2015 Group Dental Plans from Blue Cross of Idaho Choose coverage that fits. Form No. 3-765 (01-15) Policy Form Numbers: 3-229 (11-09) 3-141 (11-09) 3-202 (09-12) 18-083 (01-15)
DENTAL PLANS Idaho employers have a difficult job: balancing the need to manage costs while providing employees with affordable, quality dental benefits. BLUE CROSS OF IDAHO WANTS TO MAKE YOUR JOB EASIER At Blue Cross of Idaho, we are dedicated to delivering the best value in dental insurance to our customers. We offer a variety of dental plan benefits to make sure your employees receive the dental services they need with affordable coverage options. ENSURING QUALITY BY MANAGING YOUR BENEFITS Quality is important to Blue Cross of Idaho. Our customer advocates and claims staff earn high marks from our providers and their staffs. Our on-site dental consultants ensure that the dental treatments provided to our members are appropriate and costeffective. ADDING VALUE THOUGH BETTER ACCESS AND PRICES Blue Cross of Idaho has extensive dental provider networks in Idaho and nationwide giving our members choice and convenience for their dental care. The contracting dentists in our traditional and preferred provider organization (PPO) networks agree to recognize our maximum allowance as their maximum fee for eligible services. DENTAL COVERAGE WHEREVER YOU ARE Blue Cross of Idaho has joined forces with other participating Blue Cross Blue Shield plans nationwide for exclusive access to the national Dental GRID, one of the country s largest networks of dental providers, which allows our members in-network benefits nationwide. When choosing Blue Cross of Idaho for your dental and medical coverage, you get the added value and convenience of one billing contact, one account manager and one renewal all designed to help you manage your healthcare programs. 2 DENTAL PLANS from BLUE CROSS OF IDAHO Groups
Value-Added Benefit: Dental Maximum Carryover Dental Maximum Carryover adds value to your Blue Cross of Idaho dental benefits by encouraging your employees to take advantage of the low or no-cost routine preventive dental care cleanings and exams to improve overall oral health and by providing extra dollars for future dental services. IF YOU DON T USE IT, YOU DON T LOSE IT When your employees use $500 or less for dental claims in a benefit period, we carry over $250 to be used in the future. Carryover dollars may be used to pay for covered dental services once the benefit period maximum has been reached, saving your employees out-of-pocket expenses. Cavities aren t just for kids! Changes that occur with aging make cavities an adult problem too. Regression of the gums can expose tooth roots to plaque which leads to decay. Decay around the edges of fillings is also common in adults. Over the years, fillings weaken and can fracture and leak. Bacteria accumulate in these cracks and can cause decay. CHOOSE COVERAGE THAT FITS bcidaho.com 3
ACA Qualified Plans for Small Groups (2-50 employees) Our Group Dental Choice sm and Group Dental Choice Plus sm plans offer low s and low out-of-pocket maximums with no waiting periods for Basic and Major Dental Services for covered members under age 19. SMALL GROUP DENTAL PLANS (2-50 employees) GROUP DENTAL CHOICE (Under Age 19) GROUP DENTAL CHOICE (Age 19 and Over) - - dividual Deductible $50 per member, $100 per member, $50 per member, $100 per member, Annual Pocket Maximum $350 dividual/ $700 Two or more $10,000 None None Benefit Period Maximum None None $1,000 Preventive Dental Services (No waiting period) Oral Exams X-rays pays $50.. pays $25.. Cleanings Fluoride treatments Basic Dental Services Fillings Extractions.... Oral Surgery 6-month waiting period for members age 19 and over Major Dental Services Crowns, Bridges & Dentures lays/onlays Repairs to bridges & dentures.... Crown repair Dental Implants 12-month waiting period for members age 19 and over Orthodontia. 24-month waiting period for members under age 19; medically-necessary, non-cosmetic treatment. Prior authorization required. pays 80%. No Benefit No Benefit This brochure describes the general features of our dental plans. It is not a contract. All the provisions of the Policy issued to the group apply. The benefits of the Policy are governed primarily by the laws of the State of Idaho. 4 DENTAL PLANS from BLUE CROSS OF IDAHO Groups
Healthy employees have a direct impact on your success and good oral health contributes to overall health. SMALL GROUP DENTAL PLANS (2-50 employees) GROUP DENTAL CHOICE PLUS (Under Age 19) GROUP DENTAL CHOICE PLUS (Age 19 and Over) - - dividual Deductible $50 per member, $100 per member, $50 per member, $100 per member, Annual Pocket Maximum $350 dividual/ $700 Two or more $10,000 None None Benefit Period Maximum Preventive Dental Services (No waiting period) Oral Exams X-rays Cleanings Fluoride treatments Basic Dental Services Fillings Extractions Oral Surgery Major Dental Services Crowns, Bridges & Dentures lays/onlays Repairs to bridges & dentures Crown repair Dental Implants Orthodontia None None $1,000 pays $40....... 24-month waiting period for members under age 19; medically-necessary, non-cosmetic treatment. Prior authorization required. pays $10.... 6-month waiting period for members age 19 and over.. 12-month waiting period for members age 19 and over pays 80%. No Benefit No Benefit ORTHODONTIC VALUES If you are a Blue Cross of Idaho member, no matter what your plan covers, you will receive a discount of $400 off the total cost of full orthodontic treatment plans for eligible family members. All you have to do is show the Blue Extras! Orthodontic Values Provider your Blue Cross member ID card. The discount applies to any treatment plan which is initiated the orthodontist s effective date. Find the list of Orthodontic Values providers at members.bcidaho.com. Select Health & Wellness, then Discount Programs. Blue Extras! is a value-added program and not a part of your group insurance coverage. This brochure describes the general features of our dental plans. It is not a contract. All the provisions of the Policy issued to the group apply. The benefits of the Policy are governed primarily by the laws of the State of Idaho. CHOOSE COVERAGE THAT FITS bcidaho.com 5
PLANS FOR ALL SIZE GROUPS Dental plans are available for groups with 2+ employees, with a minimum 75% employee participation. Orthodontia is available for groups of 51+ employees. Employer must contribute at least 50% of the monthly premium rate for each enrolled employee. There is no minimum contribution requirement for dependent coverage. 6 DENTAL PLANS from BLUE CROSS OF IDAHO Groups
BLUE CROSS OF IDAHO GROUP DENTAL PLANS Preferred Blue Dental Preferred Blue Dental plans maximize consumer choice and flexibility while delivering reduced premiums and lower out-of-pocket expenses. That s because Preferred Blue Dental provides higher benefits when seeking dental services from our network of PPO dental providers. GROUP DENTAL PLANS PREFERRED BLUE DENTAL OPTION 1 PREFERRED BLUE DENTAL OPTION 2 PREFERRED BLUE DENTAL OPTION 3 Deductible (per person, 3 family member maximum) Benefit Period Maximum (per person) $25 or $50 $25 or $50 $25 or $50 $1,000, $1,250 or $1,500 $1,000, $1,250 or $1,500 $1,000, $1,250 or $1,500 Dental Provider PPO PPO PPO Preventive Dental Services Oral Exams X-rays Cleanings Fluoride treatments pays Basic Dental Services Fillings Extractions Oral Surgery Deductible applies. Optional 6-month waiting period (except Essential Dental and Voluntary Dental) pays 30% pays 30% Major Dental Services Crowns, Bridges & Dentures lays/onlays Repairs to bridges & dentures Crown repair Dental Implants Deductible applies. Optional 12-month waiting period, except for Voluntary Dental. pays 60% pays 60% Orthodontia For Groups of 51+ employees (Lifetime Maximum of $1,000, $1,250 or $1,500) Please Note: These plans do not meet the ACA coverage requirement for those under age 19. This brochure describes the general features of our dental plans. It is not a contract. All the provisions of the Policy issued to the group apply. The benefits of the Policy are governed primarily by the laws of the State of Idaho. CHOOSE COVERAGE THAT FITS bcidaho.com 7
Deductible Dental Deductible Dental has the flexibility you need when providing dental benefits to your employees and their families. Preventive and diagnostic services are paid at 100 percent, basic dental services at 80 percent, and major dental services at 50 percent. A applies to basic and major dental services. centive Dental With centive Dental, your employees are rewarded for taking care of their smiles! Starting at 70 percent, benefit payments increase 10 percent each year up to 100 percent for preventive, diagnostic and basic dental services, as long as they visit a dental provider each consecutive year. For each year that a member does not receive dental services, the payable will decrease by 10 percent. Major dental services are covered at 50 percent with no. Tips for preventing cavities Eat nutritious and balanced meals and limit snacking. Check with your dentist about the use of supplemental fluoride and dental sealants (protective coating for back teeth). Visit your dentist regularly for exams and cleanings. GROUP DENTAL PLANS Deductible (per person, 3 family member maximum) Benefit Period Maximum (per person) Dental Provider Preventive Dental Services Oral Exams X-rays Cleanings Fluoride treatments Basic Dental Services Fillings Extractions Oral Surgery Deductible applies. Optional 6-month waiting period (except Essential Dental and Voluntary Dental). Major Dental Services Crowns, Bridges & Dentures lays/onlays Repairs to bridges & dentures Crown repair Dental Implants Deductible applies. Optional 12-month waiting period, except for Voluntary Dental. Orthodontia DEDUCTIBLE AND INCENTIVE DENTAL Deductible Dental centive Dental 1 $25 or $50 No Deductible pays of allowed of allowed $1,000, $1,250 or $1,500 Traditional/PPO pays 30% of allowed for 1st year; 20% for 2nd year; 10% for 3rd year; in 4th year. pays 30% of allowed for 1st year; 20% for 2nd year; 10% for 3rd year; in 4th year. No applies of allowed No applies (Lifetime Maximum of $1,000, $1,250 or $1,500) Footnotes: 1 centive Dental: must have at least one covered dental service for incentive level to increase. Please Note: These plans do not meet the ACA coverage requirement for those under age 19. This brochure describes the general features of our dental plans. It is not a contract. All the provisions of the Policy issued to the group apply. The benefits of the Policy are governed primarily by the laws of the State of Idaho. 8 DENTAL PLANS from BLUE CROSS OF IDAHO Groups
BLUE CROSS OF IDAHO GROUP DENTAL PLANS Essential Dental Essential Dental is our low cost dental care option, providing your employees with benefits for preventive, diagnostic and basic dental services. Major dental services are not covered, which keeps premiums lower than other dental plans. Dental Blue Connect* Dental Blue Connect offers extensive dental coverage with: No s No benefit period maximums No waiting periods No claim forms Orthodontia, with no age limit, is available for all eligible members on all Dental Blue Connect plans. All necessary dental services are covered at 100 percent applicable copayments when performed by dentists and specialists at Willamette Dental Group. GROUP DENTAL PLANS Deductible (per person, 3 family member maximum) Benefit Period Maximum (per person) Dental Provider Preventive Dental Services Oral Exams X-rays Cleanings Fluoride treatments Basic Dental Services Fillings Extractions Oral Surgery 6-month waiting period for Essential Dental ESSENTIAL DENTAL DENTAL BLUE CONNECT for Groups 51+ $25 OR $50 No Deductible pays $1,000 None PPO Benefits do not apply to Benefit Period Maximum mandatory 6 month waiting period and satisfied pays 40% mandatory 6 month waiting period and satisfied Willamette Dental Group (POS) pays applicable office visit copayments pays applicable copayments No applies Reimbursement to your employee up to $10 per date of service Reimbursement to your employee up to $10 per date of service * Available only to groups of 51+ employees when offered as a dual-option with another Blue Cross of Idaho dental plan. Major Dental Services Crowns, Bridges & Dentures lays/onlays Repairs to bridges & dentures Crown repair Dental Implants Major Dental Services are not covered pays applicable copayments No applies Reimbursement to your employee up to $10 per date of service Orthodontia Orthodontia services are not covered pays applicable copayments (adult and child. cluded in all Dental Blue Connect Plans) Please Note: These plans do not meet the ACA coverage requirement for those under age 19. This brochure describes the general features of our dental plans. It is not a contract. All the provisions of the Policy issued to the group apply. The benefits of the Policy are governed primarily by the laws of the State of Idaho. CHOOSE COVERAGE THAT FITS bcidaho.com 9
Voluntary Dental Voluntary Dental is a great way to provide your employees with easy access to dental care coverage. As implied by the name, the plan is entirely voluntary, meaning that your employees decide whether or not they want to participate. Voluntary Dental is available to groups with 3 or more employees. At least one employee must elect coverage. Employer contribution is optional. GROUP DENTAL PLANS Deductible (per person, 3 family member maximum) Benefit Period Maximum (per person) VOLUNTARY DENTAL PLAN A VOLUNTARY DENTAL PLAN B $25 or $50 $50 or $75 $25 or $50 $50 or $75 $1,000, $1,250 or $1,500 $1,000, $1,250 or $1,500 Dental Provider PPO PPO Preventive Dental Services Oral Exams X-rays Cleanings Fluoride treatments pays $20 copayment per visit pays 30% pays $25 copayment per visit Tips for preventing cavities Brush twice a day with a fluoride toothpaste. Clean between your teeth daily with floss or an interdental cleaner. Replace your toothbrush frequently. Bristles wear out and clean less efficiently. Basic Dental Services Fillings Extractions Oral Surgery 6-month waiting period Major Dental Services Crowns, Bridges & Dentures lays/onlays Repairs to bridges & dentures Crown repair Dental Implants 12-month waiting period Orthodontia pays 60% pays 30% pays 60% pays 70% mandatory 24 month waiting period (For groups of 51+, Lifetime Maximum $1,000, $1,250 or $1,500) Please Note: These plans do not meet the ACA coverage requirement for those under age 19. This brochure describes the general features of our dental plans. It is not a contract. All the provisions of the Policy issued to the group apply. The benefits of the Policy are governed primarily by the laws of the State of Idaho. 10 DENTAL PLANS from BLUE CROSS OF IDAHO Groups
BLUE CROSS OF IDAHO GROUP DENTAL PLANS EXCLUSIONS & LIMITATIONS addition to any other exclusions and limitations of the Policies, the following exclusions and limitations apply to dental services: There are no benefits for services, supplies, or other charges that are procedures that are not included in the Closed List of Dental Covered Services; or that are not Medically Necessary for the care of an sured s covered dental condition; or that do not have uniform professional endorsement. Charges incurred for services that were started prior to the sured s Effective Date. A service furnished to an sured for cosmetic purposes, unless necessitated as a result of Accidental juries received while the sured was covered by Blue Cross of Idaho. excess of the Maximum Allowance. Any procedure, service or supply required directly or indirectly to treat a muscular, neural, orthopedic or skeletal disorder, dysfunction or Disease of the temporomandibular joint (jaw hinge) and its associated structures including, but not limited to, myofascial pain dysfunction syndrome. Temporary dental services. Charges for temporary services are considered an integral part of the final dental services and are not separately payable. Any service, procedure or supply for which the prognosis for success is not reasonably favorable. For hospital patient or Outpatient care for extraction of teeth or other dental procedures. Not prescribed by or upon the direction of a Provider. vestigational in nature. Provided for any condition, Disease, Illness or Accidental jury to the extent that the sured is entitled to benefits under occupational coverage, obtained or provided by or through an employer under state or federal Workers Compensation Acts or under Employer Liability Acts or other laws providing compensation for work-related injuries or conditions. This exclusion applies whether or not the sured claims such benefits or compensation or recovers losses from a third party. Provided or paid for by any federal governmental entity or unit except when payment under this Policy is expressly required by federal law, or provided or paid for by any state or local governmental entity or unit where its charges therefor would vary, or are or would be affected by the existence of coverage under this Policy; or for which payment has been made under Medicare Part A and/or Part B. Provided for any condition, Accidental jury, Disease or Illness suffered as a result of any act of war or any war, declared or undeclared. Furnished by a Provider who is related to the sured by blood or marriage and who ordinarily dwells in the sured s household. Received from a dental, vision or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trust or similar person or group. For personal hygiene, comfort, beautification or convenience items even if prescribed by a Dentist, including but not limited to, air conditioners, air purifiers, humidifiers, physical fitness equipment or programs. For telephone consultations; for failure to keep a scheduled visit or appointment; for completion of a claim form; or for personal mileage, transportation, food or lodging expenses, or for mileage, transportation, food or lodging expenses billed by a Dentist or other Provider. For Congenital Anomalies, or for developmental malformations, unless the patient is an Eligible Dependent child. For the treatment of injuries sustained while committing a felony, voluntarily taking part in a riot, or while engaging in an illegal act or occupation, unless such injuries are a result of a medical condition or domestic violence. Any services or supplies for which an sured would have no legal obligation to pay in the absence of coverage under this Policy or any similar coverage; or for which no charge or a different charge is usually made in the absence of insurance coverage. Provided to persons who were enrolled as Eligible Dependents they cease to qualify as Eligible Dependents due to a change in Eligibility status which occurs during the Policy term. Provided outside the United Sates, which if had been provided in the United States, would not be Covered Services under this Policy. Not directly related to the care and treatment of an actual condition, Illness, Disease or Accidental jury. CHOOSE COVERAGE THAT FITS bcidaho.com 11
P.O. Box 7408 Boise, ID 83707 1 888 GO CROSS (1 888-462-7677) bcidaho.com Meridian STREET ADDRESS 3000 E. Pine Avenue Meridian, ID 83642-5995 MAILING ADDRESS P.O. Box 7408 Boise, ID 83707 208-387-6683 CLAIMS INQUIRIES 208-331-7347 800-627-1188 Coeur d Alene Idaho Falls Lewiston Pocatello Twin Falls 1450 NW Blvd., Suite 106 Coeur d Alene, ID 83814 208-666-1495 1910 Channing Way Idaho Falls, ID 83404 208-522-8813 1010 17th St. Lewiston, ID 83501 208-746-0531 275 S. 5th Ave., Suite 150 Pocatello, ID 83201 208-232-6206 1503 Blue Lakes Blvd. N. Twin Falls, ID 83301 208-733-7258 2015 by Blue Cross of Idaho, an independent licensee of the Blue Cross and Blue Shield Association