Comprehensive Dental Coverage
Dental Plan for Active Employees
Quality dental care through United Concordia with no deductibles and generous coverage for preventive and major services.
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Important Notice
Benefit Effective Date
Who is Eligible?
Coverage eligibility for active members and dependents
Eligible Members
- •PFT Bargaining Unit Members: Teachers, Non-Teaching Assistants, Comprehensive Early Learning Centers, Food Service Managers, Para Professionals, Secretarial/Clerical, Pre-Kindergarten Head Start, Professional Technical, and Supportive Services Assistants
- •Spouse: The member's legally married spouse or domestic partner
- •Dependent Children: Unmarried, dependent children under 26 years of age
When Are Benefits Available?
Coverage start date
Benefits become available when the member has completed the required waiting period.
How Are Fees Determined?
Understanding usual and customary fees
United Concordia Companies, Inc. Dental Program provides for payment on the basis of "Usual and Customary" fees rather than on a fee schedule or table of allowances.
The "Usual and Customary Fee" is Determined By:
- 1.Usual Fee: The fee charged by a dentist to the majority of their patients for the procedure performed
- 2.Customary Fee: The fee charged in a particular geographical and economic area for services performed by dentists of similar training and experience
- 3.Reasonable Fee: The fee charged for services involving unusual circumstances requiring additional time, skill, or special consideration
- 4.Fund Administration Limits: Limits determined by the Fund Administration
What is a Participating Dentist?
Understanding in-network and out-of-network options
Participating Dentists (In-Network)
A Participating Dentist is a dentist who has signed a contract with United Concordia. The Participating Dentist agrees to accept the total allowable charge determined by United Concordia as the basis for 100%, 80%, or 50% determination.
How It Works
- •The statement sent by United Concordia to the member shows the total charge allowed (the "prevailing fee")
- •The Participating Dentist must accept the total allowed charge ("prevailing fee") as their fee
- •United Concordia pays 100%, 80%, or 50% of the permitted total (depending on the service)
- •Member pays either nothing, 20%, or 50% of the prevailing fee (depending on the service)
- •Payments are made directly to the participating dentist
Charges Exceeding Allowed Fee
Non-Participating Dentists (Out-of-Network)
A Non-Participating Dentist may charge more than the prevailing fee. There are no controls over the fees of Non-Participating Dentists.
What to Expect
- •United Concordia will pay only 100%, 80%, or 50% of the total allowed fee (depending on the service)
- •The member may have to pay a fee even though the service is a 100% coverage item
- •The member may have to pay more than 20% or 50% of the total allowed charge
- •Payment will be made to the subscriber (not the dentist)
Recommendation
What Are the Benefits?
Comprehensive coverage breakdown by service type
100% Coverage
100% of the total allowable fee or the amount charged (whichever is lower) – no additional charge to the member – for the following basic services:
- •Oral examination, including treatment plan if necessary (every 6 months)
- •Periapical and bitewing x-rays as required (complete mouth x-rays limited to once every 3 years unless special need is shown)
- •Topical fluoride application for dependents under age 19 (not more than once in any 6-month period)
- •Prophylaxis, including cleaning, scaling and polishing (every 6 months)
- •Repair of broken dentures
- •Palliative emergency treatment for conditions which cause dental pain
- •Fillings consisting of silver amalgam and synthetic tooth color restorations
- •Simple extractions
- •Endodontics, including pulpotomy, pulp capping and root canal treatment
- •Anesthetic services (performed by or under direct supervision of a dentist other than the operating dentist; local infiltrations or block anesthetic not covered)
- •Consultations (limited to one per consultant during hospitalization when condition requires and dentist requests)
- •Space maintainers (not made of precious metals, for dependent children under 19; no payment for duplicates)
80% Coverage
80% of the total allowable fee or the amount charged (whichever is lower) for Supplemental Basic Services approved by United Concordia after treatment plan submission:
- •Inlays and single crowns (single and unconnected)
- • Not part of a bridge or resulting from periodontal disease
- • Crowns as part of fixed bridge are 50%
- • No payment for precious metal restoration unless tooth cannot be restored with another metal
- • Splints are not covered
- • Predetermination required
- • Replacement covered only if at least 5 years have elapsed and existing restoration is unserviceable
- •Oral surgery consisting of cutting procedures
- • For treatment of diseases (excluding periodontal disease)
- • Including post-operative care normally included in surgical charge
- • Treatment of fractures and dislocations of the jaw
- • Extraction of impacted teeth (partially or totally covered by bone)
- • Removal of teeth and maxillary or mandibular intrabony cysts
- • Procedures for preparation of mouth for dentures
- • Appicoectomy (dental root resection)
50% Coverage - Prosthetic Services
50% of the total allowable fee or the amount charged (whichever is lower), approved by United Concordia after treatment plan submission:
- •Dentures, full and partial, and adjustments during 6-month period following insertion
- •Removable bridges, including pontics and abutment crowns, inlays and onlays
- •Services for fixed bridges (provided only when replacement cannot be made by other methods)
- •Full denture or bridge replacement after 5 years have elapsed (provided existing denture/bridge cannot be made serviceable)
- •Repair of broken crown, inlay, onlays or bridges
- •Relining or rebasing of dentures more than 6 months old (not more than once in any 36 consecutive months)
Important Notes
- • Preauthorization by United Concordia required routinely for prosthetic services
- • Services not provided for denture/bridge replacement due to loss or theft
- • If cast chrome or acrylic partial denture will restore arch satisfactorily, payment limited to this; balance is subscriber responsibility
- • No payment for veneers on other than the 10 upper and 10 lower anterior teeth
50% Coverage - Periodontic Services
50% of the total allowable fee or the amount charged (whichever is lower), approved by United Concordia after treatment plan submission:
- •Periodontic examination
- •Periodontic Prophylaxis (4 in any 12-month period – not in addition to regular prophylaxis)
- •Gingivectomy curettage
- •Gingivectomy and gingivoplasty
- •Osseous surgery, including flap entry and closure
- •Mucogingivoplastic surgery
- •Management of acute infection and oral lesions
Preauthorization Required
50% Coverage - Orthodontic Services
50% of the total allowable charges or the amount charged (whichever is lower) with a maximum allowance of $1,200.00 lifetime
- •Treatment plan must be approved by United Concordia
- •Services must be for handicapping malocclusions performed by a dentist qualified in orthodontics
- •Payments made quarterly over a period not exceeding the approved payment plan length
- •Initial payment shall be no more than 25% of total United Concordia liability
- •If services terminated before completion, United Concordia responsibility ceases with payment through month of termination
- •Charges for replacement/repair of any appliance not paid by United Concordia
- •Includes diagnosis (radiographs and study models) and retention treatment following active treatment
25% Coverage - Implants
Limited to endosseous, subperiosteal, transosseous, and unspecified implant procedures as a result of a congenital deformity.
What is Predetermination?
Treatment plan review process
Predetermination is the submission by the dentist of a treatment plan. United Concordia reviews the treatment plan and contacts the dentist if they feel the plan may be inadequate. It provides a review and check on the work.
Predetermination is Routinely Required For:
- •Crowns
- •Bridges
- •Inlays
- •Onlays
- •Periodontal surgery
- •All services that cost $300 or more
What Happens if a Member Has Coverage from Two Plans?
Coordination of benefits
Coordination of Benefits Rules
- •The plan under which the member has been enrolled the longest will determine its benefits first
- •The plan covering the member as an employee will determine benefits before the plan which covers the member as a dependent
- •When this dental plan is first, benefits will be paid without regard to coverage under any other plan
- •When this dental plan is not first, but there are remaining expenses after other coverage, this plan will pay its regular benefit up to the amount of the remaining expenses (these must be for services covered by this plan)
Active/Retired Spouse Coverage
If an active, eligible spouse member retires and elects to purchase Retiree dental coverage and the other spouse is still in active service, the following coordination takes place:
- • The active spouse coverage shall be first
- • The Retiree Dental plan shall be second
- • This is true for both Retiree Single or Retiree Family Coverage
How Does an Eligible Person Obtain the Benefit?
Step-by-step process
Process for Obtaining Benefits
- 1.When a member becomes eligible, they receive a United Concordia Dental Card in the mail
- 2.New dental cards are issued every April 30th and October 31st
- 3.The eligible member takes this card to the dentist
- 4.Participating Dentists should have United Concordia forms. If they do not, call the Health and Welfare Fund Office
- 5.If using a Non-Participating Dentist, call the Health and Welfare Fund Office for a form
- 6.The form is sent to United Concordia
- 7.Payment is made directly to Participating Dentist by United Concordia
- 8.Payment for Non-Participating Dentist services is usually made directly to the member
Keep Records
Exclusions
Services not covered by the dental plan
The following services and situations are not covered under the dental plan:
- •Services received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trustee or similar person or group
- •Services for which the subscriber incurs no charge
- •Services for any occupational conditions arising out of and in the course of covered employment under Workman's Compensation or similar legislation; or provided by Veterans Administration; or provided without cost by any federal, state, county, or municipal hospital, agency, or instrumentality
- •Services for congenital malformations (except Implants under special conditions) or primarily for cosmetic or esthetic purposes
- •Services where cost has been or is later recovered in any action at law or in compromise or settlement of any claim
- •Services or supplies provided by any governmental body pursuant to any program under which any periodic payment or premium is made by or for the subscriber
- •Appliances or restorations used solely to increase vertical dimensions (splinting)
- •Charges exceeding what would have been made and actually collected if no coverage existed
- •Services in a hospital performed by a dentist who is compensated by the hospital for similar services when performed for patients
- •Local anesthesia when billed separately by the dentist
- •Gold foil restorations
- •General anesthesia
- •Complete mouth x-rays more than once in any three-year period (unless special need is shown)
- •Oral examinations, periapical and bitewing x-rays, fluoride applications, and prophylaxis services more than once in any six-month period
- •Services other than those specifically covered
- •Unusual and experimental procedures and techniques
- •Plaque control
- •Sealants and oral hygiene and dietary instruction
- •Temporary items
- •Loss or theft replacements
- •Charges for completion of insurance forms
- •Implantology (except for congenital conditions)
- •TMJ
Optional Treatment Methods
Multiple Dentists
What Benefits are Available for Dependents of Deceased Employees?
Continued coverage for surviving family members
Spouse Coverage
Spouses of Health and Welfare members who die will continue to be eligible for full benefits for the remainder of the current benefit period, and for all the next benefit period.
Benefit Periods
Benefit periods last 6 months:
- • May 1 to October 31
- • November 1 to April 30
Example: If a covered member dies on September 1, the spouse is covered for 8 months (September through the next April).
Children Coverage
Benefit coverage is extended to eligible children of deceased employees as long as they remain dependent under the rules of the benefits involved.
Questions About Dental Care?
PFT Health & Welfare Fund Office
1816 Chestnut Street, Philadelphia, PA
(215) 561-2722
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