COMPARISON OF PLAN BENEFITS

ORTHODONTIA

The Dental Plan provides a separate benefit of orthodontic treatment for your dependent child.  Covered expenses are payable at 50% of the orthodontist's fees up to a maximum of $2,000.00. 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 Preferred Plan, 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 adults and dependent children. The plan will pay 50% of the covered expense up to $995. You will pay a maximum of $995. There is no deductible for orthodontia.

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 18) is not covered under this plan. Review the list of Panel Orthodontists here.

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 lifetime allowance of $850 for TMJ therapy.  This includes examination, x-rays, MRIs, therapy, internal appliances and surgical correction.

The Dental Consultant retained by the Trustees is a licensed practicing dentist.  The Dental Consultant's duties are to review all requests for pre-authorization, discuss any problem areas with the individual's dentist, and review 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.

DENTAL PLAN LIMITATIONS

1. Sealants are covered only for children under age 14 and are limited to $22 per tooth.

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

3. Prosthetic appliances (dentures, partials, fixed bridgework and crowns) are covered only once every 2 years.

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

5. Full mouth x-rays or 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 19 and is limited to once every 6 months.

8. Replacement of amalgam, silicate or plastic fillings is limited to one replacement per year.

9. Post-operative x-rays are required for all root canal therapy.

10. 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.

11. Fixed bridges are not covered for patients under age 16 (except in special cases approved by the Board of Trustees).

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

13. 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.

14. Jackets, crowns, inlays, onlays, and fixed bridges are a covered benefit only once in any 3-year period unless the need for replacement can be determined by special report.

15. 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:

1. Orthodontic treatment for adults unless enrolled in the United Concordia Preferred Plan.

2. Congenital malformations (covered under Medical Plan).

3. Services purely cosmetic in nature (such as bleaching or whitening).

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

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

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. Replacement of lost or stolen dentures or partials.

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

14. Pre-medication 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 where covered.

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.