Operating Engineers Health & Welfare Fund

Dental Plan


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.

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 $25.00 annual deductible per person, with a $75.00 family maximum. 

 

The aggregate amount payable for dental services rendered to each eligible individual in any two consecutive calendar years is $6,000.00. For example, if you had $6,000 of dental work done in 1999, you will not be eligible for a new $6,000 benefit until 2001.

All covered benefits are subject to review by the Fund's Dental Consultant. 


Preauthorization for claims in excess of $600.00 is required.  X-rays are required on all claims over $600.00 and for claims under $600.00 when removal of teeth, periodontal treatment, root canal therapy, fixed or removable bridgework or gold restorations are involved.

What happens if my claim is not pre-authorized?  

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.

There are three dental plan options available:

  • You may obtain dental service from any dentist of your choice. The Fund will pay for the services provided according to a fixed schedule of fees. Regardless of the dentist's charge for services, the Fund will not pay more than the allowed amount on the fee schedule. Because of this, you may incur some out-of-pocket expense. This option requires no special enrollment.

  • Operating Engineers Dental Panel - By choosing this option, you may select the dentist of your choice from the Fund's list of participating panel dentists. These dentists have agreed to accept the Fund's payment as full payment for the services provided. There is a $25 deductible with a maximum of $75 per family. There will be no other out-of-pocket expense if you use the services of a panel dentist unless you have something done that is not a covered expense or if you exceed the $5,000 maximum. Please note that this option requires no special enrollment.

  

  • The DeltaCare PMI Plan - You may enroll in the DeltaCare PMI Plan, but you must remain in the program for one full year assuming you are eligible during that full year. This requirement also applies to all eligible dependents. Enrollment in the DeltaCare PMI Plan means that you and your dependents must go to the dentist designated in your geographical area. You have a limited choice of dentists and there could be some out-of-pocket expense for some dental services not covered entirely by the DeltaCare PMI Plan. 

    You must complete an enrollment form for this program.  For a DeltaCare PMI enrollment form, contact the Fund Office.

COMPARISON OF PLAN BENEFITS

The following examples help to show the difference between plans.
Description

Average Charge

 Health & Welfare Allowance Non- Panel Dentist* Your Cost

Delta		 H&W Panel Dentist*
Teeth Cleaning

$ 55

$ 55

$ 39

$  0

$  0
1 Surface filling

67

45

42

0

0
2 Surface Filling

82

60

49

0

0
Porcelain Crown

580

600

400

55

0
Root Canal-3Roots

585

600

400

75

0
Full Upper Denture

680

900

445

75

0
Full Lower Denture

680

900

445

75

0
Full Cast Partial Denture

935

700

120

75

0

* After $25 deductible is satisfied.

ORTHODONTIA

The Dental Plan provides a separate benefit of orthodontic treatment for your dependent child.  Covered expenses are payable at 50% of the dentist's fees up to a maximum of $2,000.00. There is no deductible.

Orthodontia is a covered expense for dependent children only, and only when provided by a Board eligible orthodontist, unless there is no Board eligible orthodontist within 20 miles of your home.  

You may also choose from the Fund's Orthodontic Panel.  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 $1,990.  The Fund will pay 50% of the covered expense up to $995.  You will pay a maximum of $995.  There is no deductible for orthodontia.  Adult orthodontia (over age 19) is not covered.   

TEMPOROMANDIBULAR JOINT (TMJ) TREATMENT
The Fund covers the treatment of temporomandibular joint problems under the Dental Plan, not the Medical Plan.  Nominal allowances will be made for both the surgical and non-surgical correction of TMJ problems, subject to review by the Fund's Dental Consultant.  The Plan has a maximum allowance of $850 for TMJ therapy.  This includes examination, x-rays, MRIs, therapy and internal appliances.

 
DENTAL CONSULTANT
The Dental Consultant retained by the Trustees is a practicing dentist.  His duties are to review all requests for pre-authorization.  He discusses any problem areas with the individual's dentist, if necessary,  and reviews all requests for reconsideration of denied claims.

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 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.

EXPENSES NOT COVERED

Dental benefits are not payable for:

  1. Orthodontic treatment for adults.

  2. Congenital malformations (covered under Medical Plan).

  3. Services which are purely cosmetic in nature (such as bleaching).

  4. Fees for instruction in personal oral hygiene, dietary planning or prevention.

  5. Service provided by a "denturist", except in Oregon and Idaho.

  6. Pulp caps.

  7. Experimental procedures.

  8. Procedures associated with overlays.

  9. Precision attachments for partials.

  10. Occlusal adjustments.

  11. Charges for the completion of dental claim forms.

  12. Lost or stolen dentures or partials.

  13. Services provided by any person who is the spouse, parent, child, brother or sister of the eligible member or dependent.

  14. Premedication and analgesia (nitrous oxide), except for documented handicapped or uncontrollable patients.

  15. Orthodontics if provided by someone other than a board eligible orthodontist.

  16. Study models except as part of orthodontic treatment for dependent children.

  17. X-rays that are unreadable or not diagnostically acceptable.

  18. Hospitalization for dental treatment unless Medical necessity is established.

  19. Unilateral removable bridges.

  20. Implants must be pre-authorized and will be covered only under certain circumstances.

 

DENTAL PLAN LIMITATIONS

  1. Sealants are covered only for children under age 14 and are limited to $10 per tooth.

  2. Removable partials, fixed bridgework, and porcelain, porcelain fused to metal and cast metal crowns are not covered for children under age 16.

  3. Dentures, partials, fixed bridgework and crowns, inlays and onlays are covered only once every 3 years.

  4. TMJ (Temporomandibular joint) therapy is limited to a maximum of $850 which includes exam, x-rays, therapy and internal appliance.

  5. Full mouth x-rays and bitewing x-rays series, including periapical anterior films, are covered only once each 24 months.

  6. Prophylaxis (cleaning) is covered only once every 6 months.

  7. Fluoride treatment is covered only for persons under age 18 and is limited to once each year.

  8. Replacement of amalgam, silicate or plastic fillings is limited to once every two years.

  9. The fee allowed for a partial denture includes all teeth and clasps.

  10. Replacement of a second or third molar is not generally covered unless as part of a bridge restoring other missing teeth.

  11. Routine post-operative visits are considered part of, and included in, the fee for the total surgical procedure.