Teamsters Local 251 Health Services & Insurance Plan

SECTION SIX: Dental Benefits

Healthy teeth and gums are important to your well being. That's why the Plan provides 100% coverage for preventive and diagnostic dental treatment when you visit a participating Delta Dental provider. Dental benefits are not covered as part of your HealthMate Coast to Coast coverage.

You do not have to meet a deductible to receive dental care.
The Delta Dental network gives you the freedom to choose a dentist in or out of the network and still receive benefits.
You and your eligible dependents are covered at 50% of the allowance for Othodontia, up to a lifetime maximum of $2,000 per covered person.

What You Need To Do:

To get the most value for yourself and the Fund, find a dentist who participates in the network. You may contact the Fund Office, or log on to the Delta Dental website at www.deltadentalri.com to find a Delta Dental provider near you.
Show your Delta Dental ID card at the time of your appointment to receive the discounted rate for services.

Delta Dental

Your dental program is administered by Delta Dental's nationwide DeltaUSA program. That means you have access to the largest dental network in the country — more than 108,000 dentists participate in all 50 states. Dentists who belong to one of DeltaUSA's networks agree to a negotiated fee for services and handle all claim filings and paperwork for you.

Your benefits are paid according to an allowance — a pre-negotiated rate for services. When you receive treatment from a participating Delta Dental provider, the provider accepts the allowance as payment in full. You are only responsible for your coinsurance, if any applies.

Your Dental Benefits At A Glance

Preventive/Diagnostic/Minor Restorative Includes one oral exam per calendar year, two cleanings per calendar year, x-rays and fillings	100% of the allowance
Major Restorative Includes extractions and root canals	100% of the allowance
Major Restorative Crowns	80% of the allowance
Periodontics	80% of the allowance
Implants	50% of the allowance to a lifetime maximum of $3,500
Prosthodontics Includes bridges and partial and complete dentures	80% of the allowance
Orthodontics	50% of the allowance to a lifetime maximum of $2,000 per covered person

Annual Maximum Dental Benefit

The Plan will pay up to $1,800 per covered person per year.

Out-of-Network benefits

Of course, you are free to visit any dentist you'd like, even one that does not participate in the network. If you receive dental care from an out-of-network provider, you may have to pay the entire cost at the time you receive services, and you may have to file your own claim form to receive reimbursement. Ask the dentist to complete a standard American Dental Association claim form and mail it to:

Delta Dental of Rhode Island
P.O. Box 1517
Providence, RI 02907-1517

Filing Your Claims

Dental claims must be filed within one year of the date of service in order to be considered for payment.

You will have to pay any amount that the dentist charges above the allowance amount. In other words, the Plan will only reimburse you for the amount that a Delta Dental provider would have charged.

For Example: Jim needs to have some dental work done. The chart below shows Jim's out-of-pocket expenses if he uses a Delta Dental provider, or a provider who does not participate in the network.

	Delta Dental Dentist	Out-of-Network Dentist
Cost	The Plan pays 100% of the allowance for the treatment Jim needs. The Plan has negotiated with Delta Dental for a rate of $200 for these services.	The Plan Pays 100% of the allowance for Jim's treatment. Jim's out-of-network provider charges $250 for these services.
Payment	The Plan pays the entire cost of $200.	The Plan pays 100% of the allowance, or $200. Jim must pay the difference between the out-of-network rate and the allowance — $50.
Claim Forms	The Delta Dental dentist files Jim's claim forms.	Jim may need to file his own claim forms.
Jim's out-of-pocket costs	$0	$50

Emergency Coverage

If you have an urgent dental condition, you should seek treatment at the nearest dentist's office, regardless of whether the dentist participates in the Delta Dental network. You do not need prior approval before seeking treatment, however, if you seek care from a non-network dentist, Delta Dental will only pay for covered benefits, up to the allowance. You will be responsible for any amount the provider charges above the Delta Dental allowance.

Pre-Treatment Authorization

If your dentist recommends treatment that is expected to cost $300 or more, it is recommended that your dentist file a pre-treatment estimate with Delta Dental for review. Delta Dental will determine how much of the treatment will be covered under the Plan so that you will know your out-of-pocket costs in advance.

What's Not Covered

The Plan does not cover dental services:

If services do not qualify for payment under the Plan according to Delta Dental's guidelines. A service may not qualify for coverage under these guidelines even though it was furnished or recommended by a dentist.
Unless specifically covered in the Plan's Certificate of Coverage.
Received from a dental or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trustee or similar person or group.
For an illness or injury that Delta Dental determines arose out of and in the course of employment.
For which you are not required to pay, or for which you would not be required to pay if you did not have Delta Dental coverage.
For an illness, injury or dental condition for which benefits in one form or another are available, in whole or in part, thorough a government program or would have been available if you did not have coverage through Delta Dental.
Rendered by someone other than a licensed dentist or a licensed hygienist if operating as authorized by applicable law.
For consultations.
For specialty oral exams (exams provided by endodontists, periodontists, oral surgeons, orthodontists or prosthodontists),
To treat temporomandibular joints (TMJ);
To increase the height of teeth (vertical dimension) or restore occlusion.
For restorations for reason other than decay or fracture, such as erosion, abrasion or attrition.
That are meant primarily to change or improve your appearance.
For occlusal guards and splints.
For bone grafts and transplants.
To stabilize teeth when required due to disease such as periodontal splinting.
For any lab exams or reports.
For temporary, complete dentures and temporary, fixed bridges or crowns.
Related to congenital anomalies other than for orthodontic services that may be covered by the Plan's orthodontic rider.
For prescription drugs.
For general anesthesia for non-surgical extractions, diagnostic, preventive or minor restorative services, including anesthesiologist fees.
For more than one crown on the same tooth; partial or complete denture in the same arch or more than one fixed bridge in the same arch, space maintainers or orthodontic appliance in a five-year period.

Delta Dental also reserves the right to adopt and to apply administrative policies when reasonable in approving the eligibility of members and the appropriateness of treatment plans and related charges.