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The City of Kannapolis, NC | Plan Year: July 1, 2008 - June 30, 2009
   
 

Dental Plan
   
  Dental Plan II
  Dental Plan III

     
 

Plan Sponsored by:

NCLM Risk Management Services
P O Box 1310
Raleigh, NC 27602

Plan Supervised by:

CIGNA HealthCare
P O Box 182534
Chattanooga, TN 37422-7534

Claims Filing Address:

CIGNA HealthCare
P O Box 182534
Chattanooga, TN 37422-7534

For Eligibility or claims questions call: 888-336-8258

Group Account # 3211260

 
     
 

 

Dental Plan II

Dental rates are pending North Carolina League of Municipalities Board of Director’s approval, which is anticipated for May.

*Limitations - Payment will be 50% of the normal allowed amount if the participant elects coverage for himself or a dependent more than one month after the date he or his dependent is eligible regardless of the enrollment reason, unless there is a qualifying event. The following dental services will be limited:

• Restorative
• Prosthetic
• Orthodontia (for governmental units which elected this benefit)

This provision will not apply to covered dental expenses which are incurred after the Participant or his dependent has been continuously covered for 12 months.

*See a complete list of limitations in Certificate Booklet.

Overall Calendar Year Deductible - $50.00 Individual; $100.00 Family Deductible does not apply to preventive services.

Maximum Calendar Year Benefit Per Insured for Preventive, Basic, and Major Services - $1,000.00

Preventive Services - Covered at 100% UCR.

• Prophylaxis- 2 per calendar year
• Fluoride (for dependent children under age 14, once a year)
• Oral Exams- 2 per calendar year
• Bitewings- 2 per calendar year; Panorex or Complete Series- once every 3 calendar years
• X-Rays
• Space Maintainers
• Sealants (for dependent children under age 14; for permanent teeth only; once every 3 years)

Basic Services - Covered at 80% UCR.
• Extractions, including wisdom teeth extractions
• Oral Surgery, including surgical extraction
• Amalgam, silicate, acrylic, synthetic, porcelain and composite filling restorations to restore diseased or fractured teeth
• General anesthetic- if determined to be medically or orally necessary
• Root canals and other endodontic treatment
• Periodontics
• Adjustments to partials or full dentures

Major Services - Covered at 50% UCR.
• Repair or recementing of crowns, inlays, onlays, bridgework or dentures, or relining or rebasing of dentures more than six months after the installation of an initial or replacement denture

• Initial installation of fixed bridgework, including inlays and crowns as abutments, except periodontal splinting
• Initial installation of partial or full removable dentures
• Replacement of an existing partial or full removable denture or fixed bridgework by a new denture or new bridgework, or the addition of teeth to an existing partial removable denture or to bridgework - please see limitations and exceptions in certificate booklet
• Inlays, onlays, gold fillings or crown restorations to restore diseased or fractured teeth, but only when the tooth, as a result of extensive caries or fracture cannot be restored to proper function with an amalgam, silicate, acrylic, synthetic, or porcelain composite restoration (see limitations)

Orthodontics - Children up to age 19 are eligible (if a full-time student between the age of 19 through age 25, coverage still applies). The deductible does apply.

Pre-Determination of benefits
If covered expenses for a course of treatment are expected to be more than $200, the Participant should submit a description of that course of treatment and an estimate of the Dentist’s charges to the Plan Supervisor prior to the commencement of treatment.

Special claims filing note: Claims must be filed within one year from the date covered expense is incurred.

Benefit Exclusions (by way of example but not limited to):

•Treatment by anyone other than a Dentist or Physician, except of performed by a duly qualified technician under the direction of a Dentist or Physician;

•Services performed solely for cosmetic reasons;

•Replacement of a lost or stolen appliance;

•Replacement of a bridge or denture within five years following the date of its original installation;

•Replacement of a bridge or denture which can be made useable according to dental standards;

•Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontal involved teeth, or restore occlusion;

•Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars;

•Bite registrations; precision or semi-precision attachments; splinting;

•Surgical implant of any type including any prosthetic device attached to it;

•Instruction for plaque control, oral hygiene and diet;

•Dental Services that do not meet common dental standards;

•Services that are deemed to be medical services;

•Services and supplies received from a hospital; medically necessary charges incurred by a participant during confinement in a hospital, including anesthetics, will be considered for payment as a medical expense.

•Charges which the person is not legally required to pay;

•Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service;

•Experimental or investigational procedures and treatments;

•Any injury resulting from, or in the course of, any employment for wage or profit;

•Any sickness covered under any workers’ compensation or similar law;

•Charges in excess of the reasonable and customary allowances;

•Reasonable and customary other than the 90th percentile

 

Monthly Rates - Plan II
Employee Only No Cost to Employee (City pays $24.50)
Employee & Spouse $24.50
Employee & Children $45.00
Family $54.00

 

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Dental Plan III

Dental rates are pending North Carolina League of Municipalities Board of Director’s approval, which is anticipated for May.

Plan III will be available if there is a minimum of 25 participants.

*Limitations - Payment will be 50% of the normal allowed amount if the participant elects coverage for himself or a dependent more than one month after the date he or his dependent is eligible regardless of the enrollment reason, unless there is a qualifying event. The following dental services will be limited:

• Restorative
• Prosthetic
• Orthodontia (for governmental units which elected this benefit)

This provision will not apply to covered dental expenses which are incurred after the Participant or his dependent has been continuously covered for 12 months.

Overall Calendar Year Deductible - $50.00 Individual; $100.00 Family Deductible does not apply to preventive services.

Maximum Calendar Year Benefit Per Insured for Preventive, Basic, and Major Services - $1,500.00

Preventive & DIAGNOSTIC CARE - Covered at 100% UCR.- no deductible

• Oral Exams (Two per Calendar Year)Cleanings (Two per Calendar Year)

• Full Mouth X-rays (One complete set every 3 Calendar Years)

• Bitewing X-rays (Two per Calendar Year)

• Panoramic X-ray (One per every 3 Calendar Years)

• Fluoride Application (One per Calendar Year, up to age 14)

• Space Maintainers (Limited to non-orthodontic treatment)

• Sealants (Limited to permanent posterior teeth, up to age 14)

• Emergency Care to relieve pain

Basic RESTORATIVE CARE - Covered at 80% UCR- after deductible

• Fillings Root

• Canal Therapy

• Osseous Surgery

• Periodontal Scaling and Root Planing

• Denture Adjustments and Repairs

• Extractions

• Anesthetics

• Oral Surgery

Major Restorative Care - Covered at 80% UCR- after deductible

• Crowns

• Dentures

• Bridges

Orthodontia - (Limited to dependent children through age 25). Covered at 50% after plan deductible. Lifetime Maximum is $1,000.

Missing Tooth Provision - Individual is covered at 50% until insured for 24 months.

Pre-Determination of benefits
If covered expenses for a course of treatment are expected to be more than $200, the Participant should submit a description of that course of treatment and an estimate of the Dentist’s charges to the Plan Supervisor prior to the commencement of treatment.

Special claims filing note: Claims must be filed within one year from the date covered expense is incurred.

Benefit Exclusions (by way of example but not limited to):

•Treatment by anyone other than a Dentist or Physician, except of performed by a duly qualified technician under the direction of a Dentist or Physician;

•Services performed solely for cosmetic reasons;

•Replacement of a lost or stolen appliance;

•Replacement of a bridge or denture within five years following the date of its original installation;

•Replacement of a bridge or denture which can be made useable according to dental standards;

•Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontal involved teeth, or restore occlusion;

•Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars;

•Bite registrations; precision or semi-precision attachments; splinting;

•Surgical implant of any type including any prosthetic device attached to it;

•Instruction for plaque control, oral hygiene and diet;

•Dental Services that do not meet common dental standards;

•Services that are deemed to be medical services;

•Services and supplies received from a hospital; medically necessary charges incurred by a participant during confinement in a hospital, including anesthetics, will be considered for payment as a medical expense.

•Charges which the person is not legally required to pay;

•Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service;

•Experimental or investigational procedures and treatments;

•Any injury resulting from, or in the course of, any employment for wage or profit;

•Any sickness covered under any workers’ compensation or similar law;

•Charges in excess of the reasonable and customary allowances;

•Reasonable and customary other than the 90th percentile

 

Monthly Rates - Plan III
Employee Only $8.50 (City pays $24.50)
Employee & Spouse $41.50
Employee & Children $67.50
Family $78.50

 

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