Teamsters Local 805 Welfare Fund

SUMMARY PLAN DESCRIPTION -

DENTAL BENEFITS

A. GENERAL BENEFITS PROVIDED AND COMMENCEMENT

The Dental benefits pays up to the amounts shown in the Schedule of Covered Dental Expenses. Covered Dental Expenses included under the Plan are the charges of a dentist which a Participant is required to pay for dental services listed in the Schedule of Covered Dental Services and received while coverage is in effect.

For each service, however, the Covered Dental Expense will not be more than the amount set forth in the Schedule for the particular dental service. If the charges are less than the Schedule amount for a particular service, the amount included as a Covered Dental Expense will equal the actual charges.

B. ALTERNATIVE BENEFIT PROVISION

When more than one dental service could provide suitable treatment based on common dental standards, the Fund will determine the dental service on which payment will be made and the expenses that will be included as Covered Expenses.

C. PRIOR APPROVAL
Treatment plans for dental services expenses of $250.00 must be submitted to Healthplex for prior approval before the services are performed.

For any treatment plans anticipated to be in excess of $250.00, your Dentist must submit appropriate diagnostic X-rays and a detailed treatment plan along with your certified claim form to the Fund Office prior to performing any work.

The Fund reserves the right to make a determination of benefits payable, taking into account alternative procedures based on accepted standards of dental practice. To the extent that your treatment plan does not comply with generally accepted standards of dental practice, the Fund reserves the right to reduce or eliminate benefits which would have otherwise been covered expenses.

Pre-determination of benefits by the Fund does not guarantee payment. The estimate of benefits payable may change based on the benefits a person qualifies for at the time services are completed. In order to receive dental coverage, you must satisfy the plan eligibility criteria at the time services are rendered.

D. MANAGED CARE OPTION

The Plan provides all members the right to enroll in the Dentcare Managed Care option program with HealthPlex’s DentCare program.

Under the Managed Care Option, you are asked to select a dentist from the Affiliated Provider List. This dentist will provide you with all necessary care, referring you to a wide range of specialists should it become necessary. It is important to note that under this option, care provided by a non-participating dentist is NOT covered, unless arranged for by DENTCARE.

All of their affiliated dental providers undergo a rigorous selection process, meeting rigid requirements as to professional standards, office cleanliness, sufficient and qualified staff and modern equipment. Panel locations have been selected with a view to provide coverage in nearly all geographical areas.

Advantages:

• Reduces out-of-pocket expenses in most cases.
• No forms to complete.
• Specialty services covered by participating specialists.
• No deductibles or maximums.

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 dentils, DENTCARE provided 24-hour emergency service operators:

EMERGENCY REFERRAL – 24 HOUR SERVICE: 1-800-468-0600
TTY 1-800-662-1220

The Plan will mail election forms each year for you to decide which option you wish to receive, the Managed Care Option or the Standard Reimbursement Option as described in the remainder of this section. It is up to you to decide what option is the best for you and your family.

E. STANDARD REIMBURSEMENT OPTION

The Plan provides for free choice of dentists. However, Healthplex has provided a network of conveniently located dental offices that will treat Fund members with minimal out-of-pocket expense for most covered services. When a member or eligible dependent receives services from one of these participating general dental offices, he/she will only be responsible for the patient co-payment. These dental offices have agreed to accept the amounts allowed plus the patient co-payment as payment in full.

If a member or eligible dependent elects to receive services at a non-participating dental office, he/she will be responsible for all charges in excess of the Plan Reimbursements shown in the “Out of Network” column.

There is no deductible and no annual maximum. However, there is a $2,240 lifetime Orthodontic maximum.

F. SPECIAL LIMITATIONS APPLICABLE TO SPECIFIC DENTAL SERVICES

G. SCHEDULE OF COVERED DENTAL EXPENSES

A sample fee schedule is provided to all members upon initial enrollment and may be requested from the Fund or Healthplex/DentCare at any time.

H. DENTAL EXPENSES NOT COVERED

In addition to the General Exclusions set forth on page 54, no payment will be made for:

• Services performed for cosmetic reasons;
• Replacement of a lost or stolen appliance;
• Replacement for a crown, bridge or removable denture within three years of the original insertions;
• Any replacement of a bridge, crown, or denture which can be made usable according to common dental standards;
• Procedures, appliances or restorations whose main purpose is to:
  • i. Change vertical dimension
  • ii. Diagnose or treat TMJ dysfunction
  • iii. Stabilize periodontally involved teeth
  • iv. Restore occlusion
• Bite registrations, precision or semi-precision attachments or splinting;
• Removal of third molars where there is no evidence of disease;
• Instructions for plaque control, oral hygiene, diet;
• Any Experimental procedure not approved by the American Dental Association;
• Expenses incurred by the Participant or dependents, to the extent that benefits are payable through "no-fault" insurance law or an uninsured motorist law for such expenses;
• Any services from a dental department of an employer, a benefit association, labor union, trustee or other similar group;
• Any services for which the Participant or dependent incurs no charge, services usually done by an M.D., or charges which would not have been made if there was no insurance;
• Any services done by a dentist to himself or herself or his or her immediate family including parents, spouse and children;
• Any services done due to occlusal wear, erosion, abrasion, attrition and/or surface defects of the teeth or to amend vertical spacing;
• Orthodontia for patients over 19;
• Any dental services, which were not rendered or approved by a participating dentist except in cases of out-of-area dental emergency. (Managed Care Only);
• Treatment of a disease, defect, or injury covered by a major medical plan, Worker’s Compensation Law occupational disease law, or similar legislation;
• General anesthesia, analgesia or any service rendered in a hospital environment;
• Implants, grafts, precision attachments or other personalized restorations or specialized techniques;
• Treatment of unmanageable children and/or unruly patients;
• Any supply meant for home use (e.g. toothbrush, floss, mouthwash, etc);
• Charges for the failure to keep an appointment with the Dentist;
• Services or procedures which are not completed prior to submission of a claim;
• Charges by a Dentist for completing dental forms or for complying with OSHA guidelines;
• Restorations, crowns or fixed prosthetics when acceptable results can be achieved with alternative methods or materials. In cases where the selection of a more expensive treatment plan is decided upon, the plan will allow for the least costly alternative and the patient is responsible for all additional fees charged by the dentist.