FY2011 Health Benefits Booklet

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.