EmblemHealth Preferred Dental

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1 EmblemHealth Preferred Dental Unique coverage levels at affordable group rates. Here s how EmblemHealth Preferred Dental will deliver for you: Complete your benefits package with paid-infull* in-network dental coverage. Dental coverage only works if it delivers the things that matter most to you. EmblemHealth Preferred Dental can work for your group by delivering: Paid-in-full benefits* for covered preventive and diagnostic services received from network dentists and, after any applicable deductible is met, for other in-network services. Streamlined, hassle-free administration. Affordable rates that respect your budgetary needs, regardless of your group s size. * In-network coverage for preventive and diagnostic services is paid in full; other covered in-network services are paid in full after satisfaction of any applicable plan deductible(s) and until plan annual and/or lifetime benefit maximums are reached. Quality The EmblemHealth dental plans are built on GHI s half century of experience as a leading local dental insurer, with a strong, stable network established in GHI plans are the choice of more than half a million members in the New York region the best evidence of the quality of our coverage. Choice EmblemHealth Preferred Dental is available to groups of as few as two employees. If you have five or more employees you can choose to offer this plan as a voluntary option at $0 premium for you. Administrative services only (ASO) and flexible funding arrangements are available to large groups. And you have your choice of benefits designs. (See reverse for program details.) Affordability While many PPO dental plans cover in-network preventive services in full, EmblemHealth Preferred Dental takes coverage several steps further. Once any applicable deductible is met, complex procedures such as fillings, root canals, wisdom tooth extractions and related IV sedation, and periodontal services are paid at 100 percent when performed by network dentists with no additional out-of-pocket costs for your employees until applicable plan benefit maximums are met. Access to care With a fully credentialed PPO network of more than 6,100 general dentists and specialists in New York and New Jersey, EmblemHealth Preferred Dental allows your employees to see dentists and specialists without referrals. Ease Our track record for fast, efficient claims processing, online self-service capabilities for members and personalized Account Service for groups adds up to streamlined administration that takes the hassles out of dental coverage. The plan offers many member-friendly features, including the rollover of a portion of unused calendar-year maximums. Respect By respecting the fact that different customers have different needs and by creating plan options that fit those needs EmblemHealth is making dental coverage an attractive, affordable choice for your group. For more details, visit or contact your broker. Group Health Incorporated (GHI) is an EmblemHealth company. EmblemHealth dental insurance plans are underwritten by GHI. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies. EMB_GR_FLY_005840_PreferredDental_draft 2M /09

2 Sample Plan Designs EmblemHealth Preferred Dental Your Choice of Benefits Levels Offers Maximum Flexibility Each of EmblemHealth s dental benefits levels can be combined with various deductible and reimbursement options, enabling groups to consider a wide range of benefit designs and pricing at the time of purchase or renewal. Preventive/Basic* Preventive/Basic/Major Preventive/Basic/Major with Orthodontics Type A Preventive 100%/0% coinsurance 100%/0% coinsurance 100%/0% coinsurance Covers services that encourage good dental health, like exams, X-rays, cleanings, and fluoride treatments. Type B Basic 100%/0% coinsurance 100%/0% coinsurance 100%/0% coinsurance Covers emergency treatments, sealants, fillings, simple extractions, specialist consultations, periodontics, many surgical procedures, and crown, denture and bridge repair, as well as Preventive services. Type C Major Not covered 100%/0% coinsurance 100%/0% coinsurance Covers restorative services, such as dentures, 2- and 3-surface inlays, crowns, veneers, and fixed bridgework, as well as Basic and Preventive services. Type D Orthodontics Covers orthodontics (full banding/braces) Not covered Not covered Lifetime maximum of $2,000 and 20 months of treatment time with separate lifetime maximums. Calendar Year Deductible $25 individual $50 individual $50 individual $75 family $150 family $150 family Applicable to type B only Applicable to types B & C Applicable to types B & C Annual Maximum $1,000 $1,000 $1,000 Out-of-Network Reimbursement In-network schedule In-network schedule In-network schedule *Available to groups with more than 50 eligible employees Refer to GHI policy form numbers PLD-1103-C, PLD-1104-C et al.

3 PREFERRED PLAN DENTAL BENEFITS For the most up-to-date listings of participating dentists, visit click on Find a Doctor and select the Preferred Network option. CAT 9E1, 9E2 E5

4 Your EmblemHealth Preferred Dental Plan provides for a high level of coverage through EmblemHealth s network of over 6,000 Preferred dentists and specialists in New York and New Jersey. You have the freedom to choose the Preferred network dentists or specialists you use for covered services. You are not required to select a specific primary care dentist. You decide the participating provider at the time you receive care. All benefits shown below are on a per person basis. Certain types of oral surgery may be covered under the medical plan. Dependent Coverage (if included): Children to age 19 (end of calendar year); Full-time students to age 23 (end of calendar year). Predetermination of Benefits: This is a process by which EmblemHealth reviews and estimates benefits before services are rendered. It helps you to know in advance the services and materials EmblemHealth will cover or the benefits EmblemHealth will provide. It is available upon request for certain services. It is not available for Type A or basic restorative services. To obtain a Predetermination of Benefits, submit a Treatment Plan to EmblemHealth before receiving oral surgery, prosthetics or appliances. EmblemHealth will review the Treatment Plan and inform you and your provider of the results. Actual benefits may vary based upon new information received by EmblemHealth after it has issued the Predetermination of Benefits. If the services actually rendered are not the services set forth in the proposed treatment plan, then this Predetermination of Benefits shall be void. Dental Services Not : In addition to exclusions noted above, this Plan provides no coverage for: Cosmetic surgery and treatment unless involving reconstructive surgery incidental to trauma, infection, or disease of the involved part; prescription drugs and medications; services and appliances for the treatment of temporomandibular joint (TMJ) dysfunction; behavioral management; implants; transplantations; and other services not listed as covered. You are not covered for services that do not conform to accepted standards of dental practice. Annual Deductible: $50 individual, $150 family (not applicable to Type A services) Annual Maximum: $1,000 Maximum Rollover Feature If you use less than $500 of your calendar year maximum, $500 will be added to the following year s maximum for care received in-network and $250 for out-of-network services. The total accumulated rollover amount cannot exceed $1,000. It does not apply to orthodontic services. BENEFITS IN-NETWORK OUT-OF-NETWORK Type A Preventive and Diagnostic Services Examinations 2 per person per calendar year. 1 initial comprehensive examination per dentist, per lifetime. Prophylaxes (Cleanings) 2 per person per calendar year. Provider is paid 100% of the Preferred Schedule of X-Rays 4 bitewing x-rays per person per calendar year. - 1 full-mouth series of x-rays or 1 panoramic film per person once every 3 years. Fluoride Treatments 1 per person per calendar year to age 19 (end of calendar year child reaches age 19). Space Maintainers 1 per dependent child, per lifetime. Coverage provided until end of calendar year child reaches age 19. Mouth Guards 1 per dependent child, per lifetime. Coverage provided until end of calendar year child reaches age 19. Sealants 1 per covered tooth every 3 years from age 6 to age 14. The patient has no out-of-pocket expenses for the covered service rendered.

5 Type B Basic Services Simple Extractions BENEFITS IN-NETWORK OUT-OF-NETWORK Provider is paid 100% of the Preferred Schedule of Basic Restorations (Fillings) - Posterior composite fillings on molars are reimbursed at the amalgam fee. Patients who elect composite restorations on molars are responsible for the differences between the EmblemHealth payments and the dentists normal submitted fees for the services rendered. Patients should discuss these additional fees with dentists when reviewing the treatment plan and financial arrangements. Endodontics (Root canal therapy) - Pulpotomy covered once per tooth, per lifetime. Not covered if root canal done on same tooth by same provider within 3 months of the pulpotomy. Periodontics (Treatment of diseases of the gum and jaw) - 5 periodontal treatments per person per calendar year. - 1 type of periodontal surgery and/or 1 graft per quadrant. Oral Surgery (Surgical removal of an erupted tooth) - Charges for x-rays taken solely for surgery, local anesthesia, and post-operative care included in allowance for oral surgery. - Coverage includes surgery on fractured jaws, impactions, lesions in and around the mouth, and reimplantations. Anesthesia & IV Sedation for general anesthesia and IV sedation for covered services. Charges for local anesthesia are included in the allowance for the dental procedure. No separate allowance for local anesthesia. Analgesia and monitoring devices not covered. Palliative Services (Relief of pain) - 1 service per person per calendar year, emergencies only. Repair of Appliances - Replacement of broken teeth or clasps, recementation of inlays, crowns, bridges and space maintainers. Replacement of broken facings. Tests and Laboratory Exams Biopsy and examination of oral tissue. The patient has no out-of-pocket expenses for the covered services rendered, after any applicable deductible has been met. NOTE: This is not a complete benefit comparison or a contract, and should only be viewed as a brief summary to assist you in understanding this EmblemHealth benefit program. A detailed benefits description, including limitations and exclusions, is contained within the Certificate of Insurance. The terms, conditions, limits and exclusions shown in the Certificate of Insurance shall govern.

6 BENEFITS IN-NETWORK OUT-OF-NETWORK Type C Major Services Fixed and Removable Prosthetics Both immediate and permanent dentures, full or partial, repair, and crowns over implants. Major Restoration Includes crowns, related post and core procedures and inlays. - Replacement or substitution of appliances covered only after 5 years have passed since appliance was inserted. - crowns, single abutment crowns, and pontics other than porcelain fused to base metal at the allowance for predominantly base metal. Patients who elect crowns other than porcelain fused to base metal are responsible for the differences between the EmblemHealth payments and the dentists normal submitted fees for the services rendered. Patients should discuss these additional fees with dentists when reviewing the treatment plan and financial arrangements. - Coverage provided for crowns or pontics for attachment or clasp purposes only if tooth cannot be restored by fillings. - When a fixed bridge and partial denture are inserted in the same arch, only the partial denture is covered unless 5 years have passed since prior insertion of the fixed bridge or partial denture. - No separate allowance for temporary service or appliance. - Posts covered only if there is evidence of root canal on the tooth. - Charges for cementation of crown/inlay are included in allowance for the crown/inlay. - Crowns over implants are reimbursed based upon the allowance for a single crown, porcelain fused to predominantly base metal. The patient is responsible for the difference between the dentist s normal submitted fee and the EmblemHealth payment amount. Provider is paid 100% of the Preferred Schedule of The patient has no out-of-pocket expenses for the covered service rendered, after any applicable deductible has been met. Refer to Policy Forms PLD-1104-C and PLD-1103-C Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York (HIPIC) and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies. 55 Water Street, New York, New York

7 PREFERRED PLAN DENTAL BENEFITS For the most up-to-date listings of participating dentists, visit click on Find a Doctor and select the Preferred Network option. CAT 9E5, 9E6 E6

8 Your EmblemHealth Preferred Dental Plan provides for a high level of coverage through EmblemHealth s network of over 6,000 Preferred dentists and specialists in New York and New Jersey. You have the freedom to choose the Preferred network dentists or specialists you use for covered services. You are not required to select a specific primary care dentist. You decide the participating provider at the time you receive care. All benefits shown below are on a per person basis. Certain types of oral surgery may be covered under the medical plan. Dependent Coverage (if included): Children to age 19 (end of calendar year); Full-time students to age 23 (end of calendar year). Predetermination of Benefits: This is a process by which EmblemHealth reviews and estimates benefits before services are rendered. It helps you to know in advance the services and materials EmblemHealth will cover or the benefits EmblemHealth will provide. It is available upon request for certain services. It is not available for Type A or basic restorative services. To obtain a Predetermination of Benefits, submit a Treatment Plan to EmblemHealth before receiving oral surgery, prosthetics or appliances. EmblemHealth will review the Treatment Plan and inform you and your provider of the results. Actual benefits may vary based upon new information received by EmblemHealth after it has issued the Predetermination of Benefits. If the services actually rendered are not the services set forth in the proposed treatment plan, then this Predetermination of Benefits shall be void. Dental Services Not : In addition to exclusions noted above, this Plan provides no coverage for: Cosmetic surgery and treatment unless involving reconstructive surgery incidental to trauma, infection, or disease of the involved part; prescription drugs and medications; services and appliances for the treatment of temporomandibular joint (TMJ) dysfunction; behavioral management; implants; transplantations; and other services not listed as covered. You are not covered for services that do not conform to accepted standards of dental practice. Annual Deductible: $25 individual, $75 family (not applicable to Type A services) Annual Maximum: $1,500 Maximum Rollover Feature If you use less than $750 of your calendar year maximum, $700 will be added to the following year s maximum for care received in-network and $350 for out-of-network services. The total accumulated rollover amount cannot exceed $1,500. It does not apply to orthodontic services. BENEFITS IN-NETWORK OUT-OF-NETWORK Type A Preventive and Diagnostic Services Examinations 2 per person per calendar year. 1 initial comprehensive examination per dentist, per lifetime. Prophylaxes (Cleanings) 2 per person per calendar year. Provider is paid 100% of the Preferred Schedule of X-Rays 4 bitewing x-rays per person per calendar year. - 1 full-mouth series of x-rays or 1 panoramic film per person once every 3 years. Fluoride Treatments 1 per person per calendar year to age 19 (end of calendar year child reaches age 19). Space Maintainers 1 per dependent child, per lifetime. Coverage provided until end of calendar year child reaches age 19. Mouth Guards 1 per dependent child, per lifetime. Coverage provided until end of calendar year child reaches age 19. Sealants 1 per covered tooth every 3 years from age 6 to age 14. The patient has no out-of-pocket expenses for the covered service rendered.

9 Type B Basic Services Simple Extractions BENEFITS IN-NETWORK OUT-OF-NETWORK Provider is paid 100% of the Preferred Schedule of Basic Restorations (Fillings) - Posterior composite fillings on molars are reimbursed at the amalgam fee. Patients who elect composite restorations on molars are responsible for the differences between the EmblemHealth payments and the dentists normal submitted fees for the services rendered. Patients should discuss these additional fees with dentists when reviewing the treatment plan and financial arrangements. Endodontics (Root canal therapy) - Pulpotomy covered once per tooth, per lifetime. Not covered if root canal done on same tooth by same provider within 3 months of the pulpotomy. Periodontics (Treatment of diseases of the gum and jaw) - 5 periodontal treatments per person per calendar year. - 1 type of periodontal surgery and/or 1 graft per quadrant. Oral Surgery (Surgical removal of an erupted tooth) - Charges for x-rays taken solely for surgery, local anesthesia, and post-operative care included in allowance for oral surgery. - Coverage includes surgery on fractured jaws, impactions, lesions in and around the mouth, and reimplantations. Anesthesia & IV Sedation for general anesthesia and IV sedation for covered services. Charges for local anesthesia are included in the allowance for the dental procedure. No separate allowance for local anesthesia. Analgesia and monitoring devices not covered. Palliative Services (Relief of pain) - 1 service per person per calendar year, emergencies only. Repair of Appliances - Replacement of broken teeth or clasps, recementation of inlays, crowns, bridges and space maintainers. Replacement of broken facings. Tests and Laboratory Exams Biopsy and examination of oral tissue. The patient has no out-of-pocket expenses for the covered services rendered, after any applicable deductible has been met. NOTE: This is not a complete benefit comparison or a contract, and should only be viewed as a brief summary to assist you in understanding this EmblemHealth benefit program. A detailed benefits description, including limitations and exclusions, is contained within the Certificate of Insurance. The terms, conditions, limits and exclusions shown in the Certificate of Insurance shall govern.

10 BENEFITS IN-NETWORK OUT-OF-NETWORK Type C Major Services Fixed and Removable Prosthetics Both immediate and permanent dentures, full or partial, repair, and crowns over implants. Major Restoration Includes crowns, related post and core procedures and inlays. - Replacement or substitution of appliances covered only after 5 years have passed since appliance was inserted. - crowns, single abutment crowns, and pontics other than porcelain fused to base metal at the allowance for predominantly base metal. Patients who elect crowns other than porcelain fused to base metal are responsible for the differences between the EmblemHealth payments and the dentists normal submitted fees for the services rendered. Patients should discuss these additional fees with dentists when reviewing the treatment plan and financial arrangements. - Coverage provided for crowns or pontics for attachment or clasp purposes only if tooth cannot be restored by fillings. - When a fixed bridge and partial denture are inserted in the same arch, only the partial denture is covered unless 5 years have passed since prior insertion of the fixed bridge or partial denture. - No separate allowance for temporary service or appliance. - Posts covered only if there is evidence of root canal on the tooth. - Charges for cementation of crown/inlay are included in allowance for the crown/inlay. - Crowns over implants are reimbursed based upon the allowance for a single crown, porcelain fused to predominantly base metal. The patient is responsible for the difference between the dentist s normal submitted fee and the EmblemHealth payment amount. Provider is paid 100% of the Preferred Schedule of The patient has no out-of-pocket expenses for the covered service rendered, after any applicable deductible has been met. Refer to Policy Forms PLD-1104-C and PLD-1103-C Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York (HIPIC) and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies. 55 Water Street, New York, New York

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