The Scheduled Dental Benefit PlanThe 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 Benefit 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.
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 see the “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
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
- 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.
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.