Download Benefits Summary Prime and Complete Dental

Benefits
Summary
Prime and Complete Dental
For New York Employer Groups
Choice of Dental Program
Choose either Dental Prime, which uses our lower cost contracted network or Dental Complete, our even larger contracted network.
Then select your plan design below.
PLAN DESIGNS AVAILABLE TO SMALL GROUPS WITH 2-50 EMPLOYEES
Passive
or
Active
In-network
Out-of-network
Annual
Deductible
Choice
Annual
Maximum
Choice
Endodontic,
Periodontal and
Oral Surgery
Category
Orthodontic
Coverage
(Ortho)
Waiting Periods
(Major and Ortho)
Annual
Maximum
Carryover
Value Dental plans – coverage for the basics like cleanings, exams, X-rays and fillings.
Passive 100% D&P
80% Basic
0% Major
100% D&P
80% Basic
0% Major
$50
$500 or $1,000
Basic
Not covered
None
Not available
Active 100% D&P
80% Basic
0% Major
80% D&P
60% Basic
0% Major
$50
$500 or $1,000
Not covered
Not covered
None
Not available
Classic Dental plans – coverage for basic dental services, plus additional coverage for most major services, all with generous annual maximums.
Plus, annual maximum carryover options.
Passive 100% D&P
80% Basic
50% Major
100% D&P
80% Basic
50% Major
$25 or $50
$1,000 or $1,500
Basic or Major
50% child only,
50% child or adult,
or not covered
None
Optional
Active 100% D&P
80% Basic
50% Major
80% D&P
60% Basic
50% Major
$25 or $50
$1,000 or $1,500
Basic or Major
50% child only,
50% child or adult,
or not covered
None
Optional
Enhanced Dental plans – the greatest level of coverage, with choices for even higher annual maximums and lower coinsurance amounts.
Plus, annual maximum carryover options.
Passive 100% D&P
90% Basic
60% Major
100% D&P
90% Basic
60% Major
$25 or $50
$2,000
Basic
50% child only,
50% child or adult,
or not covered
None
Optional
Active 100% D&P
90% Basic
60% Major
80% D&P
70% Basic
50% Major
$25 or $50
$2,000
Basic
50% child only,
50% child or adult,
or not covered
None
Optional
Voluntary Dental plans – access to high-quality, comprehensive dental coverage for your employees at little or no cost to you.
Plus, annual maximum carryover options.
Passive 100% D&P
80% Basic
50% Major
100% D&P
80% Basic
50% Major
$25 or $50
$1,000 or $1,500
Major
50% child only,
or note covered
12 month
Optional
Active 100% D&P
80% Basic
50% Major
80% D&P
60% Basic
50% Major
$25 or $50
$1,000 or $1,500
Major
50% child only,
or note covered
12 month
Optional
20335NYEENEBS Rev. 6/11
Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc.,
licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
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Plan Description
Deductible
Waived for diagnostic & preventive
Family deductible equals three individual deductibles.
Ortho lifetime maximum
For plans with orthodontic coverage, per member lifetime maximum equal to the plan’s annual maximum
Waiting period for voluntary plans
12 month waiting period applies for major and orthodontic services. Waived if employer shows prior comparable
coverage with enrollment paperwork.
Dependent age limit
Up to age 26 or 30
Out-of-network Reimbursement
Option to pay Maximum Allowable Charge (MAC) or 90th percentile
Participation Guidelines (For employers with 2-50 employees)
Employer-paid: options from 50% to 100% of net eligible employees at 10% increments.
Voluntary: minimum participation of 2 enrolled employees.
Dual Option: not available
Ortho: minimum 10 enrolled employees.
PLAN DESIGNS AVAILABLE TO LARGE GROUPS WITH 51 OR MORE EMPLOYEES
Plan Design Options
Active plan options
(Different coinsurances in-network and out-of-network available)
Passive plan options
(Same coinsurances in-network and out-of-network)
Diagnostic and
preventative
Coinsurance
Options:
100%, 95%, 90%, 85%, 80%, 75%,
70%, 65%, 60%, 55% or 50%
Basic Services
Coinsurance
Options:
100%, 95%, 90%, 85%, 80%, 75%,
70%, 65%, 60%, 55%, 50%, or not covered
Major services
Coinsurance
Options:
100%, 95%, 90%, 85%, 80%, 75%,
70%, 65%, 60%, 55%, 50%, or not covered
$0, $15, $20, $25, $30, $35, $40, $45, $50, $55, $60,
$65, $70, $75 , $80, $85, $90, $95, $100
or a $100 Lifetime Maximum
Deductible – contract or calendar year option
May be waived for D&P; Family aggregate options: 2X , 3X or none
Annual maximum – contract or calendar year option
$500; $750; $1,000; $1,250; $1,500; $1,750; $2,000; $2,250 or $2,500
Benefit categories
Endodontic, periodontal and oral surgery
Orthodontic coverage
Options to not cover, child only or adult and child
Annual maximum and orthodontic maximum do not have to be the same
Out-of-network dentist reimbursement
Basic or Major
Coinsurance
Options:
Lifetime
Maximum:
100%, 95%, 90%, 85%, 80%, 75%,
70%, 65%, 60%, 55%, 50%, or not covered
$500; $750; $1000; $1,250; $1,500;
$2,000; $2,225 or $2,500
Maximum Allowable Charge (MAC) or 50th, 60th, 70th, 80th 90th percentile
Waiting periods
Basic, Major or Orthodontic Services may have different waiting periods
For voluntary plans
Major and Orthodontic services have a 12-month waiting period. Waiting period is waived if
employer shows prior comparable coverage with enrollment paperwork.
Annual maximum carryover
Dependent age limit
Out-of-network Reimbursement
None, 6 or 12 months for Basic and Major Services
None or 12 months for Orthodontic Services
Optional
Up to age 23, 26 or 30
Option to pay Maximum Allowable Charge (MAC) or
percentile (50th, 60th, 70th, 80th, or 90th)
Participation Guidelines (For employers with 51 or more employees)
Employer-paid: minimum 60% participation of net eligible employees
Voluntary: minimum participation of 2 enrolled employees.
Dual Option:
- Employer-paid plans: minimum of 5 employees must enroll in each of the two options, employee-only rate tier must have at least 20% rate differential, and all other group participation guidelines apply.
- For Voluntary plans: dual option is not available.
Ortho: minimum 10 enrolled employees.
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Benefit Description
Time Frames
Comments
Diagnostic and Preventive (D&P)
Services
Oral exams of any type (including
emergency and specialist)
Covered 2 times per calendar year
Full mouth/panoramic X-rays
1 every 60 months
Bitewing X-rays
One series of films per 12-month period for Members to
age 18; and one series of films per 24-month period for
Members age 18 and older
Periapical X-rays
4 per 12-month period
Routine cleanings
2 routine cleanings or periodontal maintenance per
calendar year
Topical fluoride application
1 per 12-month period to age 19
Sealants
Once per 24-month period to age 16
Sealants once per 24-month period to age 16 For 1st and 2nd molars.
Unless quoted otherwise, standard coverage for sealants is considered
a D&P Service.
Restorations
XXAmalgams
XXComposite restorations
Limited to only 1 service per tooth surface per
24-month period
Unless quoted otherwise, coverage for a composite restoration on a
posterior (back) tooth is limited to the allowance for the equivalent
amalgam restoration. The member is responsible for the difference in
cost between the composite and the amalgam filling. Large groups may
elect to cover composite restorations on posterior teeth based on the
composite allowance.
Space maintainers
Covered 1 time per lifetime to the age of 17
Covered for extracted primary posterior (back) teeth. Repair or
replacement of lost/broken appliances are not a covered benefit.
Covered 1 time every 36 months for Members age 20 to
40. Limited to 1 per 12-month period per Member age 40
and above.
Brush Biopsy coverage is considered a standard benefit; however, large
groups have the option to not cover this service.
Root canals
1 time per tooth per lifetime
On permanent teeth only
Periodontal maintenance
2 cleanings or periodontal maintenance per calendar year
Cleanings paid at the preventive coinsurance
Periodontal scaling and
root planing
Covered 1 time per 36 months if the tooth has a pocket
depth of 4 millimeters or greater
Osseous surgery
Only 1 complex surgical periodontal service is covered per
36-month period per single tooth or multiple teeth in the
same quadrant and only if the pocket depth of the tooth is
5 millimeters or greater
Periodontal maintenance paid at the periodontal coinsurance
Basic Services
Emergency treatment
for the relief of pain
Basic extractions
Brush biopsy
Endodontic, Periodontal and
Oral Surgery
Surgical extraction
Surgical removal of 3rd molars (wisdom teeth) are only covered when there
are symptoms of oral pathology
General anesthesia or
intravenous sedation
When given in conjunction with a complex surgical service
See the certificate for additional endodontic, periodontic, and oral surgery procedures that may be covered under the plan.
The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract. In the event of a conflict
between the Group Contract and this description, the terms of the Group Contract will prevail.
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Benefit Description
Time Frames
Comments
Major Restorative Services
Permanent crowns or onlays
Covered 1 time per 7 year period
Removable prosthetic services
(dentures and partials)
Covered 1 time per 7 year period
All prosthetic services are subject to a 12 month missing tooth exclusion
Fixed prosthetic services (bridge)
Covered 1 time per 7 year period
All prosthetic services are subject to a 12 month missing tooth exclusion
Single tooth implant body,
abutment and crown
Covered 1 time per 7 year period
Implants are covered as a major restorative service. All prosthetic services
are subject to a 12 month missing tooth exclusion. For members age 16
and over. Coverage includes only the single surgical placement of the
implant body, implant abutment and implant/abutment supported crown.
Implants are considered a standard benefit for small groups. Large group
may choose to cover implants or not.
See your certificate for additional major restorative procedures that may be covered under your plan.
Orthodontics
Optional coverage for classic, enhanced, and voluntary plans. Child only coverage covers children up to age 19.
XXChoice of child only (8 up to age 19), child and adult, or
no coverage.
XXOrthodontia is not an option for Value plans.
Annual Maximum Carryover
Unused benefit dollars in one year
can be carried over into the next
coverage year
Optional plan feature for classic, enhanced, and
voluntary plans.
XX$250 maximum carryover per member per year.
XXAt the end of each year, carryover will be recorded
in a separate Carryover Account. Once the Carryover
Account has reached $1,000 per member, no further
amounts will accumulate.
XXAnnual maximum carryover is not an option for
Value plans.
Following requirements must be met:
XXMember must be enrolled under this plan for a full calendar year, and
XXMember must have submitted at least one claim for the coverage
year, and
XXMember did not exceed $500 in covered services applied to their
annual maximum.
The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract. In the event of a conflict
between the Group Contract and this description, the terms of the Group Contract will prevail.
When selecting a dental carrier, please consider the Dental Prime
and Complete Value-Added benefits. For details, talk to your Empire
representative or visit empireblue.com.
XX
Easy-to-access information. With Empire you have 24/7 online access
to your dental claim and benefit information.
XX
International dental emergency care: members traveling outside the
U.S., automatically have coverage for emergency dental services
through a worldwide network of English-speaking dentists.
XX
Education materials to promote dental health.
XX
Healthy discounts for your employees: savings on alternative medicines, vision
products, and fitness club memberships through our SpecialOffers program.
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