Provisional Members

• You
• Your spouse
• Your domestic partner

*Your unmarried dependent children up to age 19 and up to age 25 if they are full-time students at accredited educational institutions.

*Dependent coverage is also extended to any unmarried child, regardtess of age, who is incapable of self-sustaining employment by reason of a mental or physical handicap and who becomes so prior to attainment of age 19 and who resides with and is wholly dependent on the covered member for financial support. You must submit proof of your dependent child’s incapacity to the Fund Office 31 days after the date he/she attains the age at which his/her coverage would otherwise terminate, or within 31 days after you are notified of his/her termination of eligibility, whichever is later. Proof of the continued existence of such incapacity shall be furnished to the Fund Office from time to time as requested.

Your dependents are your lawful spouse, registered domestic partner and each unmarried child up to their 19th birthday and who are enrolled by you with the Fund as your dependent. “Child” is defined as a natural child, stepchild or adopted child, provided such child is dependent upon you for support and maintenance, and proof of such (e.g., adoption papers) is provided to the Fund Office. Coverage for a dependent child may be continued up to their 25th birthday if he or she is a full time student in an accredited educational institution, and proof of such (i.e., an original letter from Registrar’s office with raised seal) is provided to the Fund Office within one month of the start of the current semester.

If your child reaches age 19 during a school vacation period, coverage will continue, as long as the child is enrolled in an accredited secondary or preparatory school or college or other accredited educational institution, provides written notification that the child plans to resume classes on a full-time basis at the end of the vacation period, and subsequently provides an original letter from the school’s Registrar’s office within one month of the start of the current semester.

It is important that you notify the Fund Office immediately of any change in your family status (to add dependents due to marriage, birth or adoption of a child, or to drop dependents due to death, divorce, legal separation, termination of domestic partnership or a child reaching an ineligible age or losing full-time student status and of any change of address. Failure to do so could result in loss or delay of benefits.

It is important and to your advantage that you keep the Fund up-to-date on your current status.

• Participating Dentists under the Self-Insured Plan.
• Self-Insured Dental Claim Forms
• To view claims go to www.dhclaims.com

How do Reimbursement Dental Expense Benefits work?

Reimbursement Dental Benefits provide scheduled reimbursement for expenses you incur for preventive, basic and major non-orthodontic dental services with no deductible required.

What does the plan pay?

Your Reimbursement Dental Benefits program pays a set amount for covered expenses you have for preventive, basic, and major dental services up to a maximum benefit of $2,750 per calendar year* for each covered person. A dental reimbursement schedule of dental procedures is provided upon request. * Effective January 2009

Who is eligible for the orthodontic benefit?

Eligible dependent children up to their 19th birthday, all orthodontic work must be completed by the child's 19th birthday.

How does the orthodontic benefit work?

Orthodontic services are reimbursed according to a fee schedule up to a lifetime maximum of $3,442. A period of orthodontic treatment starts on the first day your dependent incurs a covered expense for orthodontia and extends for a period of 24 consecutive months or less if the treatment is completed in less time. The orthodontic benefit is NOT included in the yearly dental maximum.

What are covered orthodontic expenses?

*The Initial work up: $142 *The diagnosis and insertion of the initial appliance; Once, up to $900*. *$100* per active monthly visit with a maximum of 24 consecutive visits. If your dependent misses a monthly visit, the Fund will not reimburse for that month but it will be counted toward the 24 consecutive visits. *Effective January 2009 Please note that the initial work up and the initial appliance are reimbursed only once during a period of orthodontic treatment.

Participating Providers are dental care providers who have agreed to provide covered dental procedures at No out-of-pocket expense to Fund members and their eligible dependents. We have selected participants in the dental care panel who have agreed to accept the Fund’s fee schedule as PAYMENT IN FULL FOR COVERED SERVICES. In addition, we have sought out providers who have treated Fund members in the past. The Fund does not recommend the services of any particular provider.

Please remember that Fund members and their dependents are still subject to annual and lifetime coverage limits as specified in the dental plan description. The only time that you will have to make a payment is for procedures that are not covered and for procedures performed after you have reached the annual maximum.

If, for any reason you encounter any irregularity or trouble with the services provided by a participating dentist, please contact our Dental Plan Administrator, Daniel H. Cook Associates, Inc., at (212) 505-5050.

Also, contact the Dental Plan Administrator if you are charged for any covered service. DO NOT PAY ANY SUCH CHARGE.

What is Pre-Authorization?

When a dentist’s charges for a course of treatment will amount to $500 OR MORE, dental services must be authorized by the Fund before treatment is provided. Pre-authorization by the Fund’s dental consultant is required for any proposed course of treatment in which a dentist’s charges will amount to $500 or more. X-rays must be included with treatment plans submitted for pre-authorization.

Preauthorization by the Fund’s dental consultant is limited to the approval of the course of treatment proposed; it does not include approval of payment for services not covered under the dental plan, nor is it a determination of the patient’s eligibility or of the amount to be paid under the Fund’s dental schedule.

The covered member’s or eligible dependent’s dentist is required to submit x-rays and a treatment plan to the Fund Office for review by the Fund’s dental consultant no later than 30 days after the initial examination. A claim submitted for pre-authorization will be returned to the dentist indicating the preauthorization decision. Your dentist should contact you upon receipt of the claim form. The dentist may proceed to provide dental services as soon as the treatment plan has been authorized by the Fund. The Fund reserves the right to modify or deny payment of claims amounting to $500 or more which have not been approved by the Fund before the beginning of treatment.

How do you submit a claim?

Claim forms are available at the Fund office and/or your delegate. The forms themselves provide instructions concerning proper filing. Read these forms carefully and entirely. When you have a claim, you should promptly submit the completed claim form. Claims submitted 90 days after completion of dental services will be denied. It may become necessary to require additional proof or information concerning a particular claim, and therefore the Fund reserves the right to require such proof or information, including but not limited to any or all of the following:

• A dental chart showing work done before the treatment for which claim is made.
• X-rays, lab or hospital reports.
• Cast molds or other evidence of the dental condition or treatment.
• Post-treatment examination of the patient, at the Fund’s expense, by a dentist it selects.

How are your benefits affected by the alternate benefit provision?

When more than one dental service would provide suitable treatment, your benefits will be based on the treatment determined by the Fund to be best suited to your condition by accepted standards of dental practice. If two services provide satisfactory results according to accepted standards of dental practice and one service is less expensive than the other, the Fund will reimburse up to the scheduled allowance for the less expensive treatment.

Exclusions

Benefits will not be paid for charges for:

• treatment from anyone other than a licensed dentist or physician, except routine cleaning of teeth and fluoride application which is performed by a licensed dental hygienist under the direct supervision of, and billed by, a dentist or physician
• facings, veneers, or similar material placed on molar crowns or pontics
• services performed by a member of your or your spouse’s immediate family, unless acceptable proof of payment is provided for those services
• services or supplies that are cosmetic in nature or directed toward a cosmetic end
• any service or supplies incurred, installed, or delivered before you or your dependent(s) become eligible for benefits from this Fund
• replacing a lost, missing or stolen prosthetic appliance
• a broken appointment
• any service that is not medically necessary or is not normally performed for proper dental care of the condition or any service that is not approved by the attending dentist
• services or supplies that do not meet accepted standards of dental practice including experimental or investigational services or supplies
• services or supplies received as a result of dental disease, defect, or injury due to an act of war, declared or undeclared
• any duplicate prosthetic appliance except as specifically provided
• completing claim forms
• oral hygiene, or dietary instruction or plaque control programs
• wiring or bonding teeth or crowns to act as a splint for any reason
• an injury arising from employment
• illness covered by Workers’ Compensation
• services or supplies for which you are not required to pay
• appliances, restorations, or any procedure to alter vertical dimension for cosmetic purposes
• services or supplies not specifically listed under covered expenses

Dental Fee Schedule

What is Dentcare(Healthplex)?

Dentcare (Healthplex), a DMO, is a prepaid, insured dental plan provided by Dentcare Delivery Systems. Under this plan, services are provided by Dentcare’s network of dentists.

How do you enroll for the Dentcare Plan?

On an annual basis through the Fund Office. All members will be notified of the open enrollment period.

Please call Member Services at 800-468-0600 to obtain your Member ID then go to http://www.yourdentalplan.com/healthplex to register/create an account to access the Member portal.

Dentcare/HealthPlex - Group # 1735498 

How do you select a dentist?

You must choose from a listing of Dentcare’s affiliated providers. This selected dentist will service you and your eligible dependents. You must use an affiliated dentist in order to receive benefits under this plan. Should you or your eligible dependents go outside the Dentcare network, you will be fully responsible for any fees incurred.

To view a list of participating providers please visit http://www.yourdentalplan.com/healthplex:

1. Under "Find Your Dentist", look for "In-Network Dentists / Find a local dentist or dental care in your area", then click Find Dentist; 
2. In the "Select You Plan Type" popup, select Dentcare Commercial; 
3. In the "Select a Network" pulldown, select DHMO Comprehensive; 
4. Next to "Search for Dentist", enter search criteria.

What if you need a specialist?

Referrals to Dentcare screened specialists are handled only through your Dentcare affiliated provider either at his/her office or at conveniently located sites.

Do you have to change dentists if your present dentist is not a listed provider?

Yes. It is important to note that under this option, care provided by a non-participating dentist is NOT covered, unless arranged for by Dentcare.

Can we change our Dentcare dentist?

Yes, but only during an open enrollment period.

What happens in the case of an emergency?

In cases of emergency, you are covered for a maximum of two visits per member per contract year for services rendered by an affiliated provider. However, if you have had regular check-ups, or are undergoing treatment, the two visit limitation will be waived. If the emergency occurs out-of-area, or in the unlikely event you are unable to reach an affiliated provider, you will be reimbursed up to $25 per family member per contract year, upon presentation of bills for palliative care rendered by a non-participating dentist until treatment can be obtained from your participating provider. In the event you are unable to reach your own affiliated dentist, DENTCARE provides 24-hour emergency service operators. EMERGENCY REFERRAL 24 HOUR SERVICE (516) 794-3000 (800) 468-0600

Is there a claim review procedure?

Yes. Pre-certification by a Plan Dentist with the approval of the Dental Plan Director is necessary before any prosthetic services will be provided.

What are the exclusions and limitations?

Benefits shall not be provided for:

• Any dental services which were not rendered, prescribed, arranged, or approved by plan dentist except in cases arising out of a dental emergency.
• General anesthesia.
• Consultation by non-Plan Dentists unless specifically directed by Dentcare.
• Any dental procedures which are undertaken primarily for cosmetic reasons.
• Any service or appliance unless required in accordance with accepted standards of dental practice.
• Prosthetic benefits are not covered where in the view of the Plan Dentist, sound restorations can be achieved by amalgam or alternative methods.
• Replacements or substitutions of appliances supplied by Plan until five (5) years have elapsed.
• Services or appliances used solely as an adjunct to periodontal care or for some cosmetic purposes.
• Implants, sealants and other services not listed in the Schedule of Benefits.
• More than two (2) oral examinations and oral prophylaxis (cleaning, scaling and polishing of teeth) per member per year. (Once every six months).
• Orthodontia – Lost or Broken Appliance – There is a charge of $100.00 to replace appliance under the Comprehensive Option.
• Broken Appointments – If specified by Plan Dentist for appointments not canceled 24 hours in advance, there is a $30.00 charge.
• Dentures, crown, inlays, onlays, bridgework or other appliances or procedures altering vertical dimension, restoring or maintaining occlusion, splinting or replacing tooth structure lost by abrasion or attrition, or treatment or a temporo-mandibular joint disturbance.
• A new denture or bridgework if the existing denture or bridgework can be made serviceable.
• Orthodontic services for eligible dependent children consisting of the necessary diagnosis and treatment of class 2 and 3 malocclusions which cause interference with normal function.