- Dental Plan
When you and your family members are eligible for the medical and hospital benefits provided by the Fund, you are also eligible for the benefits of the Dental Plan. COBRA participants are eligible for dental coverage only if they have elected and paid for it. Retirees in the HMO Plan are eligible for the DeltaCare USA Plan only.
There are four dental plan options available:
The Operating Engineers Dental PPO Plan
This is the default dental plan unless you elect one of the optional dental plans below. Under the Dental PPO Plan, you may use any dentist you wish. If you use a PPO dentist your benefits will be higher and out-of-pocket costs lower than if you use a Non-PPO dentist.
- PPO Dentist
- If you use a dentist from the Fund’s list of participating PPO dentists, you will have no out-of pocket cost for covered services other than your deductible and any services provided in excess of the biennial (every two years) maximum. See below for more details. Subject to these limitations, you will have no out-of-pocket costs when you utilize one of our PPO dentists because these dentists have agreed to accept the Fund’s payment in full for the services provided.
- Non-PPO Dentist
- If you use a dentist that is not a PPO dentist, the Fund will pay for covered services according to a fixed schedule of fees. Regardless of the dentist’s charges for services, the Fund will not pay more than the allowed amount on the fee schedule. After the deductible (see below), the Fund will pay up to the amount listed in the dental schedule, not to exceed the Plan maximum, and you will be responsible for the balance. Because of this, you may incur sizable out-of-pocket expenses when using a Non-PPO dentist.
- Whether you use a PPO or Non-PPO dentist, covered dental benefits are those listed procedures necessary to prevent and eliminate oral disease and services required to restore and maintain function. There is a $25 annual deductible per person, with a $75 family maximum deductible. The aggregate amount payable under the plan for dental services rendered to each eligible individual in any two consecutive calendar years is $6,200. For example, if you had $6,200 of dental work done in 2016 or $2,200 in 2015 and $4,000 in 2016, you will not be eligible for a new $6,200 benefit until 2017.
- Covered benefits are subject to review by the Fund’s Dental Consultant.
- Preauthorization for claims in excess of $600 is required.
X-rays are required on all claims over $600 and for claims under $600 when removal of teeth, periodontal treatment, root canal therapy, fixed or removable bridgework or gold restorations are involved. If the claim is not pre-authorized, it would still be processed but you could be left with a large out-of-pocket expense if certain services are not covered by the Fund. Pre-authorization lets you and the dentist know the amount the Fund will pay and the amount of your out-of-pocket expense before you begin treatment.
United Concordia Preferred
This is a comprehensive dental PPO (preferred provider organization) plan available to all eligible employees and their eligible dependents regardless of where you live. This plan provides you with access to more than 45,000 dentists and specialists nationwide through the Concordia Advantage Network.
You do not have to pre-select a dental office – you may choose any network provider at any time. There is a $25 per person annual deductible ($75 maximum per family) when network dentists are used or $100/$300 when non-network dentists are used. The calendar year maximum benefit is $3,000 per person. There are no co-payments (except for orthodontia) unless you have work performed by an out-of-network dentist.
Visit United Concordia to locate participating dentists in your area under “Concordia Advantage Network” or call 1-800-332-0366.
United Concordia Plus
This is a DHMO (Dental Health Maintenance Organization) plan available only to residents of California. You may choose from more than 1,200 offices in California. As a DHMO member, you must pre-select a primary dental office to provide and coordinate all your dental care. There is no deductible, there are no co-payments (except for orthodontia, additional cleanings within a 6-month period, general anesthesia, and bleaching), and there is no calendar year maximum if you select this option.
Visit United Concordia to look for participating dentists in your area under “DHMO Concordia Plus” or call 1-800-357-3304.
Delta Care USA
This is a DHMO (Dental Health Maintenance Program) with over 5,000 participating dental offices throughout California and Nevada. Members choosing this option must pre-select a primary dental office to provide and coordinate all your dental care. There is no deductible and no maximums, but there are some co-payments for certain procedures (See comparison below).
Visit the Delta Dental Website and under “Find a Dentist” click on
Delta Care USA for a list of dentists in your area.
You must complete an enrollment form for these last three programs. For a United Concordia or a DeltaCare USA enrollment form, contact the Fund Office.
COMPARISON OF PLAN BENEFITS
The following examples help to show the difference between plans.
|Your estimated cost if you select:|
|Description||Average Charge||Non-PPO Dentist*||United Concordia Preferred*||H&W PPO Dentist*||Delta Care USA|
|Periodic Oral Exam (D0120)||$55||$37||$0||$0||$0|
|Teeth cleaning (D1110)||$100||$61||$0||$0||$0|
|X-Rays, complete series (D0210)||$150||$74||$0||$0||$0|
|2-surface filling (D2150)||$200||$144||$0||$0||$0|
|Porcelain/Metal Crown (D2750)||$1,300||$900||$0||$0||$0|
|Extraction, erupted tooth (D7140)||$200||$148||$0||$0||$0|
|Extraction, impacted tooth, completely bony (D7240)||$525||$348||$0||$0||$0|
|Periodontal scaling/root planning, per quad (D4341)||$300||$196||$0||$0||$0|
|Root Canal – 3 roots (D3330)||$1,150||$750||$0||$0||$60|
|Full denture (D5110/5120)||$2,000||$1,555||$0||$0||$65|
|Full cast partial denture (D5213/5214)||$2,000||$1,422||$0||$0||$75|
|* After $25 deductible is satisfied.||No Deductible|
The sample table above is a small selection of common procedures. The average charges will vary based on the location of your dentist.
The PPO Dental Plan provides a separate orthodontia benefit for dependent children. Covered expenses are payable at 50% of the orthodontist’s fees up to a lifetime maximum of $3,000. There is no deductible for orthodontia. The lifetime maximum amount payable for dependent children with cleft lip, alveolus or palate is $3,000.
For all plans except the Concordia Plus Plan or the Delta Dental Plan (DHMO) orthodontia is a covered expense only for dependent children, and only when provided by a Board eligible orthodontist, unless there is no Board eligible orthodontist within 20 miles of your home. Under the Concordia Preferred Plan, orthodontia is a covered expense for dependent children only, under the United Concordia HMO Adult and children.
You may also choose from the PPO Dentists Locator. These orthodontists have agreed to limit their fees for the usual and customary orthodontic treatment (24 months of active treatment and 24 months of retention) to $6,000. The Fund will pay 50% of the covered expense up to $3,000. You will pay a maximum of $3,000. There is no deductible for orthodontia. Adult orthodontia (over age 18) is not covered under this plan. Review the Panel Dentists Locator here.
EXTENDED BENEFIT (DENTAL)
In the event you or your dependents lose eligibility for benefits under the Operating Engineers Health and Welfare Plan, the Fund will make payment for completing procedures which were actually in progress at the time eligibility terminated, but not beyond 30 days following the loss of eligibility.
For example, if your eligibility terminates before dental work for prosthetic procedures (including bridges and crowns) has been completed, benefits will be provided if the impressions were made while you were eligible and the prosthetic appliance, bridge or crown is installed or delivered within 30 days after your eligibility terminates.
The 30-day extension does not apply if the only work completed when eligibility terminated was prophylaxis and x-rays.
DENTAL PLAN LIMITATIONS
- Sealants are covered only for children under age 14 and are limited to $22 per tooth.
- Removable partials, fixed bridgework, and porcelain, porcelain fused to metal and cast metal crowns are not covered for children under 16 years of age.
- Prosthetic appliances (dentures, partials, fixed bridgework, etc…) are covered only once every 2 years.
- TMJ (temporomandibular joint) therapy is limited to a maximum of $850 which includes exam, x-rays, therapy, internal appliance and surgical correction.
- Full mouth x-rays or bitewing x-rays series, including periapical anterior films, are covered only once each 24 months.
- Prophylaxis (cleaning) is covered only once every 6 months.
- Fluoride treatment is covered only for persons under age 19 and is limited to once every 6 months.
- Replacement of amalgam, silicate or plastic fillings is limited to one replacement per year.
- Post-operative x-rays are required for all root canal therapy.
- The fee allowed for a partial denture includes all teeth and clasps. Removable cast partial dentures for eligible individuals under age 16 must be approved by the Fund based on a written report from a dentist.
- Fixed bridges are not covered for patients under age 16 (except in special cases approved by the Board of Trustees).
- Replacement of a second or third molar is not generally covered unless as part of a bridge restoring other missing teeth.
- Where a large number of teeth are missing in the same arch and moderate to advanced periodontal bone loss is evident radiographically, fixed prostheses are not a covered benefit, except in special circumstances approved by the Board of Trustees and by report.
- Jackets, crowns, inlays, onlays, and fixed bridges are a covered benefit only once in any 2-year period unless the need for replacement can be determined by special report.
- Routine post-operative visits are considered part of, and included in, the fee for the total surgical procedure.
EXPENSES NOT COVERED
Dental benefits are not payable for:
- Orthodontic treatment for adults unless enrolled in the United Concordia Plus Plan or the Delta Dental Plan (DHMO).
- Congenital malformations (covered under Medical Plan).
- Services purely cosmetic in nature (such as bleaching or whitening).
- Fees for instruction in personal oral hygiene, dietary planning or prevention.
- Service provided by a “denturist”, except in Idaho, Maine, Montana, Oregon and Washington.
- Pulp caps.
- Experimental procedures.
- Procedures associated with overlays.
- Precision attachments for partials.
- Occlusal adjustments.
- Charges for the completion of dental claim forms.
- Replacement of lost or stolen dentures or partials.
- Services provided by any person who is the spouse, parent, child, brother or sister of the eligible employee or dependent.
- Pre-medication and analgesia (nitrous oxide), except for documented handicapped or uncontrollable patients.
- Orthodontics if provided by someone other than a Board eligible orthodontist, unless there is no Board eligible orthodontist within 20 miles of your home.
- Study models except as part of orthodontic treatment where covered.
- X-rays that are unreadable or not diagnostically acceptable.
- Hospitalization for dental treatment unless medical necessity is established.
- Unilateral removable bridges.
- Implants must be pre-authorized and will be covered only under certain circumstances.