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Dental Plan Details
Calendar Year
Deductible
$50.00 per individual for Type
I (Basic) and Type II (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 80-90-100% U&C*. $50.00
deductible applies.
• Sealants (Under age
17)
• Anesthesia
• Limited Exams (Problem Focused)
• Oral Surgery - Complex Extractions
• Denture Repair
• Oral Surgery - Simple Extractions
• Restorative Amalgam & Resin
(excluding inlays & crowns)
Type II - Major Procedures
Type II Benefits are payable at 50% U&C* $50.00
deductible applies.
• Endodontics (Root
Canal)
• Restorative - Crown
• Periodontics (Gum Disease)
• Crown Repair
• Crowns - Stainless Steel
• Prosthodontics - Removable Dentures,
Partials
• Prosthodontics - Fixed Pontics or
Abutments
Orthodontia
Paid at 50% U&C* with a $1,000
lifetime maximum per person. No deductible applies.
Annual Maximum Benefit
Type I, II and III Procedures -$1,000
per calendar year per person.
Orthodontia Procedures -$1,000 Lifetime per person.
*This plan includes a maximum carryover for dental. Each insured (employee and/or dependent) will qualify for a dental maximum carryover if they:
1. Visit a dentist between January 1 and
December 31 of the plan year.
2. Submit a claim for payment prior to March 1 of the following year.
3. Total benefits paid for the Calendar Year must be less than $500.
If you meet all 3 requirements
you will have an additional $250 available in the Annual Dental Maximum for the
next plan year. In future years if you have benefits
paid of less than $500, additional amounts of $250 will be added to the
carryover. However, the most you can accumulate in the maximum carryover is
$1,000. Therefore, the maximum annual benefit may never exceed $2,000 in any one
year.
Eligible Employees
You
are eligible for insurance if you are a full-time active employee working at
least 30 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.)
100% Preventive, 80-90-100%
Incentive
Everyone insured on the effective date of the Company's policy begins
with 100% coinsurance for Type 1 (Preventive) and 80% coinsurance level for
Type II (Basic) procedures and will remain at that level until the next
January 1.
If you visit a dentist during each Calendar Year and have at least one covered dental procedure performed while insured under the Company's policy, your Type II (Basic) procedures will advance to the 90% level on the following January 1 and to 100% on the next January 1. Your Type II (Basic) procedures will remain at 100% each year as long as you visit a dentist during each subsequent calendar year and have at least one covered dental procedure performed while insured under the Company's policy.
If you do not have at least one covered dental procedure performed during any calendar year while insured under the Company's policy, you will revert back to 80% coinsurance level during the next calendar year and must begin to progressively advance to the next levels as described above.
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.
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.
Late Entrant
If you do not elect to participate in the dental program when first
eligible, you will be considered a Late Entrant and you must wait 12
months for most benefits. If an employee or dependent does not elect to
participate when initially eligible, and elects to participate at the
policyholders next annual election period, they will become a Late Entrant.
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.
Certificate of Insurance
The Certificate of Insurance issued to you describes in detail the benefits
and limitations of this plan. This brochure is for general information only.
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.
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.
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.
Monthly Dental Rates
|
Employee |
$ 0.00 (Paid by Davidson County) |
|
Employee + Spouse |
$50.30 |
|
Employee + Child(ren) |
$53.48 |
|
Employee + Family |
$103.78 |
*Usual and Customary
