FY2011 Health Benefits Booklet

More documents

Recommendations

Info

42 s u m m a r y o f g e n e r a l b e n e f i t s j u l y 2 0 1 0 – j u n e 2 0 1 1 Dental Benefits Your Choices Dental coverage is available to all individuals who are eligible for State health benefits. United Concordia offers two dental plans from which to choose: a• Dental Health Maintenance Organization (DHMO) plan a• Dental Preferred Provider Organization (DPPO) plan Both the DHMO and DPPO plans offer a preventive benefit called The Smile for Health ® Maternity Dental Benefit. This benefit provides pregnant women with an additional cleaning during the course of pregnancy, regardless of whether they have met the cleaning limitation. This benefit helps control periodontal disease, which has been linked to premature births and low birthweight babies and also helps address a common condition known as pregnancy gingivitis. How the Plans Work The dhMO Plan When you enroll, you must select a Primary Dental Office (PDO) from the UCCI DHMO network of participating dentists. The DHMO allows you to select a different PDO for each member of your family. Your PDO will provide, or coordinate, all of your dental care services, including referrals to specialists. You may change your primary provider site selection at anytime during the plan year by contacting United Concordia. The DHMO plan will only pay benefits for in-network coverage, unless it is an out-of-area emergency (see page 43). Please note: It is highly recommended that you contact your dental provider before enrolling in dental benefits and before each annual Open Enrollment period to be sure he/she still participates in the plan you have selected. The State cannot guarantee the continued participation of a particular provider in any of the benefit plans. If your dentist discontinues participation in the plan, is terminated from the network, or closes his/her practice to new patients, you will not be allowed to change your plan or withdraw from the plan until the next Open Enrollment period. If this happens, contact your dental plan to select another provider. Predetermination of Benefits There is no requirement for you or your dentist to seek predetermination of benefits before treatment starts. However, you are encouraged to do so for major dental procedures so that you and your dentist will know exactly what will be covered and what you will need to pay out-of-pocket. What’s Covered – DHMO Plan Annual deductible Annual maximum Feature Preventive and diagnostic services, including exams, X-rays, cleanings, sealants, fluoride treatments, treatment of pain, other preventive care services Restorative services, including restoration of teeth, space maintainers, extraction of teeth, endodontic (root canal) services, periodontal services (including surgical and non-surgical services), oral surgery, general anesthesia Major Restorative services, including crowns, inlays, onlays, bridges, dentures, denture repair, implants Orthodontia (for adults and children), including evaluation and consultation, orthodontic treatment, orthodontic retention None None Benefit Coverage (In-Network Services Only) You pay $0 You pay according to the DHMO Benefit Schedule* You pay according to the DHMO Benefit Schedule* You pay according to the DHMO Benefit Schedule* * review the Schedule of Benefits carefully for the fee schedule amounts associated with each type of dental service. Services not listed on the Schedule of Benefits provided by the plan are not covered. The Schedule of Benefits for the DHMO plan is located on the State website at www.dbm.maryland.gov, click on Health Benefits. They are also available on the plan website.
Maryland State Employees and Retirees 43 Out-of-Area Emergencies The United Concordia DHMO will pay a maximum of $50, subject to your fee schedule, for emergency dental services when you are traveling out of the area (more than 50 miles from your dentist’s office). To receive payment for out-of-area emergency care, you must submit a bill itemizing the charges and services performed, and forward the claim to UCCI for processing. DHMO Network If you live in an area or move to an area that is not in the DHMO network of dentists, please contact UCCI to determine other options. To enroll in the DHMO plan, you must reside within the Maryland service area (MD, DC, VA, DE, WV, PA). In addition, you may request that the plan evaluate the dentist of your choice for inclusion in the network. However, there is no guarantee that a provider that you request will choose to participate in the plan network. In the DHMO plan, you can only receive coverage for services from a DHMO plan provider. The DPPO Plan The DPPO plan is also available through United Concordia. Under this Plan, you do not have to select a PDO. You may choose to receive services from any dentist of your choice whenever you need care. If you use an out-of-network dentist, you will need to submit a claim form for reimbursement and may be billed by the dentist for the amount charged that exceeds the allowed amount. No referrals are needed for specialty care. Orthodontia services are only covered for eligible children age 25 and younger. When you use an in-network DPPO dentist, the in-network dentist will directly bill the plan for the amount the plan will pay, and will bill you for the amount you are required to pay under the plan. DENTAL BENEFITS What’s Covered – DPPO Plan Annual deductible Annual maximum Feature Class I: Preventive services, initial periodic and emergency examinations, radiographs, prophylaxis (adult and child), fluoride treatments, sealants, emergency palliative treatment Class II: Basic Restorative services, including composite/resin fillings, inlays, endodontic services, periodontal services, oral surgery services, general anesthesia, prosthodontic maintenance, relines and repairs to bridges, and dentures, space maintainers Class III: Major services, including crowns and bridges, dentures (complete and partial), fixed prosthetics, implants Class IV: Orthodontia [for eligible child(ren) only, age 25 or younger], diagnostic, active, retention treatment Benefit Coverage (In-Network and Out-of-Network Services) $50 per individual; $150 per family Only applies to Class II and Class III services $1,500 per participant; only applies to Class II and Class III services Plan pays 100% of allowed amount Plan pays 70% of allowed amount, after deductible Plan pays 50% of allowed amount, after deductible Plan pays 50% of allowed amount, up to $2,000 lifetime maximum For More Information If you have questions about the dental plans, refer to the inside cover of this guide for the phone number and website of UCCI.
Page 1 and 2: State of Maryland July 2010 - June
Page 3 and 4: Table of Contents Introduction.....
Page 5 and 6: Maryland State Employees and Retire
Page 45: Maryland State Employees and Retire
Page 77 and 78: u If you decide to enroll in a Medi
Page 84: DEPARTMENT OF BUDGET & MANAGEMENT 3

FY2011 Health Benefits Booklet

Create successful ePaper yourself

Delete template?

Save as template?