums (Non-Contributory), or
share in part of the cost of
premiums for any class(s)) of
individuals (Contributory). Also,
employers may sponsor a group plan
where the employee pays 100% of the
premiums (Voluntary) through
selected insurance companies. |
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Dependent |
Coverage maybe provide to legal
spouse and / or dependent child to
age 19 (23 to 26, if full time
student) |
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Leave of Absence |
Individuals maybe covered up to 12
weeks under FMLA, and an employer
may elect to cover Individuals who
require voluntary "non-medical"
leave for periods from 30 to 180
days, subject to underwriting
approval by the selected carrier.
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Type of Coverage |
Plans maybe selected to include a
Preferred Dental Organization (PDO)
and / or Dental Managed Organization
(DMO) |
Preferred Care |
Non-
Preferred Care |
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In -
Network |
Out
of Network |
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Network |
Offers
a dual opt or freedom of choice |
PDO
and / or DMO Network |
PDO
Network Only |
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Deductible |
Calendar Year |
May
include a annual deductible for the
Individual & Family (Spouse &
Children) |
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Type I Preventive Care
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May
Include oral exam, cleanings, x-rays
and Fluoride & sealants for children |
Deductible
- Waived Ind & Family |
Deductible
- Waived Ind & Family |
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Co-insurance
- May cvrd 100%, or less |
Co-insurance
- May cvrd 100%, or less |
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Combined Maximum - $500 to $3,000 |
Combined Maximum - $500 to $3,000 |
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Type II Basic Care
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May
Include Fillings, Root Canal
Therapy, Osseous Surgery,
Endodontics - Periodontal Scaling &
Root Planning, Denture Adj.&
Repairs, Oral Surgery, Extractions,
Anesthetics, Repairs to Bridges,
Crowns & Inlays |
Deductible - $50 Ind & $150 Family |
Deductible - $50 Ind & $150 Family |
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Co-insurance
- May cvrd 60% to 100% |
Co-insurance
- May cvrd 60% to 100% |
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Combined Maximum - $500 to $3,000 |
Combined Maximum - $500 to $3,000 |
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Type III Restorative or Major
Care |
May
Include onlays, crowns, dentures,
fixed bridgework, gold fillings,
Prosthodontics |
Deductible - $50 Ind & $150 Family |
Deductible - $50 Ind & $150 Family |
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Co-insurance
- May cvrd 40% to 60% |
Co-insurance
- May cvrd 40% to 60% |
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Combined Maximum - $500 to $3,000 |
Combined Maximum - $500 to $3,000 |
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Type IV Orthodontia |
Coverage usually applies for
children only. Adult coverage maybe
available, subject to the selected
benefits plan and carrier.
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Deductible - $50 Ind & $150 Family |
Deductible - $50 Ind & $150 Family |
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Co-insurance
-elect 40% to 60% |
Co-insurance
- elect 40% to 60% |
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Lifetime Maximum - $500 to $3,000 |
Lifetime Maximum - $500 to $3,000 |
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Co-Pay |
Office
Visit |
Elect
$5 to $20, subj. to plan and Carrier |
Elect
$5 to $20, subj. to plan and Carrier |
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Benefit UCR |
Based
on Usual & Customary Charges |
Does
Not Apply |
Out
of network
- benefits maybe subject to the
usual & customary charges from 80%
to 90%, based on the selected plan
and carrier |
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Fourth Quarter Carry Over
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Deductible credit maybe applied to
new year, subject previous year 4th
quarter ending treated expenses |
May be
included, subject to the selected
plan and carrier |
May be
included, subject to the selected
plan and carrier |
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Treatment of TMJ |
Temporomandibular Joint
Dysfunction), occlusal devices/occlusal
guards (night guards) |
Treatment - usually not covered,
limited benefit provided by select
carriers |
Treatment - usually not covered,
limited benefit provided by select
carriers |
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Deferred Services |
Type
II and / or Type III services may be limited during the first plan year, subject to plan
and carrier |
May
limit the amount coverage, or
benefits within the Type II and / or
III services for a period of up to
12 months |
May
limit the amount coverage, or
benefits within the Type II and / or
III services for a period of up to
12 months |
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