EmblemHealth Preferred Plus Dental

Transcription

1 EmblemHealth Preferred Plus Dental Coverage every group needs and any group can afford. Here s how EmblemHealth Preferred Plus Dental will deliver for you: A range of attractive dental benefits with flexible cost-sharing options. Dental coverage only works if it delivers the things that matter most to you. EmblemHealth Preferred Plus Dental can work for your group by delivering: A broad range of benefits through a national Out-of-network coverage. Streamlined, hassle-free administration. Affordable rates and cost-sharing options that respect your budgetary needs, regardless of your group s size. 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 Plus 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, plus the special Value Package available only with this plan. (See reverse for program details.) Affordability EmblemHealth Preferred Plus Dental offers a range of cost-effective choices: EPO options with in-network-only benefits. MAC plans that use the network schedule to determine out-of-network reimbursement. Reimbursement at 50th, 80th or 90th percentiles of INGENIX/HIAA schedules. Our provider discounts keep plan costs down, and flexible plan designs encourage in-network care. Our Value Package option can reduce your exposure to certain costly claims, while providing an array of attractive benefits. Access to care With a fully credentialed PPO network of more than 7,500 general dentists and specialists in New York and New Jersey, plus a nationwide network, EmblemHealth Preferred Plus Dental allows your employees to see dental providers 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_PreferredPlusDental_draft 2M /09

2 Sample Plan Designs EmblemHealth Preferred Plus 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. Type A Preventive Type B Basic Preventive/Basic* 100%/0% coinsurance in and out of Covers emergency treatments, sealants, fillings, simple extractions, specialist consultations, and crown, denture and bridge repair, as well as Preventive services. 80%/20% coinsurance in and out of Preventive/Basic/Major (with Value Package)** 100%/0% coinsurance in and out of 80%/20% coinsurance in and out of Type C Major Not covered Covers periodontics, endodontics, many surgical procedures and restorative services, such as dentures, 2- and 3-surface inlays, crowns, veneers, and fixed bridgework, as well as Basic and Preventive services. 50%/50% coinsurance in and out of Preventive/Basic/Major with Orthodontics 100%/0% coinsurance in and out of 80%/20% coinsurance in and out of 50%/50% coinsurance in and out of Type D Orthodontics Not covered Not covered Covers comprehensive orthodontics (full banding/braces) with separate lifetime maximums, as well as Major, Basic, and Preventive services. $1,000 lifetime maximum. 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 *Available to groups with more than 50 eligible employees. 80th percentile (INGENIX/HIAA reimbursement schedule) 80th percentile (INGENIX/HIAA reimbursement schedule) ** By shifting many type B services to type C, the Value Package limits your exposure to certain costly claims, lowers your premium rate and helps minimize premium increases. EmblemHealth s Standard Package reimburses endodontics, periodontics, oral surgery, general anesthesia and IV sedation as type B services. Refer to GHI policy form numbers PLD-1103-C, PLD-1104-C et al.

3 PREFERRED PLUS PLAN DENTAL BENEFITS For the most up-to-date listings of participating dentists, visit click on Find a Doctor and select the Preferred Plus Network option. CAT 9EJ, 9EQ E+14

4 Your EmbleHealth Preferred Plus Dental Plan provides for a high level of coverage through EmblemHealth s network of over 7,500 Preferred Plus dentists and specialists in New York and New Jersey. You have the freedom to choose the Preferred Plus 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: $1,500 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. *EmblemHealth uses charge data from the 80th percentile of the Ingenix/Health Insurance Association of America Health Care Charges System to develop the EmblemHealth Allowed Charges. 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 EmblemHealth reimburses you up to 100% of the Plan s allowed schedule.* You are responsible for any dental charges that exceed this payment. 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 80% of the EmblemHealth reimburses you up to 80% of the Plan s allowed schedule.* You are responsible for any dental charges that exceed this payment. 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 Preferred Plus plan allowances 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 (Dentures) - 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 is responsible for paying 20% of the Preferred Plus allowance to the provider for the covered service rendered. 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. - EmblemHealth reimburses crowns, single abutment crowns, and pontics other than porcelain fused to base metal at the allowance for predominantly base metal. Patients who elect a crown other than percelain fused to base metal are responsible for the difference between the allowance for the crown received and the allowance for the predominantly base metal crown, in addition to the 50% coinsurance. 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 50% of the The patient is responsible for paying 50% of the Preferred Plus allowance to the provider for the covered service rendered. EmblemHealth reimburses you up to 50% of the Plan s allowed schedule.* You are responsible for any dental charges that exceed this payment. 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 PLUS PLAN DENTAL BENEFITS For the most up-to-date listings of participating dentists, visit click on Find a Doctor and select the Preferred Plus Network option. CAT 9EF, 9EP E+11

8 Your EmbleHealth Preferred Plus Dental Plan provides for a high level of coverage through EmblemHealth s network of over 7,500 Preferred Plus dentists and specialists in New York and New Jersey. You have the freedom to choose the Preferred Plus 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: $1,500 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 EmblemHealth reimburses you up to 100% of the Plan s allowed schedule. You are responsible for any dental charges that exceed this payment. 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 Basic Restorations (Fillings) BENEFITS IN-NETWORK OUT-OF-NETWORK Provider is paid 80% of the EmblemHealth reimburses you up to 80% of the Plan s allowed schedule. You are responsible for any dental charges that exceed this payment. - 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 Preferred Plus plan allowances for the services rendered. Patients should discuss these additional fees with dentists when reviewing the treatment plan and financial arrangements. Palliative Services (Relief of pain) - 1 service per person per calendar year, emergencies only. Repair of Appliances (Dentures) - 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. Type C Major Services 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. The patient is responsible for paying 20% of the Preferred Plus allowance to the provider for the covered service rendered. Provider is paid 50% of the The patient is responsible for paying 50% of the Preferred Plus allowance to the provider for the covered service rendered. EmblemHealth reimburses you up to 50% of the Plan s allowed schedule. You are responsible for any dental charges that exceed this payment. 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. - EmblemHealth reimburses crowns, single abutment crowns, and pontics other than porcelain fused to base metal at the allowance for predominantly base metal. Patients who elect a crown other than percelain fused to base metal are responsible for the difference between the allowance for the crown received and the allowance for the predominantly base metal crown, in addition to the 50% coinsurance. 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 50% of the The patient is responsible for paying 50% of the Preferred Plus allowance to the provider for the covered service rendered. EmblemHealth reimburses you up to 50% of the Plan s allowed schedule. You are responsible for any dental charges that exceed this payment. 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