Welcome to YOUR healthier smile!

Transcription

1 Dental benefits provided by: Dental Health Services Welcome to YOUR healthier smile! Protecting your child s oral health is now easy and affordable with Dental Health Services First Smile sm - EarlyCare dental plans! Certified by Washington Healthplanfinder to satisfy the essential pediatric dental benefit requirement, First Smile sm - EarlyCare dental plans give your child quality dental care coverage that meets your family s needs and budget. Your child will receive excellent care from one of our participating Quality Assured dentists, who has met our 107-point program for quality and service. A vast majority of our dentists have experience working with children s oral health care needs. When you have any questions about your child s dental benefits, your local Member Service Specialists are always happy to assist you every step of the way! Take the first step to achieving a brighter, healthier smile. Enroll your child in a First Smile sm - EarlyCare dental plan today! For more information, please call Dental Health Services at or visit our website at We re always happy to help you! WASHINGTON HEALTHPLANFINDER CERTIFIED Contact Washington Healthplanfinder to enroll today! Need a dental plan for yourself? Visit for quality, affordable dental coverage options for adults. 0815WM Dental Health Services 1

2 Your local advocate for your oral health & overall wellness Who is Dental Health Services? Dental Health Services is a local, independent, employee-owned dental benefits company. We specialize in prepaid dental plans and have been serving the oral health needs of employers, organizations, individuals, families, and labor unions in Washington state since We re proud to partner with Washington Healthplanfinder and offer our First Smile sm - EarlyCare Pediatric Dental Plans to children needing care. Why should I select a First Smile sm - EarlyCare dental plan for my child? First Smile sm - EarlyCare plans feature: Low copayments Access to a Network of Quality Assured participating dentists Fully disclosed coverage with exact copayments Medically necessary orthodontic coverage No deductibles, claim forms or waiting periods How does First Smile sm - EarlyCare work? First Smile sm - EarlyCare dental plans deliver dental care through a network of privately owned, neighborhood dental offices. Choose between a lower monthly payment with First Smile sm - EarlyCare, or you can pay less out of pocket for basic procedures with First Smile sm - EarlyCare Plus. What are my next steps to get started? 1. You must complete your enrollment by sending your binder payment to Dental Health Services. You will not be an eligible member until your binder payment is received. 2. Choose a conveniently located participating dentist. This will maximize your First Smile sm - Early Care coverage. 3. Your dentist will assess your child s oral health and outline his or her treatment plan. At the dentist, you pay only the copayment for each service rendered, as listed in your Schedule of Covered Services and Copayments. How does my child receive dental care? Simply call your child s selected participating dental office and schedule an appointment. Tell the office your child is a Dental Health Services member. Your selected participating dental office receives a membership eligibility list each month, so it isn t necessary to have your child s membership card to make an appointment or receive dental care. 2

3 Dental Health Services FirstSmile Early Care Plan Type: Prepaid Coverage Period: 1/1/ /31/2016. Coverage for: Child(ren) age This is only a summary. If you want more detail about a child s coverage and costs under this plan, you can get the complete terms in the policy or plan document at or by calling Important Questions What is the premium amount? What is the overall deductible? Does the deductible apply to Preventive Services? What is the out-of-pocket maximum on my expenses? What is not included in the out-of-pocket maximum? Is there an overall annual limit on what the plan pays? Answers $21.25 $0 N/A $350 for individual $700 for family Premiums, non-covered services, non-essential Health Benefit services No Why this Matters The premium amount is a monthly fee you must pay to your insurance company to receive dental insurance. You must pay all the costs related to covered services up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 4 for how much you pay for covered services after you meet the deductible. The deductible does not apply to preventive exams, cleanings, or other preventive services. See the chart starting on page 4 for how much you pay for covered preventive services. The out-of-pocket maximum is the most you could pay during a coverage period (usually one year) for your share of the cost of Essential Health Benefit services. This limit helps you plan for dental care expenses. Even though you pay these expenses, they don t count toward the out-of-pocket maximum. There is no overall annual limit on what the plan will pay. The chart starting on page 4 describes any limits on what the plan will pay for specific covered services. Who is included in this plan s network of providers? Do I need a referral to see a specialist? Do I need preauthorization before receiving certain dental services? Are there services this plan doesn t cover? See services.com/wa or call for a list of participating providers. You must use an in-network provider, and this plan will pay some or all of the costs of covered services. Be aware, your in-network dentist may use an out-of-network provider (e.g., a hospital) for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 4 for how this plan pays different kinds of providers. Your child is able to see a specialist as deemed necessary by your participating dentist and approved by the plan. You do not need to call the plan before receiving general dental services. To see a specialist, you must visit your participating general dentist and follow the referral process. See your policy or plan document for additional information. This plan does not cover adult dental services. Some of the other services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. 3

4 Dental Health Services FirstSmile Early Care Plan Type: Prepaid Coverage Period: 1/1/ /31/2016..Coverage for: Child(ren) age Copayments are fixed dollar amounts (for example, $15) you pay for covered dental care, usually at the time of the service. Coinsurance, which is different from copayments, is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for a restorative procedure (e.g., a crown) is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-ofnetwork provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network dentist charges $1,500 for a crown and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan requires you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Dental Treatment If my child needs a routine check up Services You May Need Your Cost If You Use an In-network Provider Your Cost If You Use an Out-of-network Provider Limitations & Exceptions Exams $20 Not Covered Once every 6 months Cleanings $20 Not Covered Under 19: every 6 mos. 19 & up: once a yr. Fluoride $20 Not Covered Frequency limit. See copayment sched. Sealants $20 per tooth Not Covered Frequency limit. See copayment sched. If my child needs a cavity filled If my child needs other restorative care If my child needs a tooth extraction If my child needs advanced oral surgery If my child needs medically necessary orthodontia X-rays $20 Not Covered Once in a 2- or 3- year period. Nitrous oxide $30 Not Covered Amalgam filling $30 Not Covered Composite filling $30 Not Covered Nitrous oxide $30 Not Covered Treatment of gums $30 Not Covered Crowns $325 Not Covered Root canals $325 Not Covered Replacement of teeth $30 Not Covered Extraction $30 Not Covered Oral surgery $325 Not Covered Braces $350 Not Covered Removable appliances $350 Not Covered 4

5 Dental Health Services FirstSmile Early Care Plan Type: Prepaid Coverage Period: 1/1/ /31/2016. Coverage for: Child(ren) age Excluded Services & Other Covered Services: Services This Plan Does NOT Cover (This isn t a complete list. Check the policy or plan document for other excluded services.) Services not specifically listed in the Schedule of Covered Services and Copayments Adult care. Grievance and Appeals Rights If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Dental Health Services 100 W Harrison St. S-440, South Tower Seattle, WA membercare@dentalhealthservices.com Does this Coverage Provide Minimum Essential Coverage? This plan or policy meets the Affordable Care Act s minimum value and benefits requirements for pediatric dental care. 5

6 Dental Health Services FirstSmile Early Care Plus Plan Type: Prepaid Coverage Period: 1/1/ /31/2016. Coverage for: Child(ren) age This is only a summary. If you want more detail about a child s coverage and costs under this plan, you can get the complete terms in the policy or plan document at or by calling Important Questions What is the premium amount? What is the overall deductible? Does the deductible apply to Preventive Services? What is the out-of-pocket maximum on my expenses? What is not included in the out-of-pocket maximum? Is there an overall annual limit on what the plan pays? Answers $22.75 $0 N/A $350 for individual $700 for family Premiums, non-covered services, non-essential Health Benefit services No Why this Matters The premium amount is a monthly fee you must pay to your insurance company to receive dental insurance. You must pay all the costs related to covered services up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 7 for how much you pay for covered services after you meet the deductible. The deductible does not apply to preventive exams, cleanings, or other preventive services. See the chart starting on page 7 for how much you pay for covered preventive services. The out-of-pocket maximum is the most you could pay during a coverage period (usually one year) for your share of the cost of Essential Health Benefit services. This limit helps you plan for dental care expenses. Even though you pay these expenses, they don t count toward the out-of-pocket maximum. There is no overall annual limit on what the plan will pay. The chart starting on page 7 describes any limits on what the plan will pay for specific covered services. Who is included in this plan s network of providers? Do I need a referral to see a specialist? Do I need preauthorization before receiving certain dental services? Are there services this plan doesn t cover? See services.com/wa or call for a list of participating providers. You must use an in-network provider, and this plan will pay some or all of the costs of covered services. Be aware, your in-network dentist may use an out-of-network provider (e.g., a hospital) for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 4 for how this plan pays different kinds of providers. Your child is able to see a specialist as deemed necessary by your participating dentist and approved by the plan. You do not need to call the plan before receiving general dental services. To see a specialist, you must visit your participating general dentist and follow the referral process. See your policy or plan document for additional information. This plan does not cover adult dental services. Some of the other services this plan doesn t cover are listed on page 8. See your policy or plan document for additional information about excluded services. 6

7 Dental Health Services FirstSmile Early Care Plus Plan Type: Prepaid Coverage Period: 1/1/ /31/2016..Coverage for: Child(ren) age Copayments are fixed dollar amounts (for example, $15) you pay for covered dental care, usually at the time of the service. Coinsurance, which is different from copayments, is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for a restorative procedure (e.g., a crown) is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-ofnetwork provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network dentist charges $1,500 for a crown and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan requires you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Dental Treatment Services You May Need Your Cost If You Use an In-network Provider Your Cost If You Use an Out-of-network Provider Limitations & Exceptions If my child needs a routine check up Exams $12 Not Covered Once every 6 months Cleanings $12 Not Covered Under 19: every 6 mos. 19 & up: once a yr. Fluoride $12 Not Covered Frequency limit. See copayment sched. Sealants $12 per tooth Not Covered Frequency limit. See copayment sched. X-rays $12 Not Covered Once in a 2- or 3- year period. Nitrous oxide $15 Not Covered If my child needs a cavity filled If my child needs other restorative care Amalgam filling $15 Not Covered Composite filling $15 Not Covered Nitrous oxide $15 Not Covered Treatment of gums $15 Not Covered Crowns $150 Not Covered Root canals $150 Not Covered Replacement of teeth $15 Not Covered If my child needs a tooth extraction If my child needs advanced oral surgery If my child needs medically necessary orthodontia Extraction $15 Not Covered Oral surgery $150 Not Covered Braces $350 Not Covered Removable appliances $350 Not Covered 7

8 Dental Health Services FirstSmile Early Care Plus Plan Type: Prepaid Coverage Period: 1/1/ /31/2016. Coverage for: Child(ren) age Excluded Services & Other Covered Services: Services This Plan Does NOT Cover (This isn t a complete list. Check the policy or plan document for other excluded services.) Services not specifically listed in the Schedule of Covered Services and Copayments Adult care. Grievance and Appeals Rights If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Dental Health Services 100 W Harrison St. S-440, South Tower Seattle, WA membercare@dentalhealthservices.com Does this Coverage Provide Minimum Essential Coverage? This plan or policy meets the Affordable Care Act s minimum value and benefits requirements for pediatric dental care. 8