Description of the Basic Dental Plan:
Retirees

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General Information

• Fees—Basic Plan
• Dependents Eligible for Enrollment
• Changes in Your Address or Family Status
• How Benefits Are Received
• Termination of Coverage

United Concordia Basic Group Dental Program

• Payment of Benefits
• The Basic Program
• Oral Surgery
• Prosthetic and Crown, Inlay and Onlay Restorations
• Exclusions and Limitations
• Peridontal Services
• Predetermination 
• Alternate Treatment

Alternative Dental Plan—DentalPLUS Program

What Is Not Covered

• You are not covered for services, supplies or charges that:
• You are not covered for:
• Payment for services is limited as follows:

Coordination of Benefits—United Concordia Program

Claim Appeal Procedure

General Information

Fees—Basic Plan

Single:  $20.68/month.

Two People:  $40.02/month.

Family:  $53.01/month.  Back to Top

Dependents Eligible for Enrollment

Your spouse and all unmarried children under 19 years of age are eligible for enrollment. Unmarried dependent children that are enrolled and in full-time attendance at an accredited secondary school, college, university, or approved post high school educational program may be included up to age 25.  Back to Top

Changes in Your Address of Family Status

It is important that you notify the H&W office promptly of any change in your address or your family status -- including marriage, divorce, birth or adoption of a child, marriage of dependent children, death of spouse or child. Change forms and application cards should not be sent directly to the United Concordia Plan Office.  Back to Top

How Benefits Are Received

United Concordia Plan (Dentist's Charges)
Present your United Concordia Identification Card at the time services are provided by a network dentist. The dentist will submit a claim form directly to United Concordia on your behalf. The payment will be sent to the dentist and United Concordia will notify you of the final disposition of the claim. A non-participating dentist, in most cases, will submit a claim to United Concordia on your behalf. However, if they will not submit a claim, it will be your responsibility to do so within one year from the date of services. Request an itemized bill which shows:

1. Patient's name and address
2. Date of service
3. Type of service and diagnosis
4. Itemized charges
5. Dentist's complete name and address

Then add the subscriber's name, group and agreement numbers (as shown on your identification card), and the patient's birthday. If you need assistance, contact United Concordia at 1-800-332-0366. If you do not need assistance, please send your receipt to:

United Concordia Companies, Inc.
P.O. Box 898268
Camp Hill, PA 17011

When services are performed by non-participating dentists, the payment must be made directly to the subscriber.  Back to Top

Termination of Coverage

Failure to pay your Concordia Dental Retirees bill will terminate retiree dental coverage.  Back to Top

United Concordia Basic Group Dental Program

Our group dental program consists of the services listed below.

Payment of Benefits—Usual, Customary and Reasonable (UCR) Method

Usual, Customary and Reasonable (UCR) means that fee determined and payable by United Concordia for covered services as follows:

• The Usual fee is the fee that an individual dentist most frequently charges the majority of his patients for the procedure performed.
• The Customary fee is the fee determined by United Concordia based on charges made by most providers of the same specialty in comparable geographical/economic areas for the procedure performed.
• The Reasonable fee (which may differ from the usual or customary charge) determined by United Concordia by considering unusual clinical circumstances; the degree of professional involvement; or the actual cost of equipment and facilities involved in providing the service.
• Payment for services performed by United Concordia Participating Dentists (those dentists with whom United Concordia has a contract with respect to payment for services) will be made to the dentist on the basis of a percentage of the UCR allowance (as specified below) or the amount charged, whichever is less.
• A participating dentist must accept United Concordia's allowance as payment in full for covered services. You are responsible for any coinsurances, deductibles and amounts exceeding the maximum (if applicable under your program) or any service not covered by United Concordia. The sum of your payment and the United Concordia payment will be accepted as payment in full provided that your payment is made to the participating Professional Provider within 60 days of notification by United Concordia. If your payment is not made within 60 days, the participating Professional Dentist may bill you the difference between the charge and the UCR allowance.
• Payment for covered services performed by Non-Participating Dentists will be made to you on the basis of a percentage of the UCR allowance (as specified below) or the amount charged, whichever is less. Non-participating dentists are not obligated to accept the UCR allowance as payment-in-full. Such payment will constitute full discharge of United Concordia's responsibility under the Program. You are responsible for payment of the remaining charge.
  Payment under the program is limited to a maximum of $1,500 per person for all services rendered in any calendar year.
• The Basic Program 80% UCR
• Diagnostic Services 80% UCR
• Preventive Services 80% UCR
• Minor Restorations 80% UCR
• General Services 80% UCR
• Oral Surgery 50% UCR
• Prosthetics and Crown, Inlay and Onlay 50% UCR
• Restorations 50% UCR
• Periodontics 50% UCR
• Benefits will be provided for eligible dental services when billed by the dentist in charge of the case. This professional care can be performed anywhere unless otherwise indicated.  Back to Top

You are entitled to a payment for the following covered services you receive from a dentist provided they are deemed dentally necessary by United Concordia:

The Basic Program

1. Diagnostic Services:
   1. Routine oral examinations, but not more than once in any period of 6 consecutive months.
   2. Dental X-rays:
   • Full mouth x-rays, but not more than once in any period of 36 consecutive months.
   • Bitewing x-rays but not more than once in any period of 6 consecutive months.
   • Periapical x-rays as required.
2. Preventive Services:
   1. Routine prophylaxis (including cleaning, scaling and polishing of teeth), but not more than once in any period of 6 consecutive months.
   2. Topical fluoride application for dependent children under 19 years of age, but not more than once in any period of 6 consecutive months.
   3. Space maintainers (not made of precious metals) that replace prematurely lost teeth for dependent children under 19 years of age.
3. Minor restorations: Amalgam, silicate, acrylic, synthetic porcelain, and composite filling restorations to restore diseased or accidentally broken teeth.
4. General Services:
   1. Repair of broken partial or full removable dentures.
   2. Palliative emergency treatment of an acute condition requiring immediate care.
   3. Simple extractions.
   4. Endodontics, including pulpotomy, direct pulp capping and root canal treatment.
   5. Administration of anesthesia in connection with covered services when rendered by or under the direct supervision of a dentist other than the surgeon, assistant surgeon or attending dentist.
   6. Inpatient consultations if the condition requires it and the dentist in charge of the case requests the consultation. You are limited to one consultation per consultant during any one inpatient stay.  Back to Top

Oral Surgery

1. Surgical removal of teeth.
2. Surgical removal of maxillary or mandibular intrabony cysts.
3. Procedures performed for the preparation of the mouth for dentures.
4. Apicoectomy (dental root resection).
5. Services of a dentist who actively assists the operating surgeon in the performance of covered surgery when the condition of the patient or the type of surgery performed requires assistance. Surgical assistance is not covered when performed by a dentist who himself performs and bills for another surgical procedure during the same operative session.

Limitation on Oral Surgery: If more than one oral surgical procedure is performed by the same dentist during the same operative session, United Concordia shall pay 100% of the UCR allowance for the highest paying procedure and no allowance for additional procedures except where United Concordia deems that an additional allowance is warranted.  Back to Top

Prosthetic and Crown, Inlay and Onlay Restorations

Coverage for prosthetics, crowns, inlays and onlays may be limited to the least expensive but adequate treatment plan consistent with established dental standards. A more expensive treatment plan than that covered under this dental program may be selected with the understanding that the subscriber will be responsible for paying the difference in cost between the treatment received and the United Concordia allowance. (Refer to Alternate Treatment Section.)

1. Initial insertions of bridges (including pontics and abutment crowns, inlays and onlays).
2. Initial insertion of partial or full dentures (including any adjustments during the 6 month period following insertion).
3. Replacement of an existing partial or full denture or bridge by a new denture or by a new bridge, but only if satisfactory evidence is presented that:
   1. The existing denture or bridge was inserted at least 5 years prior to the replacement; and
   2. The existing denture or bridge is not serviceable and cannot be made serviceable.
   If the existing denture or bridge can be made serviceable, payment will be made toward the cost of the services which are necessary to render such appliance serviceable.
4. Single unconnected crowns, inlays and onlays (none of which is part of a bridge or are splinted together).
5. Replacement of crowns, inlays and onlays, but only if satisfactory evidence is presented that at least 5 years have elapsed since the date of the insertion of the existing crown, inlay or onlay, and only if the existing crown, inlay or onlay is unserviceable and cannot be made serviceable.
6. The addition of teeth to an existing partial denture or to a bridge, but only if satisfactory evidence is presented that the addition of teeth is required to replace one or more teeth extracted after the existing denture or bridge was inserted.
7. Relining or rebasing of dentures more than six months after the insertion of an initial or replacement denture, but not more than one relining or rebasing in any period of 36 consecutive months.
8. Repair of broken crowns, inlays, onlays and bridges.

Exclusions and Limitations on Prosthetics and Crown, Inlay and Onlay Restorations:

1. If a cast chrome or acrylic partial denture will restore the dental arch satisfactorily, payment of the applicable percentage of the UCR allowance for such procedure will be made toward a more elaborate or precision attachment denture or bridge that the subscriber and dentist may choose to use, and the balance of the cost is your responsibility.
2. If the personalized dentures, bridges or crown, inlay and onlay restorations or specialized techniques as opposed to standard procedures are chosen, payment of the applicable percentage of the UCR allowance for the standard covered services will be made toward such treatment and the balance of the cost is your responsibility.
3. Payment will be made for crown, inlay and onlay restorations only if the tooth cannot be restored with another material, such as amalgam. However, if the tooth can be restored with another material, payment of the applicable percentage of the UCR allowance for that procedure will be made toward the charge for the restoration selected. The balance of the treatment charge is your responsibility.
4. Any denture or bridge replacement made necessary by reason or loss or theft or subscriber alteration of a denture or bridge shall not be considered a covered service.
5. No payment will be made for any crown, inlay or onlay restoration or for any denture or bridge and the fitting thereof which was prescribed while the subscriber was not covered under this Program or for which the restorative treatment was initiated or the denture or bridge prescribed while you were covered under this Program and which is finally inserted more than 30 days after termination of coverage.
6. No payment will be made for precious metal dentures. Payment of the applicable percentage of the UCR allowance for a nonprecious metal denture will be made toward the charge for the precious metal denture selected by the subscriber and dentist. The balance of the treatment charge is your responsibility.
7. No payment will be made until services are completed. Crowns, inlays, onlays, bridges and dentures shall be considered completed on the date they are finally inserted.  Back to Top

Periodontal Services

1. Diagnosis and treatment planning including periodontal examination.
2. Nonsurgical periodontal therapy including periodontal scaling and root planning and special periodontal appliances.
3. Surgical periodontal therapy.
4. Maintenance -- post treatment preventive periodontal procedures (periodontal prophylaxis).

Limitation on Periodontal Services: Post treatment preventive periodontal procedures are limited to 4 in any period of 12 consecutive months. This maximum shall be reduced by the number of routine prophylaxis received during that 12 month period so that the total number of prophylaxis for a give 12 month period, including both routine and periodontal prophylaxis, shall not exceed 4.  Back to Top

Predetermination

• Predetermination is used by United Concordia to determine eligibility of the subscriber and to review the treatment plan to determine the extent of coverage. This assures both the subscriber and the dentist that the particular service that will be performed is a covered service. However, approval by United Concordia of the treatment plan during the predetermination process does not necessarily constitute acceptance by United Concordia of liability for the services involved in the treatment plan. For example: If the patient's coverage is terminated before the planned treatment is completed, United Concordia will not be liable for any services provided after the date of such termination.
• Predetermination is required for:
  • All treatment plans of $300 or more;
  • The extraction of six or more teeth;
  • Prosthetics and Crown, Inlay and Onlay Restorations;
  • Periodontics.  Back to Top

Alternate Treatment

• Frequently your dentist can choose from several alternate methods of treating a particular dental problem. For example, a tooth can be restored with either a crown or a filling. And missing teeth can be replaced with either a fixed bridge or a partial denture. In cases where alternate methods of treatment are possible, United Concordia will make payment based on its allowance for the less expensive procedure provided that the less expensive procedure meets accepted standards of dental treatment. Whenever this alternate treatment provision is applied, a United Concordia Dental Advisor reviews the claim
• United Concordia's decision on the allowance it will pay does not commit you to the less expensive procedure. You may decide to have the more costly treatment and to be responsible for the additional charges beyond those for the treatment paid by United Concordia.  Back to Top

Alternative Dental Plan—DentalPLUS Program - The DentalPLUS Program is not accepting new applicants.

Overview

• DentalPLUS is an alternative to the Basic Retiree dental plan.  The DentalPLUS Program is not accepting new applicants.
• You make the choice - you may join the Basic Retiree dental plan or you may choose to join an office in the alternative program, DentalPLUS.
• You may not belong to both plans.
• You may change offices within the plans.
• You may drop out of DentalPLUS and return to your Basic Retiree program. It will take 30 days to make the change effective. Then there will be a two year waiting period if you wish to rejoin DentalPLUS.  Back to Top

DentalPLUS Office Visits

The Primary Dental Offices will be available to answer your questions concerning their offices. If you wish to visit their offices, simply call to arrange a time.

Program

• DentalPLUS is a dental program offered to all retired members of the Philadelphia Federation of Teachers Health and Welfare Fund in Southeastern Pennsylvania as an option to your Basic Retiree dental program.
• DentalPLUS stresses preventive care by encouraging regular and early treatment.
• DentalPLUS provides you with easy access to dental care while, in many cases, reducing your out-of-pocket expenses.  Back to Top

An Alternative Dental Choice

• DentalPLUS offers improved benefits to the eligible Retiree members. (See the Comparison Chart)
• With DentalPLUS...
  • There are no frequency limitations.
  • There are no insurance form for the members to complete.
  • Member's out-of-pocket expenses can be greatly reduced.

Dental Offices

• DentalPLUS services must be performed by, or arranged through, the DentalPLUS Primary Dental Office that you select.
• Under DentalPLUS, the costs of all care, as described in the comparison chart, are covered , including specialists. The plan covers the services of specialists to whom you are referred by your Primary Dental Office.
• You may select any one of the area's DentalPLUS Offices.
• Currently, there are 170 Primary Dental Offices in the five county Philadelphia area representing a total of 489 dentists. Additional offices are being reviewed and will be made available to you as they join the DentalPLUS Program. Offices will be added as needed to meet market demands.  Back to Top

Enrollment

• To enroll in DentalPLUS, you must complete a Subscriber Application form and indicate the name of the Primary Dentist Office of you choice. Call the Fund Office at 215-561-2722 to obtain the form.
• Return both parts of the Subscriber Application form to the Philadelphia Federation of Teachers Health and Welfare Office.  Back to Top
  

Fees

Rates subject to change.  Back to Top

Comparison Chart

Here's how the benefits of your Basic Dental Program compare to DentalPLUS*

Note: All percentages are of Concordia's Usual, Customary and Reasonable Allowances.

This chart is a general overview only.  Back to Top

What is Not Covered

Except as specifically provided in this section, you are not covered for services, supplies or charges that:

• Are not prescribed by or performed by or under the direct supervision of a dentist;
• Are not medically or dentally necessary as determined by United Concordia;
• Are experimental or investigative in nature;
• Are for any illness or bodily injury which occurs in the course of employment if benefits or compensation are available, in whole or in part, under the provisions of any legislation of any governmental unit. This exclusion applies whether or not you claim the benefits or compensation;
• The cost of which has been or is later recovered in any action at law or in compromise or settlement of any claim except where prohibited by law;
• Are provided by any governmental unit;
• You would have no legal obligation to pay in the absence of this or any similar coverage;
• Are received from a dental or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trust, or similar person or group;
• Are performed prior to the effective date;
• Are incurred after your termination date unless otherwise indicated;
• Are not necessary, according to accepted standards of dental practice, or which are not recommended or approved by the attending dentist;
• Do not meet accepted standards of dental practice;
• Are for unusual procedures and techniques;
• Are not billed by the dentist;
• Are performed by a dentist who in any case is compensated by the facility for similar covered services performed for patients.

You are not covered for:

• Telephone consultations, charges for failure to keep a scheduled appointment, or charges for completion of a claim form;
• Services which are cosmetic in nature, including, but not limited to, charges for personalization or characterization of prosthetic appliances;
• Duplicate and temporary devices, appliances, and services;
• Services related to the diagnosis and treatment of temporomandibular joint dysfunctions;
• Sealants;
• Plaque control programs and for oral hygiene and dietary instructions;
• Implantology and related services;
• Services to alter vertical dimension and/or restore or maintain the occlusion. Such procedures include, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation, restoration for malalignment of the teeth;
• Local anesthesia when billed for separately by a dentist;
• Gold foil restorations;
• Treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid or payable under a plan or policy of motor vehicle insurance, including a certified self-insured plan, or payable by the Catastrophic Loss Trust Fund established under the Pennsylvania Motor Vehicle Financial Responsibility Law;
• Any other dental service or treatment except as provided by the Plan;
• Orthodontics.

Payment for services is limited as follows:

• If dental care is transferred from one dentist to that of another dentist during the course of treatment, or if more than one dentist performs covered services for one dental procedure, United Concordia shall be liable for not more than the amount it would have been liable for had but one dentist performed the service.
• In all cases involving covered services in which the dentist and subscriber select a more expensive course of treatment than is customarily provided by the dental profession, consistent with sound professional standards of dental practice for the dental conditions concerned, payment under this Program will be based on the charge allowed for the lesser procedure.
• A contract between subscriber and dentist, prior to the effective date of coverage under this program, is not invalidated by a subsequent contract made between United Concordia and/or subscriber and/or dentist. You will be liable for any difference due to the dentist under such a contract after the United Concordia liability had been satisfied.
• Any additional treatment that is necessitated because of lack of cooperation with the dentist or non-compliance with prescribed dental care that results in additional liability will be your responsibility.  Back to Top

Coordination of Benefits—United Concordia Program

• In addition to this program's broad scope of benefits the program has a Coordination of Benefits provision. The purpose of this provision is to conserve funds associated with health care. Coordination of benefits is applicable only when you, your spouse or your dependent(s) are eligible for benefits under more than one group health plan.
• When you receive services that are also covered under another plan, a determination is made as to which plan is "primary" and which plan is "secondary". The primary plan considers the services without regard to the secondary plan. The secondary plan will then consider the balances on covered services according to the limitations of its programs.
• If this plan is determined to be the secondary plan, payment for covered services will not exceed the difference between the primary plan's payment and the charge. However, United Concordia will not pay more than it would have, had their been no other coverage.
• The primary plan will be determined in the following order:
  1. If the other plan does not include a provision to coordinate benefits, it will be the primary plan.
  2. If the other plan does include a provision to coordinate benefits then:
  1. The plan covering the patient as the employee/subscriber is the primary plan.
  2. Except for situations where the parents of a child are separated or divorced, the plan of the male parent is primary.
  3. In those situations where the parents are separated or divorced, the primary plan is determined as follows:
  1. the plan covering the parent with custody of the child is primary
  2. if the parent with custody of the child has remarried, the stepparent's plan will pay for covered services before the plan of the parent without custody
  3. a court decree may determine the primary plan
  4. When the determination cannot be made with the above rules, then the plan that has covered the patient for the longer period of time is the primary plan.
  3. If the retiree elects to purchase the retiree dental coverage and has a spouse still in active service and the active service spouse has dental coverage then the primary coverage for the retired spouse is the coverage provided by the active spouse. The retiree's coverage is just for coordination purposes.
  4. If the retiree chooses other than single coverage, the active service spouse shall coordinate with the retiree spouse's coverage.  Back to Top

Claim Appeal Procedure

• If you feel a payment denial is incorrect, call the H&W Office (215-561-2722 )
• If your claim has been denied in whole or in part, you will be notified by United Concordia. This rejection letter will set forth the specific reasons for such denial. If you wish to appeal this decision, you may write to your company's employee benefits department or directly to the address which appears on the rejection letter (marked to the attention of the person who signed the letter, if any).
• First, however, it is important for you to understand the reasons for the denial of benefits in order to decide whether you want to appeal and request that the claim can be reviewed again. You should examine your group agreement, which is on file with your employer. The group agreement is a legal document setting forth the full terms and conditions of your professional coverages and excluded services. You may also request a fuller explanation of the rejection decision by calling 1-800-332-0366.
• You may appeal a denial of benefits within 60 days of the date of the rejection by sending a letter stating why you think your claim should not have been denied, including a copy of the denial letter and with any additional claim. Be sure to include in your letter your group number, your identification number, claim number, if any, your employer's name and the date of services for which benefits were denied.
• Upon receipt of your letter and any additional information you provide, your records will be reviewed; and the results of this review will be sent to you normally within 60 days. In unusual cases, as when review of your claim requires examination by qualified medical personnel, including consulting physicians, the review may take longer than 60 days.
• This section describes the principal features of your program. It is an attempt to explain the benefits available to you as clearly and briefly as possible. More complete terms or specific questions concerning benefits should be directed to the Health & Welfare Fund at 215-561-2722.  Back to Top