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Tri-State Preferred Plan SPD >> Dental Benefits
How the Plan Works
The Plan provides coverage for necessary dental care received through:
the 32BJ Dental Center at 101 Avenue of the Americas, a participating dental provider, or
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a non-participating dentist.
Necessary dental care is a service or supply that is required to identify or treat a dental condition, disease or injury. The fact that a dentist prescribes or approves a service or supply or a court orders a service or supply to be rendered does not make it dentally necessary. The service or supply must be all of the following:
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provided by a dentist, or solely in the case of cleaning or scaling of teeth, performed by a licensed, registered dental hygienist under the supervision and direction of a dentist
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consistent with the symptoms, diagnosis or treatment of the condition, disease or injury
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consistent with standards of good dental practice
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not solely for the patient's or the dentist's convenience, and
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the most appropriate supply or level of service that can safely be provided to the patient.
Covered services are listed in the "Schedule of Covered Dental Services" subject to the frequency limitations that are stated in that Schedule. The Plan pays no benefits for procedures that are not on the Schedule, but may provide an alternate benefit if approved by the Fund. Whether you have to pay for those services and, if so, how much, depends on whether you choose to receive your dental care from the 32BJ Dental Center, from a participating dental provider or from a non-participating dentist.
The 32BJ Dental Center
The 32BJ Dental Center is equipped to provide a broad range of dental services, except those that require general anesthesia. If you receive your dental care from the 32BJ Dental Center, you will not have to pay for any of that care.
Participating Dental Providers
The Plan’s dental benefits include a “participating dentist” feature. Dentists who are in the Plan’s participating dental provider network have agreed to accept the amount that the Plan pays as payment in full for their dental services. If you choose to receive your care from a participating dental provider, you will not have to pay anything for covered dental care you receive, except for osseous surgery, for which you will have to make a $125 co-payment for each quadrant.
Non-Participating Dentists
The Plan will pay for dental work performed by any properly accredited dentist, but the Plan will pay no more than the amount listed on its Schedule of Allowed Amounts. (Contact the Member Service Center for a copy of the Schedule of Allowed Amounts.) If the dentist charges more than those amounts for your dental care, you will be responsible to pay the difference between what the dentist charges and what the Plan pays. Be sure to ask the dentist before you start treatment what the charges will be, so that you will know what your out-of-pocket expenses may be.
The Fund will pay the smaller of the dentist’s actual charge for a covered dental service or the allowed amount for that procedure, as indicated in the Schedule of Allowed Amounts.
Prior Approval
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For all treatment plans of $300 or more, your dentist must send a claim form for prior authorization to the Fund before any treatment begins, except in the case of an emergency. If you start non-emergency treatment before you receive prior approval from the Fund, you may have to pay the full amount that the dentist charges.
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Prior approval is necessary even if your dentist is a participating dental provider.
Prior approval is not necessary before receiving services from the 32BJ Dental Center.
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An approved treatment plan submitted by a dentist can be used only by that dentist and only within one year of the approval.
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Changes to your current approved treatment plan require submitting a new treatment plan for review and approval.
In order to submit a proposed treatment plan for review, your dentist should send all the information, including diagnostic quality X-rays, to:
Daniel H. Cook Associates, Inc.
C/o Building Service 32BJ Health Fund
Dental Claims
P.O. Box 676
New York, NY 10013-0819
What Dental Services Are Covered
The Plan covers a wide range of dental services, including:
• Preventive and diagnostic services such as routine oral exams, cleanings, X-rays, topical fluoride applications and sealants
• Basic therapeutic services such as extractions and oral surgery, intravenous conscious sedation when medically necessary for oral surgery, gum treatment, fillings and root canal therapy
• Major services such as fixed bridgework, crowns, dentures, and gum surgery, and
• Orthodontic services such as diagnostic procedures and appliances to realign teeth. There is a separate lifetime maximum on orthodontic services of $1,500 for patients age 16 and older, and $2,500 for patients under age 16.
See the "Schedule of Covered Dental Services" section for details.
Frequency Limitations
Benefits are subject to the frequency limits shown in the "Schedule of Covered Dental Services" section.
Frequency Limitations
Benefits are subject to the frequency limits shown on the Schedule of Covered Dental Services above
Alternate Benefit
There is often more than one way to treat a given dental problem. For example, a tooth could be repaired with an amalgam filling, a resin composite or a crown. If this is the case, the Plan will generally limit benefits to the least expensive method of treatment that is appropriate and that meets acceptable dental standards. For example, if your tooth can be filled with amalgam and you or your dentist decide to use a crown instead, the Plan pays benefits based on the amalgam. You will have to pay the difference.
What Is Not Covered
The Plan's dental coverage will not reimburse or make payments for the following:
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any services performed before a patient becomes eligible for benefits or after a patient’s eligibility terminates, even if a treatment plan has been approved
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reimbursement for any services in excess of the frequency limitations specified in the Schedule of Covered Dental Services
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charges in excess of the Allowed Amounts – contact the Member Service Center for the Schedule of Allowed Amounts for dental care
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services that required prior approval, but are initiated without approval, with the exception of emergency treatment (e.g., single tooth root canal)
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treatment for accidental injury to natural teeth that is provided more than 12 months after the date of the accident
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services or supplies that the Plan determines are experimental or investigative in nature
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services or treatments that the Plan determines do not have a reasonably favorable prognosis
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any treatment performed principally for cosmetic reasons, including, but not limited to, laminate, veneers and tooth bleaching
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special techniques, including precision dentures, overdenture, characterization or personalization of crowns, dentures, fillings or any other service. This includes, but is not limited to, precision attachments and stress-breakers. Full or partial dentures that require special techniques and time due to special problems, such as loss of supporting bone structure, are also excluded.
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any procedures, appliances or restorations that alter the "bite," or the way the teeth meet (also referred to as occlusion and vertical dimension) and/or restore or maintain the bite, except as provided under orthodontic benefits. Such procedures include, but are not limited to, equilibration, periodontal splinting, full-mouth rehabilitation, restoration of tooth structure lost from attrition, and restoration for misalignment of teeth.
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any procedures involving full-mouth reconstruction, or any services related to dental implants, including any surgical implant with a prosthetic device attached to it
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diagnosis and/or treatment of jaw joint problems, including temporomandibular joint disorder (TMJ) syndrome, craniomandibular disorders, or other conditions of the joint linking the jaw bone and skull or the complex of muscles, nerves, and other tissue related to that joint
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double or multiple abutments
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treatment for self-inflicted injury or illness
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treatment to correct harmful habits, including, but not limited to, smoking and myofunctional therapy
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habit-breaking appliances, except under the orthodontics benefit
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services for plaque-control programs, oral hygiene instruction, and dietary counseling
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services related to the replacement or repair of appliances or devices, including:
- duplicate dentures, appliances or devices
- the replacement of lost, missing or stolen dentures and appliances less than five years from the date of insertion or the payment date
- replacement of existing dentures, bridges or appliances that can be made useable according to dental standards
- adjustments to a prosthetic device within the first six months of its placement that were not included in the device's original price, and
- replacement or repair of orthodontic appliances.
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drugs or medications used or dispensed in the dentist's office (any prescriptions that are required may be covered by the Plan's prescription drug benefits – see the "Prescription Drug Benefits" section)
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charges for novocaine, xylocaine or any similar local anesthetic when the charge is made separately from a covered dental expense
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additional fees charged by a dentist for hospital treatment
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services for which a participant has contractual rights to recover cost, whether a claim is asserted or not, under Workers' Compensation, or automobile, medical, personal injury protection, homeowners or other no-fault insurance
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treatment of conditions caused by war or any act of war, whether declared or undeclared, or a condition contracted or accident occurring while on full-time active duty in the armed forces of any country or combination of countries
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any portion of the charges for which benefits are payable under any other part of the Plan
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if a participant transfers from the care of one dentist to another dentist during the course of treatment, or if more than one dentist renders services for the same procedure, the Plan will not pay benefits greater than what it would have paid if the service had been rendered by one dentist
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transportation to or from treatment
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expenses incurred for broken appointments
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fees for completing reports or for providing records, or
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any procedures not listed under the Schedule of Covered Dental Services.
Coordination of Dental Benefits
If you have dental coverage through another carrier, which serves as your primary dental insurer, prior approval is not required if you secured this approval through your primary dental insurer. See the "Coordination of Benefits" section for the rules that determine which carrier is primary.
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