Human Resources: Benefits

What You Need to Know About Your Dental Care Benefits

More and more, research is finding that good dental hygiene is directly related to good overall physical health. Your dental benefits are an important part of your total compensation package and help reduce your cost for necessary dental expenses. BGSU Dental Plan is fully insured with Delta Dental and is called DeltaPreferred Options USA. These benefits under the Dental Plan enable you and your covered eligible family members to obtain proper dental care when needed.

Your Dental Care Benefits at a Glance - for more detailed information see  

Summary of Benefits  or DeltaPreferred Option USA point of service Certificate

• Maximum calendar year benefit per participant	$1,500
  Calendar year individual deductible	$ 50
  Maximum orthodontic lifetime benefit per participant (for dependent children under age 19)	$1000

   

Eligibility

Employees

If you are a regular, full time employee eligible for coverage under the BGSU Health Care Program and elect to participate in one of the optional Medical Plans, you are also covered under the Dental Care Plan. Eligibility requirements are explained in Section I of this information.

Dependents

The Dental Plan extends coverage to your eligible dependents if you are an eligible employee and employee plus dependent and or you elect family coverage under one the optional Medical Plan. A dependent must meet the definitions and requirements described under Dependent Coverage in Section I of this information.

Your Dental Care Benefits

Introduction

This section details the dental procedures and services the Plan pays for and those it does not. The lists of dental procedures and services which appear under Covered Dental Expenses and Dental Limitations and Exclusions are extensive but not all inclusive. Because the technical words for dental procedures and services are complicated and hard to identify, we encourage you to call the BGSU Benefits Office or Medical Mutual of Ohio with any questions you may have about your dental coverage.

Please share this section with your family so that they also may use their dental benefit to its fullest advantage.

Contributions

The contribution amount indicated for The Medical Plan includes dental benefits.

Deductible

Before dental benefits are payable, each individual covered under the plan must pay a $50 calendar year deductible. The deductible applies to all services except preventive and orthodontic services, which require no deductible.

Coinsurance

After you and your dependents each satisfy the $50 deductible, the Plan pays benefits for covered dental expenses as follows:

 Summary Chart

• Type of Service	Coinsurance Amounts
  Class I Benefits (no deductible)	Covered at 100% (see A.)
  Class II Benefits	Covered at 80% (see A)
  Class III Benefits	Covered at 50% (see A)
  Orthodontic Services (no deductible) per eligible dependent to age 19	Covered at 50% (see A) up to a maximum lifetime $1000
  	(A) When using a DPO dentist covered at 100%, 80%, or 50% of the submitted fee or the DPO dentist schedule whichever is less. When using a DeltaPremier dentist covered at 100%, 80% or 50% of the submitted fee or Delta Dental's UCR whichever is less. When using a dentist who does not participate with Delta Dental covered at100%, 80% or 50% of dentist submitted fee or Delta Dental's nonparticipating fee whichever is less. If nonparticipating fee allowance is less than the submitted fee, you will be responsible for the difference in the submitted fee and the allowed fee, in addition to the applicable co-pay percentage and deductible, if any.

Maximum Benefit Paid

The maximum benefit paid under the Plan for all covered dental expenses is $1,500 per calendar year. This maximum applies for each covered person.

The Plan only covers orthodontic treatment for dependent children under the age of 19. Payment for orthodontic treatment is limited to a lifetime maximum of $1000 for each eligible dependent.

Benefit Verification

If eligible expenses for dental treatment are expected to exceed $200, it is recommended that a benefit predetermination be made before the service is rendered. The dentist should submit an estimated cost for the proposed treatment including diagnostic materials, x-rays and models. All predetermination requests should be sent to:

• Delta Dental
  P.O. Box 30416
  Lansing, MI 48909-7916

   

Once Delta Dental reviews the Dental Plan predetermination request, the dentist and employee are notified of how charges are covered under the Plan. Following these procedures ensures you receive appropriate dental care in the most cost-effective manner. Predetermination does not guarantee payment. Payment is subject to Plan limitations upon final submission of the claim.

Covered Dental Expenses

Class I - Preventative Services

The following preventive services are not subject to the deductible - refer to Summary Cart above or to Certificate: 

• Routine oral examinations with a limit of two exams per calendar year; 
• Teeth and periodontal cleanings limited to two treatments in any calendar year; 
• Topical application of fluoride, limited to two treatments per calendar year for children up to age 19; 
• Bitewing x-rays, limited to one sets per calendar year; 
• Full mouth x-ray with supplemental bitewing once every 36 months; 
• Tests and lab exams; 
• Installation of space maintainers for children under age 19; 
• Sealants for children up to age 14; and 
• Emergency treatment to relieve dental pain. 

  Class II

The following services are covered under Class II Benefits and are subject to the deductible- refer to Summary Chart above and to  Certificate

• Professional visits and examinations; 
• Filling of cavities; 
• Endodontic treatment, including root canal therapy; 
• Periodontal scaling; 
• Simple extractions; 
• Anesthetics; 
• Full or partial denture repairs; 
• Denture adjustments within six months after installation; and 
• Denture relining.
• Dental oral surgery

  Class III

The following services are covered under Class III Benefits and are subject to the deductible- refer to Summary Chart above and to Certificate

• Adding teeth to a partial denture; 
• Inlays and onlays; 
• Crowns and crown restoration; 
• Fixed bridgework (initial installation); and 
• Dentures and partials. 

  Orthodontic Treatment -Class IV

The Dental Care Plan pays for orthodontic treatment if the services are provided to your eligible dependent children under the age of 19. No deductible is required for orthodontic services. Each covered dependent is limited to a $1000 LIFETIME maximum benefit.

  Dental Limitation and Exclusions - See Certificate

Although the Plan pays for a wide range of dental procedures, some procedures are not covered, while payment of others is limited. This listing is not meant to be all inclusive. Benefits for services, supplies or charges are not provided which:

• Are not furnished by a dentist unless they are performed by a licensed dental hygienist under the supervision of a dentist; 
• Do not meet the standards set by the American Dental Association; 
• Are due to the loss or theft of an appliance; 
• Are from a health department maintained by an employer, a trustee or a similar type of service; 
• Are for myofuntional therapy, for an athletic mouthguard or for a duplicate prosthetic appliance; 
• Relate to porcelain veneered crowns or pontics placed on or in place of a tooth behind the second bicuspid; 
• Are for dentures, bridges, periodontal treatment or for orthodontic diagnosis and its evaluation and precare started before the date you became eligible under the Plan; 
• Are related to replacing prosthetic appliances more often than once within five years of installation; 
• Pertain to the initial placement of prosthetic appliances if it includes replacement of one or more natural teeth missing before you were covered under the Plan, unless the natural tooth is: 
  • Removed while you are covered under the Medical and Dental Care Plan; or 
  • Not next to the prosthetic appliance installed during the prior five years; 
• Pertain to charges which are not listed as covered services in this section, unless the unlisted service is a professionally acceptable alternative to a covered service. The charge is covered as if the covered service was rendered. 
• Are above usual, customary and reasonable (UCR) charges; 
• Are for appliances, restorations or procedures needed to alter vertical dimensions, restore occlusion or correct splitting, attrition or abrasion; 
• Are for orthodontic treatment which began before your dependent's effective date of coverage; 
• Are for cosmetic surgery or cosmetic reasons including tooth bonding and bleaching unless as a result of injury to teeth; 
• Replace an existing denture which is functional or which can be made functional; 
• Replace lost, stolen, or duplicate appliances, dentures or bridgework within five years of initial installation; 
• Are charges for services and supplies for which you receive or are entitled to receive, whether by settlement or adjudication, any benefit under the Workers' Compensation, Occupational Disease or other similar law; 
• Are due to injury resulting from or occurring during a crime committed by the covered person; 
• Which are not specified as covered services; and 
• Injectable antibiotics.
• Implants

1.  

   Note:  TMJ is not a covered dental service. This service is covered under the Medical Plan.

    

   Important Information to Help You Use Your Dental Care Plan

   How to File a Claim

   For payment of your covered dental expenses, it is necessary to have a claim form submitted within one year of the date the expenses are incurred. Claims, adjustments, and completed information requests should be mailed to: Delta Dental, P.O. Box 9085, Farmington Hills, Michigan 48333-9085

   Coordination of benefits (COB), subrogation, continuation of coverage (COBRA), and termination of coverage under the Dental care Benefits are the same as the Medical Plan. See Section VI for details.

    

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