Asheville City Schools, NC | Plan Year: October 1, 2008 to September 30, 2009
   
 

Dental Plan
 

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Dental Plan Details
 

Rates

     
 

Ameritas Dental

  
     
 

 
 

 
     
     
 

Please call your Personnel Office for
all questions concerning this plan.

  
     
     

 

 

Dental Plan Details

Combined Calendar Year Deductible
$50.00 per individual for Type II (Basic) and Type III (Major) Procedures

3 times family limit - After the date that 3 members of a family have each satisfied their individual deductible, the entire deductible or any remaining portion of the deductible for any family member will be waived for the rest of that calendar year.

Type I - Preventive and Diagnostic - Type I benefits are payable at 100% U&C*. No deductible applies.
• Evaluations ( Two per benefit period) 
• Space Maintainers
• Cleanings (Two per benefit period) 
• Radiographs (X-rays)
• Fluoride for Children (Under age 19) 
• Bitewings (Two per benefit period)

Type II - Basic Procedures - Type II benefits are payable at 80% U&C*. $50.00 deductible applies.
• Sealants (Age 16 and under) 
• Anesthesia
• Limited Exams - problem focused
• Oral Surgery - Complex Extractions
• Denture Repair 
• Oral Surgery - Simple Extractions
• Restorative Amalgam

Type III - Major Procedures - Type III Benefits are payable at 50% U&C*. $50.00 deductible applies.
• Endodontics (Root Canal)
• Crown Repair
• Endodontics (Apicoectomy)
• Restorative - Crowns
• Periodontics (Non Surgical)
• Periodontics -(Surgical)
• Prosthodontics- Fixed Pontics or Abutments
• Prosthodontics - Removable Dentures, Partials

OrthodontiA (Children and adults)
• Paid at 50% U&C*.
• No deductible applies.
• $1,000 Lifetime maximum per person.

Annual Maximum benefit
• Applies to Type II and Type III Procedures
• $1,000 per calendar year per person

Dental Exclusions (deferment Period)
During the first 36 months following your or your dependent’s Dental Coverage Effective Date, the initial placement of dentures, partial dentures, or bridges, if it includes the replacement of teeth all of which are missing prior to the effective date. (For currently covered insureds, Ameritas will use the employees Date of Hire to determine the 36 month period.) This exclusion will not apply if the prosthesis replaces a sound natural tooth which is extracted while the patient is insured under this Dental Coverage and which is replaced within 12 months of the extraction. During the first 36 months of coverage, the replacement of bridges, partial dentures, dentures, inlays or crowns is excluded.

Exceptions to this exclusion will be made if the replacement is made necessary by: a) accidental bodily injury to sound natural teeth (chewing injuries are not considered accidental bodily injuries), or b) the extraction of a sound natural tooth provided the replacement is completed within 12 months of the date of the injury or extraction.

Annual Maximum Carryover
1. Visit a dentist between January 1 and December 31 of each year.
2. Submit a claim for a covered procedure prior to March 1 of the following year.
3. Total dental benefits paid for the calendar year must be less than $500.00

If you meet all 3 requirements then you will be eligible for the Annual Maximum Carryover benefit. This benefit will provide you with an additional $250 towards your annual dental maximum for the following year. In future years, if you continue to meet these requirements you will continue to see an increase in your annual maximum by $250 until you have reached an annual maximum carryover limit of $1,000. This benefit allows you to accumulate up to a $2,000 annual dental maximum.

Eligible Employees
You are eligible for insurance if you are a full-time active employee working at least 20 hours per week.

ELIGIble Dependents
Provides Coverage On:
•Your Spouse
•Children up to age 19 and unmarried (Up to age 24 if wholly dependent upon you for maintenance and support and if enrolled as a full-time student in an accredited school or college.)

PREDETERMINATION OF BENEFITS
A treatment plan MAY be filed if a proposed course of treatment will exceed $200.00. With this information, Ameritas can determine the benefits payable under this policy prior to the work actually being done. It will give the insured the amount payable, along with an idea of the out of pocket expense.

Coordination of Benefits
If you or any of your dependents incur charges which are covered by any other group plan, the benefits of this plan will be coordinated with the benefits of the other plan so that the total benefits received are not greater than the charges incurred.

Section 125
This policy is provided as part of the Policyholder’s Section 125 Plan. Each member has the option under the Section 125 Plan of participating or not participating in this policy. A member may change their election only during an annual election period, except for a change in family status. Examples of such events would be marriage, divorce, birth of a child, death of a spouse or child or termination of employment. Please see your plan administrator for details.

Orthodontia Limitations (This is not a complete list)
No benefit is payable for expenses incurred:
• In connection with a Treatment Program which was begun before the individual became insured for orthodontic benefits.
• During any quarter of a Treatment Program if the individual was not continuously insured for orthodontic benefits for the entire quarter.
• After the individual’s insurance for orthodontic benefits terminates.

Late entrant
If you or your dependents do not elect to participate in the dental plan when first eligible, you will be considered a Late Entrant and you must wait 12 months for most procedures. For a Late Entrant, benefits will be limited to exams, cleanings, and fluoride treatments. The late entrant provision is waived if the employee comes on the plan as a result of a qualifying event.

Limitations/Exclusions (This is not a complete List)
• For any treatment which is for cosmetic purposes. Facings on crowns or pontics behind the 2nd bicuspid are considered cosmetic.
• Charges incurred prior to the date the individual became insured under this plan, or following the date of termination of coverage.
• Services which are not recommended by a dentist or which are not required for necessary care and treatment.
• Expenses incurred to replace lost or stolen appliances.
• Expenses incurred by an insured because of a sickness for which he /she is eligible for benefits under Worker’s Compensation Act or similar laws.
 

 

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Monthly Rates

Employee Only

$35.79

Employee & Child(ren)

$66.15

Employee & Spouse 

$61.69

Employee & Family

$92.04

 

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*Usual & Customary charges