2015 Dental Options - Baltimore City Public Schools

2015 Dental Options
BALTIMORE CITY
PUBLIC SCHOOLS
Baltimore City Public Schools—2015 Dental Options • C1
C2 • Baltimore City Public Schools—2015 Dental Options
Important Information
for 2015
Phone numbers
DHMO Customer Service
(410) 847-9060 or (888) 833-8464
DHMO Mailing Address
The Dental Network
P.O. Box 14118
Lexington, KY 40512-4118
PPO Dental Customer Service
(866) 891-2802
PPO Dental Mailing Address
CareFirst BlueCross BlueShield
Dental Appeals and Correspondence
P.O. Box 14114
Lexington, KY 40512-4114
Important information
The State of Maryland legalized same sex marriage in 2013.
As of January 1, 2014, the Baltimore City Public Schools
will no longer offer coverage for domestic partners because
of the legalization of this union. A court certified marriage
certificate is required during open enrollment in order to
continue coverage beyond December 31, 2014.
Baltimore City Public Schools offers its
employees and their dependents the choice of
two dental plans. Your first option is a Dental
HMO (DHMO) plan, which is offered through
The Dental Network and is available at no cost
to you and no annual maximum.
Your second option is a dental-buy up, PPO
plan (DPPO). This means that, for an additional
premium, which is shared between you and your
employer, you can “buy-up” to the CareFirst
BlueCross BlueShield Preferred dental plan.
Baltimore City Public Schools—2015 Dental Options • 1
Dental HMO (DHMO)
Frequently asked questions
Do I need to select a dentist?
Advantages of the
DHMO plan
Yes. Before you can receive benefits under this plan, you must first select a
dentist within the provider directory.
When you receive in-network care,
you enjoy the following:
Must family members go to the same dentist?
No. Each family member may select a different participating general
dental office.
What about orthodontia for adults and children?
Orthodontia is covered for both adults and children.
Do I have to fill out claim forms after each
routine visit?
There are no claim forms to complete.
Are there any benefit maximums?
There are no benefit maximums.
What happens in a dental emergency away
from home?
The dental program will cover the cost of diagnostic and therapeutic
procedures delivered by any general dentist up to a maximum of $50 per
emergency occurrence greater than 50 miles from home.
How do I find a participating DHMO dentist?
To find a DHMO dentist, visit www.thedentalnet.org and click on Members
in the upper left of your screen. Look under the Take Action section on the
lower right and choose See plan benefits and Directories. Then select 5000S
under Select Dental Plan. Click Select and you can choose to view or print the
Dental Directory.
If you are a PSASA member hired before 1/1/08 and have CareFirst
combined PPO Medical and Dental you may access your Dental providers by
visitingwww.thedentalnet.org and click on Members in the upper left of your
screen. Look under the Take Action section on the lower right and choose See
plan benefits and Directories. Then select CF City-DN70 under Select Dental
Plan. Click Select and you can choose to view or print the Dental Directory.
2 • Baltimore City Public Schools—2015 Dental Options
■■ No claim forms.
■■ No deductibles.
■■ Unlimited maximum
benefit amount.
■■ Braces covered for children
and adults.
Things to remember
■■ You can change your dentist at any
time (if no balance exists).
■■ You can choose a different dentist
for each family member.
■■ You must get a referral to see
a specialist.
DHMO Dental Plan Administered by The Dental
Network is an independent licensee of the Blue
Cross and Blue Shield Association.
Preferred Dental PPO (DPPO)
Dental Plan
Baltimore City Public Schools is giving you the option to purchase an enhanced dental
plan, called the CareFirst Preferred Dental PPO (DPPO), which provides a larger network
of dentists.
Advantages of the DPPO plan
■■ Freedom of choice, freedom to save—With Preferred
Dental coverage, you have the freedom to see any dentist.
This plan also gives you the option to reduce your out-ofpocket expenses by visiting a dentist who participates in
our network of Preferred providers. It’s your choice!
■■ Preventive care and more—Benefits for you and your
family include regular preventive care, X-rays, dental
surgery and more. A summary of your benefits is available
on page 5 of this guide.
■■ Large network—Over 2,000 general and pediatric dentists
in Maryland participate in CareFirst’s Preferred Dental
Network. There are over 320 network dentists in Baltimore
City. 77% of participating dentists are accepting new
patients. You may already be seeing a dentist who is part
of our network.
■■ Out-of-network care—For a higher out-of-pocket cost, the
Preferred plan allows you to go outside the network for
care and still receive valuable dental coverage.
■■ Easy to use—If you see a Preferred dentist, you will incur
lower out-of-pocket costs for all dental services and
you will have no claim forms to file. Preferred dentists
have agreed to accept CareFirst’s Allowed Benefit as
payment in full for covered services. Once you meet your
deductible and coinsurance, you won’t be faced with
additional expenses.
■■ Nationwide emergency coverage—Emergency dental
coverage is there when you need it, no matter where you
are using your out-of-network coverage.
Frequently asked questions
Who is eligible to enroll?
All Baltimore City Public Schools Employees and their
dependents. Eligible dependents are covered until the
end of the month in which they turn age 26 regardless of
student status.
How do I find a preferred dentist?
You can access an online directory of Dentists 24 hours a
day at www.carefirst.com.
■■ Under the Solution Center click on Find a Doctor.
■■ Then choose Dental under provider type and select
Preferred Dental (PPO).
Once you are on this page, you can find all the dentists in
your area by putting in a zip code, city and state, or you
can check to see if your dentist is in our network by typing
their last name under option 3.
How much will I have to pay for dental services?
The chart on page 4 gives you an overview of many of the
covered services along with the percentage you will pay
for each class of services, both in and out-of-network.
Is there a lot of paperwork?
There is no paperwork when you use a dentist in our
Preferred Dental Network. If you see a non-participating
dentist, you may be required to pay all costs at the time
of care, and then submit a claim form in order to be
reimbursed for covered services.
Who can I call with questions about my
dental plan?
Call CareFirst BlueCross BlueShield toll free at
(866) 891‑2802.
Baltimore City Public Schools—2015 Dental Options • 3
Summary of Dental PPO Benefits
Dental Benefits
You Pay
Coinsurance
In-Network
Coinsurance
Out-of-Network
PREVENTIVE & DIAGNOSTIC SERVICES (CLASS I)
Oral Exams (two per benefit period)
Cleanings (two per benefit period)
■■ Bitewing X-rays (two procedures per benefit period)
■■ Full mouth X-ray or panoramic and bitewing X-ray combination and one
cephalometric X-ray (once per 36 months)
■■ Fluoride treatments (two per benefit period per member, up to age 19)
■■ Sealants on permanent molars (once per tooth per 36 months per
member, up to age 19)
■■ Space maintainers for prematurely lost posterior baby teeth (once per 60
months)
■■ Emergency oral exam and palliative treatment
■■
■■
No charge
Difference between
CareFirst’s
payment and the
Non-Participating
Dentist’s charges2
20% of Allowed Benefit
after deductible1
20% of Allowed Benefit
after deductible2
40% of Allowed Benefit
after deductible
40% of Allowed Benefit
after deductible
50% of
50% of
Allowed Benefit1
Allowed Benefit2
BASIC SERVICES (CLASS II)
Fillings using approved materials (one filling per surface per 12 months)
Oral surgery (treatment for cysts, tumor and abscesses)
■■ General anesthesia rendered for a covered dental service
■■ Tooth extractions
■■
■■
MAJOR SERVICES (CLASS III)
Tooth scaling and root planing (once per 24 months, one full mouth
treatment)
■■ Gum surgery including bone surgery, tissue surgery and bite adjustments
(once per 60 months)
■■ Root canal treatment
■■ Full and/or partial dentures (once per 60 months)
■■ Fixed bridges, crowns, implants, inlays and onlays (once per 60 months)
■■ Denture adjustments and relining (limits apply for regular and immediate
dentures)
■■ Recementation of crowns, inlays and/or bridges (once per 12 months)
■■ Repair of prosthetic appliances as required (once in any 12 month period
per specific area of appliance)
■■
ORTHODONTIC SERVICES (CLASS IV)
■■
Benefits for orthodontic services (braces) are available for covered
members who meet treatment criteria. Covered services are limited to 36
consecutive months of covered services.
ANNUAL DEDUCTIBLE AND MAXIMUM
(IN- AND OUT-OF-NETWORK)
$50 Individual / $150 Family Deductible
(applies to classes II and III)
$1,500 Orthodontic Lifetime Maximum
$1,500 Annual Maximum
F or in-network providers, plan payment is based on dental plan's negotiated fee schedule. After the deductible is met, Preferred dentists accept 100% of the
Allowed Benefit as payment in full for covered dental services.
2
If you use an out-of-network provider, you will need to pay the provider and will be reimbursed by the plan using an out-of-network plan allowance schedule. Your
out-of-pocket costs will most likely be higher. Non-Participating Dentists may bill the Member for the difference (if any) between the Allowed Benefit and the NonParticipating Dentist’s actual charge for Covered Dental Services.
1
Summary of Exclusions
Not all services and procedures are covered by your benefits contract. This plan summary is for comparison purposes only and does not create rights not given through the
benefit plan.
4 • Baltimore City Public Schools—2015 Dental Options
Comparison of Benefits
This chart shows key differences between the DHMO 5000S Plan and the DPPO Plan Estimated Out-of-Pocket expenses for
the most commonly used services.
ADA
procedure
code
Description
DPPO
DHMO1 5000s
You Pay
In-Network 2
You Pay
Out-Network 3
You Pay
120
Periodic Oral Evaluations
(once per 6 months)
$0.00
$0.00
$0.00
272
Bitewings—Two Films
$0.00
$0.00
$0.00
330
Panoramic Film
$0.00
$0.00
$0.00
1110
Prophylaxis (cleaning)—Adult
(once per 6 months)
$0.00
$0.00
$0.00
1120
Prophylaxis (cleaning)—Child
(once per 6 months)
$0.00
$0.00
$0.00
2140
Amalgam—One Surface, Permanent
$0.00
$9.90
$20.40
2160
Amalgam—Three Surface, Permanent
$0.00
$15.12
$32.40
2330
Resin—Based Composite, One Surface, Anterior
$0.00
$14.40
$24.80
2332
Resin—Based Composite, Three Surface, Anterior
$0.00
$20.80
$37.60
2750
Crown—Porcelain/High Noble Metal
$245.00
$248.00
$354.80
2751
Crown—Porcelain/Noble Metal
$235.00
$238.00
$325.60
3330
Molar Root Canal
$185.00/$490.005 $238.00
$332.00
4260
Osseous Surgery
$196.00/$495.00
$239.00
$340.00
4341
Periodontal Scaling and Root Planing—Quad
$40.00/$86.005
$48.00
$81.60
5110
Complete Denture—Upper
$249.00
7140
7210
5
$267.48
$522.00
Extraction, Erupted Tooth or Exposed Root
5
$40.00/$73.00
$15.40
$25.20
Surgical Extraction of Erupted Tooth
$40.00/$80.005
$26.80
$43.40
7240
Removal of Impacted Tooth—Completely Bony
$85.00/$155.00
$45.18
$78.40
8080
Comprehensive Orthodontic Treatment—Adolescent
$1,850.00
$1,480.50
$3,198.004
9110
Palliative Treatment
$15.00
$0.00
$0.00
5
Benefits are available in-network only.
Member estimated out-of-pocket expense when services are rendered by a CareFirst Preferred Participating Dentist without consideration of deductible or annual
benefit maximum.
3
Member estimated out-of-pocket expense based upon dentist fee at 50th percentile of 2007 NDAS schedule without consideration of deductible or annual benefit
maximum. Member subject to balance billing over and above this amount.
4
Allowed Benefit ($4,698) minus the $1,500 Ortho Lifetime Maximum.
5
Member copayment when service rendered by Participating Specialist.
1
2
This document is for comparison purposes only and does not create rights not given through the benefit plan.
Baltimore City Public Schools—2015 Dental Options • 5
The Dental Network
RR# 293 — Department EAB
10802 Red Run Blvd.
Owings Mills, MD 21117
www.thedentalnet.org
The Dental Network is an independent licensee of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association.
BOK5182-1S (9/14)

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