Washington Dental
Benefits - Participating
and Nonparticipating Dentists
Members have the option of visiting both participating
and nonparticipating dentists with all packages. However,
we have negotiated set charges with participating dentists
for given dental services. If members visit a nonparticipating
dentist and the dentist’s fees are greater than
our negotiated charges, the member will be responsible
for any coinsurance, plus the additional amount charged
by the nonparticipating dentist.
Who is Eligible for Benefits
Dental coverage is available to groups with current
Regence BlueShield of Idaho medical coverage. If an
eligible employee chooses dependent coverage, then all
dependents must be covered under the dental plan. Dependents
include the employee's spouse and all eligible children.
Participation Requirements
- For groups of less than 20 employees, 100% of the
total number of employees and dependents enrolled
for medical coverage must also enroll in dental coverage.
- For groups of 20 or more employees, 80% of the
total number of employees enrolled for medical coverage
must also enroll in dental coverage. If dependent
dental coverage is chosen, those dependents must also
have medical coverage.
- The program is also available on a freestanding
basis to groups of 15 or more enrolled employees who
currently do not have medical coverage with Regence
BlueShield of Idaho. Dental coverage is contingent
upon 75% of the total number of eligible employees
and dependents enrolling for coverage.
These participation requirements will not include employees
in the process of completing probationary periods.
| Monthly
Dental Rates
(effective 1/1/05) |
Employee |
$45.00 |
Spouse |
$45.00 |
Children |
$45.00 |
Services Covered
| Class I - Preventive and Diagnostic * |
- Oral Exams (twice in any calendar year)
- Cleaning (twice in any calendar year)
- Fluoride - Age 17 and Under (twice in any
calendar year)
- Bite Wing X-Rays (twice in any calendar year)
- Full Mouth X-Rays (once every 3 years)
- Sealants - Age 17 and Under (once in any
4 year period)
- Space Maintainers - Age 11 and Under
|
| Class II - Basic Services* |
- Palliative Emergency Treatment Pulp Vitality
Tests
- Biopsies of Oral Tissue Endodontics
- Fillings Simple Extractions
- Root Canal Treatment Apicoectomy
- Hemisection Complex Periodontal Services
- Anesthesia Oral Lesions
- Mucogingivoplastic Surgery
|
| Class III - Major Restorative * |
Prosthodontic Services Including:
- Initial installation of dentures or bridgework
- Replacement of existing dentures or bridgework
(installed at least 5 years prior to replacement
and cannot be made serviceable)
- Repairs to dentures, removable dentures,
bridgework, inlays and onlays
- Denture relining (once every 2 years)
- Crowns, including repairs and recementing
- Veneer, subject to Regence BlueShield of
Idaho's approval
- Onlays, subject to Regence BlueShield of
Idaho's approval
|
This is a partial listing. A complete list of covered
services can be found in the policy.
Deductible
The deductible amount is $25 per insured each calendar
year for Class I, Class II, and Class III services.
Each insured must meet the deductible amount, however
no family shall be obligated to meet more than three
(3) separate deductibles in any calendar year.
Coinsurance Amount
Benefits are provided at 100% of the allowable
charge for Class I services, 80% of the allowable charge
for Class II services, and 50% of the allowable charge
for Class III services. In no event will Regence BlueShield
of Idaho's payment exceed charges submitted.
Annual Maximum
Benefits shall not exceed $1,000 per insured each calendar
year.
Orthodontic Benefit
Orthodontic benefits can be purchased for groups of
twenty-five (25) or more enrolled employees. Groups
without prior orthodontic coverage shall be subject
to a twelve (12) month waiting period. Benefits for
orthodontic services shall be provided at fifty percent
(50%) of the allowable charge, subject to a lifetime
maximum of $1,000.
Temporomandibular Joint (TMJ) Disorders
- Temporomandibular joint (TMJ) disorders shall include
those disorders which have one or more of the following
characteristics: Pain in the musculature associated
with the temporomandibular joint (TMJ), internal derangements
of the temporomandibular joint (TMJ), arthritic problems
with the temporomandibular joint (TMJ), or an abnormal
range of motion or limitation of motion of the temporomandibular
joint (TMJ). Benefits for treatment of disorders meeting
this criteria shall be provided for medical or dental
services.
- Dental services are those which are:
- reasonable and appropriate for the treatment
of a disorder of the temporomandibular joint (TMJ),
under all the factual circumstances of the case;
and
- effective for the control or elimination of
one or more of the following, caused by a disorder
of the temporomandibular joint (TMJ): pain, infection,
disease, difficulty in speaking, or difficulty
in chewing or swallowing food; and
- recognized as effective, according to the professional
standards of good dental practice; and (4) not
experimental or primarily for cosmetic purposes.
- Benefits from the treatment of temporomandibular
joint (TMJ) disorders shall be provided pursuant to
the terms of the policy for physicians, dentists,
hospitals, and other providers practicing within the
scope of their license.
- Benefits from the treatment of temporomandibular
joint (TMJ) disorders and/or prognathism, shall be
limited to $5,000 paid during an insured?s lifetime.
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