Your Dental Benefit Plans (You must choose only one plan)
 

Age 19 or Older
You may use either Dentcare, or a dentist who participates in the Local 1180 Scheduled Dental Benefit Plan (hereafter, “Participating Dentist”), or go out-of-network. If you or your dependent over the age of 18 chooses Dentcare or uses a Participating Dentist, most services are covered at no charge. There are no out-of-pocket expenses or annual or lifetime maximums when using a Dentcare Dentist. When using a Participating Dentist, the maximum benefit the plan will pay is $2,000 per person, per calendar year, per schedule and there are certain lifetime maximums.

Dependents Under Age 19
Dependents under age 19 must choose either Dentcare or a Participating Dentist. The plan will have no annual dollar cap for medically necessary orthodontia obtained through either a Dentcare Dentist or a Participating Dentist. However, the lifetime limits will remain in place for orthodontia that is not medically necessary – that is, other than in cases of a cleft palate or other deformities that are part of or the result of a congenital defect or anomaly of the mouth that prevents the usual and normal action of mastication and ingestion of normally solid foods. Otherwise, lifetime frequency limitations in the dental schedules do not apply to those under age 19.
THE SCHEDULED DENTAL BENEFIT PLAN:
Under this plan, the Fund will pay you, your spouse and your eligible children a set amount for covered dental expenses you incur up to a maximum of $2,000 per eligible person in any calendar year.

When Is Coverage Provided?
Coverage is provided when:
  • Services are received in accordance with the procedures described in this Summary Plan Description.
  • Services are obtained while you, your spouse or your children are eligible for coverage (See the section entitled “Eligibility”).
  • Services are medically necessary and covered hereunder.
  • Services are approved by the Fund’s Dental Consultant.
  • Services are not otherwise excluded.
What Expenses Are Covered By The Scheduled Dental Benefit Plan?
Covered Services Provided By Participating Dentists:
Participating Dentists are dentists who have agreed to provide services covered by the Plan for a fixed fee set by the Plan. If you, your spouse or eligible children use the services of Participating Dentists, the Participating Dentist will accept the fixed fee set by the Plan as payment in full for covered services you receive. There are no out-of-pocket costs to you for covered services provided by The Fund’s Participating Dentists, up to a maximum coverage limit of $2,000 per eligible person in any calendar year.
For services covered by the Scheduled Dental Benefit Plan, please see the Schedule of Dental Allowances below.
Call the Fund Office at 1-212-966-5353 for a current list of Participating Dentists.

Covered Services Provided By Dentists Who Are Not Participating Dentists:
You can go to any dentist you choose, but when you use a dentist who is not a participating dentist, you may incur out-of-pocket expenses for covered services.

Benefits payable under the Scheduled Dental Benefit Plan are based on a Schedule of Dental Allowances; please see the Schedule of Dental Allowances below. If your (non-participating) dentist charges you more than the scheduled allowance, the fees you incur that exceed the Plan’s allowance or exceed the maximum benefit of $2,000 per eligible person in any calendar year are your sole responsibility. If your (non-participating) dentist charges you less than the Plan’s Scheduled Allowance, you will be reimbursed your dentist’s actual fee, up to the maximum benefit of $2,000 per eligible person in any calendar year.
  • For example, if your (non-participating) dentist charges $100 for a covered service, but the reimbursement rate for that service under the Schedule of Dental Allowances is $85, the Plan will pay $85 and your unreimbursed, out-of-pocket expense will be $15.
For a list of dental services covered by the Scheduled Dental Benefit Plan, please click on the link “Schedule of Dental Allowances .

When Your Treatment Costs $500 or More
If your dentist expects that your treatment will cost $500 or more, the Fund must approve your treatment before the work is done.In such case, your dentist must submit for review by the Fund’s Dental Consultant:
  • The Proposed Treatment Plan
           and
  • Supporting X-rays.
After review, you and your dentist will be told:
  • What treatment will be covered
  • What the Fund estimates it will pay.
The Fund reserves the right to deny claims amounting to $500 or more which have not been reviewed by the Fund’s Dental Consultant before treatment begins.

If the Fund is the secondary plan, pre-treatment review by the Fund’s Dental Consultant is not required where the primary plan has already performed the pretreatment review.

If the primary plan has not performed a pre-treatment review, then pre-treatment review by the Fund’s Dental Consultant is required before the work is done.

Following pre-treatment review, you will receive an estimate of the benefit the Fund will pay. In order to receive payment from the Fund:
  • Treatment must be completed
        and
  • A Treatment Completion form must be signed by the dentist and submitted to the Fund after the work has been performed.
Pre-treatment review is not a guarantee of payment. No payment will be made if the patient is not eligible when services are rendered.

Getting Your Benefit
Follow these simple steps:
  • Obtain the official Local 1180 Dental Claim Form from the Fund Office.
  • Complete the patient and subscriber/employee sections and sign the form in box #39 after you have discussed the treatment plan and associated fees with your dentist. Only if you wish to assign payment directly to your dentist, also sign box #41.
  • If the total charges for the treatment are expected to be $500 or more, have your dentist submit a Pre-Treatment Estimate form and your x-rays to the Fund’s Dental Consultant. When the Pre-Treatment Estimate form is returned to your dentist with information about the benefits payable for your treatment, review these benefits with the dentist before work begins.
  • When the treatment is completed, have your dentist complete the dentist’s statement of work done.

The completed form must be sent within 90 calendar days after the completion of dental treatment to:

CWA Local 1180 Scheduled Dental Benefit Plan
Dental Claim Office
253 West 35th Street, 12 Floor
New York, NY  10001-1907


Claims submitted after the 90-day limit will be denied.

IMPORTANT NOTICE
The Fund does NOT recommend or endorse any particular dentist. You are responsible for selecting the dentist of your choice, whether the dentist is a “participating” or “non-participating” dentist. You should apply the same criteria and care in choosing a participating dentist that you would apply in selecting a non-participating one.

What If I Want To Change To A Different Dental Plan?
The Fund offers two dental plan options.  If you are enrolled in the Scheduled Dental Benefit Plan but would like to change to Dentcare, you need to follow these simple steps:
  • You can change plans during the open enrollment period.
  • Your new selection will become effective on January 1 of the following year.
  • You cannot be enrolled in the Scheduled Dental Benefit Plan and Dentcare at the same time.
What’s Not Covered
Benefits are not provided for:
  • Treatment from anyone other than a licensed dentist, except routine cleaning of teeth and fluoride application which is performed by a licensed dental hygienist under the direct supervision of, and billed by, a dentist or physician.
  • Facings, veneers, or similar material placed on molar crowns or pontics.
  • Services performed by a member of you or your spouse’s immediate family.
  • Services or supplies that are cosmetic in nature or directed towards a cosmetic end.
  • Any service or supplies incurred, installed, or delivered before you or your dependent(s) become eligible for benefits from this Fund.
  • Replacing a lost, missing or stolen prosthetic appliance.
  • A broken appointment.
  • Any services received from a medical department, clinic or any facility provided or furnished by your spouse’s employer.
  • Any service that is not medically necessary or is not normally performed for proper dental care of the condition or any service that is not approved by the attending dentist.
  • Services or supplies that do not meet accepted standards of dental practice including experimental or investigational services or supplies.
  • Services or supplies received as a result of dental disease, defect, or injury due to an act of war, declared or undeclared.
  • Any duplicate prosthetic appliance except as specifically provided.
  • Charges for completing claim forms.
  • Oral hygiene, dietary instruction or plaque control programs.
  • Wiring or bonding teeth or crowns to act as a splint for any reason.
  • An injury arising from your former employment.
  • Illness or injury covered by Workers’ Compensation.
  • Services or supplies for which you are not required to pay.
  • Appliances, restorations, or any procedure to alter vertical dimension for cosmetic purposes.
  • Services or supplies not specifically listed under the Schedule of Dental Allowances.
  • Services for in-patient or out-patient hospital care.
  • Services by a provider whose office is attached to, or a dental school which is a part of, certain hospitals within New York State (call the Fund Office for a list of     such providers).
  • Any treatment costing $500 or more which is not submitted for Pre-Treatment     Review, as required.



THE DENTCARE BENEFIT PLAN
Dentcare is a pre-paid dental program offered by Dentcare Delivery Systems, Inc., a not-for-profit dental insurance company licensed by the New York State Insurance Department.  A wide range of dental services are provided by participating dentists at no cost to you, your spouse and your eligible dependents; a few services require co-payment by you of a specified amount. There are no annual or lifetime benefit maximums.

What Coverage is Provided?
Coverage is provided when:
  • Services are received in accordance with the procedures described in this Summary Plan Description.
  • Services are obtained while you, your spouse or your children are eligible for coverage (See the section entitled “Eligibility”).
  • Services are medically necessary and covered hereunder.
  • Services are not otherwise excluded.
How Does The Program Work?
You select one participating dentist from a panel of Dentcare dentists in a geographical area convenient to you. You can change your Dentcare dentist each annual open enrollment period. A request to change your dentist must be in writing and only the member can make the change.

What Dental Services Will You Receive?
Covered Services Provided By Dentcare Dentists:
  • Covered benefits include a large variety of typical dental services.  For a list of covered dental services, please see “Covered Dental Services” on the next page.
  • If you require the services of a specialist, your Dentcare dentist will refer you to a participating specialist.
  • In cases of emergency, Dentcare covers a maximum of two visits to a Dentcare dentist per member per contract year. However, if the member has had regular checkups or is undergoing treatment, there is no limitation on emergency coverage.
  • If the emergency occurs out of the Greater New York City area or if you are unable to visit a Dentcare dentist, Dentcare will reimburse up to $25 per eligible family member per contract year if you submit copies of the bills for emergency treatment.
  • In the event you are unable to reach your own participating dentist, DENTCARE provides 24 hour emergency service operators at:  (800)-468-0600
Click on this link to see your Dentcare Benefit Plan Covered Dental Services

What If My Request For Dental Services Is Denied?
If your request for dental services is denied and you disagree with the decision, you may request a review of your claim under Dentcare’s procedures for review of such claims.
Please contact the Fund Office for more information about Dentcare’s review procedures.

What If I Want To Change To A Different Plan?
The Fund offers two dental plan options.  If you are enrolled in Dentcare but would like to change to the Scheduled Dental Benefit Plan, follow these simple steps:
  • You can change plans during the open enrollment period, which occurs once each year.
  • Your new selection will become effective on January 1st of the following year.
  • You cannot be enrolled in Dentcare and the Scheduled Dental Benefit Plan at the same time.
  • If you move out of the geographical area served by Dentcare Delivery Systems, you may change to the Scheduled Dental Benefit Plan without delay.
Exclusions and Limitations
  • If alternate methods of treatment exist, payment will not be made for treatment carrying the greater fee, unless that treatment is the only adequate treatment.
  • Crowns and/or bridgework will only be allowed when these services are used to restore tooth structure or replace missing teeth as covered by the Group Contract.
  • Reconstruction: Payment will be made toward the cost of procedures necessary to eliminate oral disease and to replace teeth which have been removed subsequent to the effective date of insurance for the covered person.
  • When a prophylaxis and gum treatment are both performed on the same day, only the prophylaxis is a covered benefit.
  • Benefits for emergency treatment for relief of pain will not be allowed if the service is rendered along with any other service (excluding x-rays).
  • Oral exams, bitewing x-rays, prophylaxis, scalings and fluoride treatments – once every six months.
  • Full mouth and panoramic x-rays – once every 36 months.
  • Crowns, bridges, dentures & periodontal surgery – once every 60 months.
  • Orthodontic treatment of Class II/Class III malocclusions – one 24 month case.
  • Certain other procedures may have age limitations.  A list of such services is available on request.
  • Any dental services which were not rendered or approved by a participating dentist except in cases of out-of-area dental emergency.
  • A service not furnished by a dentist, unless the service is performed by a licensed dental hygienist under the supervision of a dentist or for an x-ray ordered by a dentist.
  • Treatment of a disease, defect, or injury covered by a major medical plan, Workmen’s Compensation Law, occupational disease law, or similar legislation.
  • General anesthesia, analgesia and any service rendered in a hospital environment.
  • Any dental procedures which are undertaken primarily for cosmetic reasons, or dental care to treat accidental injuries, congenital or developmental malformations.
  • Restorations, crowns or fixed prosthetics when acceptable results can be achieved with alternative methods or materials. In cases where the selection of a more expensive treatment plan is decided upon, the Plan will allow for the least costly alternative and the patient is responsible for all additional fees charged by the dentist.
  • Services which were started prior to the person becoming covered under this Plan.
  • Implants, grafts, precision attachments or other personalized restorations or specialized techniques.
  • Broken Appointments – If specified by Plan Dentist for appointments not cancelled 24 hours in advance, there is a $30 charge.
  • Replacement of any existing crown, bridge or denture which can be made serviceable according to common dental standards.
  • Procedures, appliances or restorations whose main purpose is to:  change vertical dimension; diagnose or treat conditions or dysfunction of the temporomandibular joint; stabilize periodontally involved teeth; lengthen crowns or restore occlusion.
  • Treatment of unmanageable children and/or unruly patients by general dentists or pedodontists. An attempt will be made to treat all patients. However, if patient is untreatable by virtue of apprehension or any other reason, and is referred to another office for treatment, the responsibility of payment lies with either the patient or with the parents of the patient.
  • Services not listed in the “Covered Dental Services” are not covered.
IMPORTANT NOTICE
The Fund does NOT recommend or endorse any particular dentist. You are responsible for selecting the Dentcare dentist of your choice. You should apply the same criteria and care in choosing a Dentcare dentist that you would apply in selecting any dentist.
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