Health and Welfare Summary Plan Description

 
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10.1 Dental Benefits

  1. General Rules. Dental benefits are paid directly from the Plan's trust (i.e., they are not insured). The dental program is administered, however, by Delta Dental and uses Delta Dental's provider network. Employees and Early Retirees are covered under the Delta Dental Premier Plan (group ID numbers 4874-0005 and 4874-0006). Retirees are covered under the Delta Dental Preferred Option, or "DPO" (group ID numbers 4874-0015 and 4874-0016). Dependents are covered under the same plan as the Participant. To obtain dental services, a Covered Individual should make an appointment with any dentist listed on the Delta Dental provider list. All Delta Dental dentists will have Delta Dental treatment forms in their offices and should complete and submit the forms to Delta Dental for reimbursement. That Delta Dental provider list containing a complete list of Delta Dental dentists may be obtained by calling Delta's service department at (800) 427-2737 or it can be found at deltadentalca.org.

  2. Summary of Benefits. If you have specific questions regarding benefit structure, limitations or exclusions, refer to the detailed discussions below, consult the Summary of Benefits provided by Delta, or contact Delta's service department. The following is a summary of the benefits available under the dental program.
    Dental Services Percent of Delta Dental Fee Schedule Paid by Plan (Active Employees and Early Retirees) Delta Preferred Option (DPO)
    Retiree Rates
    In-Network Out-of-Network
    Diagnostic & preventive (oral exams, cleaning, x-rays) 100% 100% 80%
    Basic services (oral surgery, restorative treatment, root canals, gum treatment, ondontics, periodontics) 80%
    Implants
    Orthodontic benefits
    Crowns, jackets & other cast restorations 80% 80% 60%
    Prosthodontics (bridges, partial denture, full dental) 80% 80% 60%
    Annual maximum $4,000 $4,000 $4,000
    Maximum orthodontics $4,000 $1,500 $1,500
  3. Your Benefits. Your dental plan covers several categories of benefits, when the services are provided by a licensed dentist, and when they are necessary and customary under the generally accepted standards of dental practice.

    IMPORTANT: If you opt to receive dental services that are not covered services under this plan, your Delta Dental dentist may charge you his or her Reasonable and Customary rate for those services. Prior to providing you dental services that are not a covered benefit, your dentist should provide you with a treatment plan that includes each anticipated service to be provided and the estimated cost of each service (see Predeterminations in subsection (n) below). If you would like more information about dental coverage options, you may call our Customer Service department at (800) 765-6003. To understand your coverage fully, you may wish to review carefully the information provided here. The Plan will provide payment for these services at the percentage indicated up to a maximum of $4,000 for each Covered Individual in each calendar year. Payment for orthodontic benefits for an Enrollee is limited to a lifetime maximum of $4,000.
    1. Diagnostic and Preventive Benefits
      1. Percent Covered
        100% if provided by Delta Dental dentists;
        80% if provided by other dentists
      2. Benefits Covered
        Diagnostic - oral examinations (including initial examinations, periodic examinations and emergency examinations); x-rays; diagnostic casts, examination of biopsied tissue; palliative (emergency) treatment of dental pain; specialist consultation
        Preventive - prophylaxis (cleaning); fluoride treatment; space maintainers
    2. Basic Benefits
      1. Percent Covered
        80% if provided by Delta Dental Dentists;
        80% if provided by other dentists
      2. Benefits Covered
        Oral surgery - extractions and certain other surgical procedures, including pre- and post-operative care
        Restorative - amalgam, silicate or composite (resin) restorations (fillings) for treatment of carious lesions (visible destruction of hard tooth structure resulting from the process of dental decay)
        Endodontic - treatment of the tooth pulp
        Periodontic - treatment of gums and bones that support the teeth
        Sealants - topically applied acrylic, plastic or composite material used to seal developmental grooves and pits in teeth for the purpose of preventing dental decay
        Adjunctive General Services - general anesthesia; I.V. sedation; office visit for observation; office visit after regularly scheduled hours; therapeutic drug injection; treatment of postsurgical complications (unusual circumstances); limited occlusal adjustment
    3. Crowns, Inlays, Onlays and Cast Restoration Benefits
      1. Percent Covered
        80% if provided by Delta Dental Dentists;
        60% if provided by other dentists
      2. Benefits Covered
        Crowns, inlays, onlays and cast restorations are Benefits only if they are provided to treat cavities which cannot be restored with amalgam, silicate or direct composite (resin) restorations.
    4. Prosthodontic Benefits
      1. Percent Covered
        80% if provided by Delta Dental Dentists;
        60% if provided by other dentists
      2. Benefits Covered
        Construction or repair of fixed bridges, partial dentures and complete dentures are Benefits if provided to replace missing, natural teeth.
        Implant surgical placement and removal and for implant supported prosthetics, including implant repair and re-cementation.
    5. Orthodontic Benefits
      1. Percent Covered
        80% if provided by Delta Dental Dentists
        80% if provided by other dentists
      2. Lifetime Maximum
        $4,000 per Premier Plan Enrollee (Employees or Early Retirees and their eligible Dependents)
        $1,500 per DPO Enrollee (Retirees and their eligible Dependents)
      3. Benefits Covered
        Procedures using appliances or surgery to straighten or realign teeth, which otherwise would not function properly.
  4. Benefit Limitations
    1. Only the first two oral examinations, including office visits for observation and specialist consultations, or combination thereof, in a calendar year are Benefits while you are eligible under any Delta Dental plan.
    2. Full-mouth x-rays are a Benefit once in a five-year period while you are eligible under any Delta Dental plan. The Plan pays for a panoramic x-ray provided as an individual service only after five years have elapsed since any prior panoramic x-ray was provided under any Delta Dental plan.
    3. Bitewing x-rays are provided on request by the dentist, but no more than twice in any calendar year for children to age 18 or once in any calendar year for adults age 18 and over, while you are eligible under any Delta Dental plan.
    4. Diagnostic casts are a Benefit only when made in connection with subsequent orthodontic treatment covered under this plan.
    5. The Plan pays for two cleanings or a dental procedure that includes a cleaning each calendar year under any Delta Dental plan. Routine prophylaxes are covered as a Diagnostic and Preventive Benefit and periodontal prophylaxes are covered as a Basic Benefit.
    6. Periodontal scaling and root planing is a Benefit once for each quadrant each 24-month period.
    7. Fluoride treatments are covered twice each calendar year under any Delta Dental plan.
    8. Sealant Benefits include the application of sealants only to permanent first molars through age eight and second molars through age 15 if they are without caries (decay) or restorations on the occlusal surface. Sealant Benefits do not include the repair or replacement of a sealant on any tooth within two years of its application.
    9. Crowns, Inlays, Onlays and Cast Restorations are Benefits on the same tooth only once every five years, while you are eligible under any Delta Dental plan, unless Delta Dental determines that replacement is required because the restoration is unsatisfactory as a result of poor quality of care, or because the tooth involved has experienced extensive loss or changes to tooth structure or supporting tissues since the replacement of the restoration.
    10. Prosthodontic appliances and implants are Benefits only once every five years, while you are eligible under any Delta Dental plan, unless Delta Dental determines that there has been such an extensive loss of remaining teeth or a change in supporting tissues that the existing appliance cannot be made satisfactory. Replacement of a prosthodontic appliance not provided under a Delta Dental plan will be made if it is unsatisfactory and cannot be made satisfactory. Delta Dental will replace an implant, a prosthodontic appliance or an implant supported prosthesis you received under another dental plan if we determine it is unsatisfactory and cannot be made satisfactory. We will pay for the removal of an implant once for each tooth during the Enrollee's lifetime.
    11. The Plan will pay the applicable percentage of the dentist's fee for a standard partial or complete denture. A standard partial or complete denture is defined as a removable prosthetic appliance provided to replace missing natural, permanent teeth that are made from accepted materials and by conventional methods.
    12. If you select a more expensive plan of treatment than is customarily provided, or specialized techniques, an allowance will be made for the least expensive, professionally acceptable, alternative treatment plan. The Plan will pay the applicable percentage of the lesser fee for the customary or standard treatment and you are responsible for the remainder of the dentist's fee. For example: a crown where an amalgam filling would restore the tooth; or a precision denture where a standard denture would suffice.
    13. If orthodontic treatment is begun before you become eligible for coverage, payments will begin with the first payment due to the dentist following your eligibility date.
    14. Orthodontics payments will stop when the first payment is due to the dentist following either a loss of eligibility, or if treatment is ended for any reason before it is completed.
    15. The Plan will pay the applicable percentage of the Dentist's fee for a standard orthodontic treatment plan involving surgical and/or non-surgical procedures. If the Enrollee selects specialized orthodontic appliances or procedures chosen for aesthetic considerations, an allowance will be made for the cost of a standard orthodontic treatment plan and the Enrollee is responsible for the remainder of the Dentist's fee.
    16. X-rays and extractions that might be necessary for orthodontic treatment are not covered by Orthodontic Benefits, but may be covered under Diagnostic and Preventive or Basic Benefits.
  5. Excluded Services. Although the dental program covers many of the most commonly needed services, some services are not covered. It is important for you to know what these services are before you visit your dentist. If you are unsure whether a particular procedure is covered, or the extent to which it is covered, check with Delta Dental before proceeding. The following services are not covered:
    1. Services for injuries or conditions that are covered under workers' compensation or employer's liability laws.
    2. Services that are provided to the Enrollee by any Federal or State Governmental Agency or are provided without cost to the Enrollee by any municipality, county or other political subdivision, except Medi-Cal benefits.
    3. Services for cosmetic purposes or for conditions that are a result of hereditary or developmental defects, such as cleft palate, upper and lower jaw malformations, congenitally missing teeth and teeth that are discolored or lacking enamel.
    4. Services for restoring tooth structure lost from wear (abrasion, erosion, attrition, or abfraction), for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing the teeth. Examples of such treatment are equilibration and periodontal splinting.
    5. Any Single Procedure, bridge, denture or other prosthodontic service that was started before the Enrollee was covered by this plan.
    6. Prescribed drugs, or applied therapeutic drugs, premedication or analgesia.
    7. Procedures that are Experimental or Not Generally Accepted.
    8. Charges by any hospital or other surgical or treatment facility and any additional fees charged by the Dentist for treatment in any such facility.
    9. Anesthesia, except for general anesthesia or I.V. sedation given by a licensed Dentist for Oral Surgery services and select Endodontic and Periodontic procedures.
    10. Grafting tissues from outside the mouth to tissues inside the mouth ("extraoral grafts").
    11. Diagnosis or treatment by any method of any condition related to the temporomandibular (jaw) joints or associated muscles, nerves or tissues.
    12. Replacement of existing restoration for any purpose other than active tooth decay.
    13. Occlusal guards and complete occlusal adjustment.
    14. Charges for replacement or repair of an orthodontic appliance paid in part or in full by this plan.
  6. Other Charges. Benefits under this Plan are described above under the section "Your Benefits." If dental services are provided by a Delta Dental Dentist or a Delta Dental PPO Dentist, you are responsible for your coinsurance only. If the dental services you receive are provided by a dentist who is not a Delta Dental Dentist or Delta Dental PPO Dentist, you are responsible for the difference between the amount the Plan pays and the amount charged by the non-Delta Dental dentist.

  7. Covered Fees. It is to your advantage to select a dentist who is a Delta Dental Dentist, since a lower percentage of the dentist's fees may be covered by this plan if you select a dentist who is not a Delta Dental Dentist. A list of Delta Dental Dentists is available using the website deltadentalins.com, or by calling 800-765-6003. Payment to a Delta Dental PPO Dentist will be based on the applicable percentage of the lesser of the Fee Actually Charged, the dentist's accepted Reasonable and Customary fee on file with Delta Dental, or a fee which the dentist has contractually agreed upon with Delta Dental to accept for treating enrollees under this plan. Payment to a Delta Dental Dentist will be based on the applicable percentage of the lesser of the Fee Actually Charged, or the accepted Reasonable and Customary fee that the dentist has on file with Delta Dental.

    Payment for services by a California dentist, or an out-of-state dentist, who is not a Delta Dental Dentist will be based on the applicable percentage of the lesser of the Fee Actually Charged, or the fee that satisfies the majority of Delta Dental Dentists. Payment for services by a dentist located outside the United States will be based on the applicable percentage of the lesser of the Fee Actually Charged, or the fee that satisfies the majority of Delta Dental dentists.

  8. Choice of Dentists and Providers

    PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED.

    Nearly 29,000 dentists in active practice in California are Delta Dental Dentists. About 16,500 of these Delta Dental Dentists are also Delta Dental PPO Dentists. While covered under the PPO plan, you are free to choose any dentist for treatment, but it is to your advantage to choose a Delta Dental Dentist. This is because his or her fees are approved in advance by Delta Dental. Delta Dental Dentists have treatment forms on hand and will complete and submit the forms to Delta Dental free of charge. If you choose a Delta Dental PPO Dentist, you will receive all of the advantages of going to a Delta Dental Dentist, and you may have a higher level of Benefits for certain services. If you go to a non-Delta Dental Dentist, Delta Dental cannot assure you what percentage of the charged fee may be covered. Claims for services from non-Delta Dental Dentists may be submitted to Delta Dental at P.O. Box 997330, Sacramento, CA 95899-7330. Dentists located outside the United States are not Delta Dental Dentists. Claims submitted by out-of-country dentists are translated by Delta Dental staff and the currency is converted to U.S. dollars. Claims submitted by out-of-country dentists for Enrollees residing in California are referred to Delta Dental's Quality Assessment department for processing. Delta Dental may require a clinical examination to determine the quality of the services provided, and the Plan may decline to reimburse you for Benefits if the services are found to be unsatisfactory. A list of Delta Dental PPO Dentists and Delta Dental Dentists can be obtained by calling 800-765-6003. This list will identify those dentists who can provide care for individuals who have mobility impairments or have special health care needs. You can also obtain specific information about Delta Dental PPO Dentists and Delta Dental Dentists by using our website – deltadentalins.com or calling the Delta Dental Customer Service department at (800) 765-6003. Services may be obtained from any licensed dentist during normal office hours. Emergency services are available in most cases through an emergency telephone exchange maintained by the local dental society listed in the local telephone directory. Services from dental school clinics may be provided by students of dentistry or instructors who are not licensed by the state of California. Delta Dental shares the public and professional concern about the possible spread of HIV and other infectious diseases in the dental office. However, Delta Dental cannot ensure your dentist's use of precautions against the spread of such diseases, or compel your dentist to be tested for HIV or to disclose test results to Delta Dental, or to you. Delta Dental informs its panel dentists about the need for clinical precautions as recommended by recognized health authorities on this issue. If you should have questions about your dentist's health status or use of recommended clinical precautions, you should discuss them with your dentist.

  9. Continuity of Care
    1. Current Enrollees. Current Enrollees may have the right to the benefit of completion of care with their terminated Delta Dental Dentist for certain specified dental conditions. Please call Delta Dental's Quality Assessment Department at (415) 972-8300 to see if you may be eligible for this benefit. You may request a copy of the Delta Dental's Continuity of Care Policy. You must make a specific request to continue under the care of your terminated Delta Dental Dentist. We are not required to continue your care with that dentist if you are not eligible under our policy or if we cannot reach agreement with your terminated Delta Dental Dentist on the terms regarding your care in accordance with California law.
    2. New Enrollees. A New Enrollee may have the right to the qualified benefit of completion of care with their non-Delta Dental Dentist for certain specified dental conditions. Please call Delta Dental's Quality Assessment Department at (415) 972-8300 to see if you may be eligible for this benefit. You may request a copy of the Delta Dental's Continuity of Care Policy. You must make a specific request to continue under the care of your current provider. We are not required to continue your care with that dentist if you are not eligible under our policy or if we cannot reach agreement with your non-Delta Dental Dentist on the terms regarding your care in accordance with California law. This policy does not apply to new Enrollees of an individual subscriber contract.
  10. Public Policy Participation by Enrollees. Delta Dental's Board of Directors includes Enrollees who participate in establishing Delta Dental's public policy regarding Enrollees through periodic review of Delta Dental's Quality Assessment program reports and communication from Enrollees. Enrollees may submit any suggestions regarding Delta Dental's public policy in writing to: Delta Dental of California, Customer Service Department, P. O. Box 997330, Sacramento, CA 95899-7330.

  11. Saving Money on Your Dental Bills. You can keep your dental expenses down by practicing the following:
    1. Compare the fees of different dentists;
    2. Use a Delta Dental Dentist;
    3. Have your dentist obtain a predetermination from Delta Dental for any treatment over $300;
    4. Visit your dentist regularly for checkups;
    5. Follow your dentist's advice about regular brushing and flossing;
    6. Avoid putting off treatment until you have a major problem; and
    7. Learn the facts about overbilling. Under this Plan, you must pay the dentist your coinsurance share (see YOUR BENEFITS). You may hear of some dentists who offer to accept insurance payments as "full payment." You should know that these dentists may do so by overcharging your plan and may do more work than you need, thereby increasing plan costs. You can help keep your dental Benefits intact by avoiding such schemes.
  12. Your First Appointment. During your first appointment, be sure to give your dentist the following information:
    1. Your Delta Dental group number : 4874-1005;
    2. The Covered Plan is the San Francisco Electrical Workers Health & Welfare Plan;
    3. Primary Enrollee's ID number (which must also be used by Dependents);
    4. Primary Enrollee's date of birth; and
    5. Any other dental coverage you may have.
  13. Accessibility and Services for After-Hours and Urgent Care. If you or a family member has special needs, you should ask your dentist about accessibility to their office or clinic at the time you call for an appointment. Your dentist will be able to tell you if their office is accessible taking into consideration the specific requirements of your needs. Routine or urgent care may be obtained from any licensed dentist during their normal office hours. Delta Dental does not require prior authorization before seeking treatment for urgent or after-hours care. You may plan in advance, for treatment for urgent, emergency or after-hours care by asking your dentist how you can contact the dentist in the event you or a family member may need urgent care treatment or treatment after normal business hours. Many dentists have made prior arrangements with other dentists to provide care to you if treatment is immediately or urgently needed. You may also call the local dental society that is listed in your local telephone directory if your dentist is not available to refer you to another dentist for urgent, emergency or after-hours care.

  14. Predeterminations. After an examination, your dentist will talk to you about treatment you may need. The cost of treatment is something you may want to consider. If the service is extensive and involves crowns or bridges, or if the service will cost more than $300, we encourage you to ask your dentist to request a predetermination.
    A predetermination does not guarantee payment. It is an estimate of the amount the Plan will pay if you are eligible and meet all the requirements of your plan at the time the treatment you have planned is completed.

    In order to receive a predetermination, your dentist must send a claim to us listing the proposed treatment. Delta Dental will send your dentist a Notice of Predetermination which estimates how much you will have to pay. After you review the estimate with your dentist and decide to go ahead with the treatment plan, your dentist returns the statement to us for payment when treatment has been completed. Computations are estimates only and are based on what would be payable on the date the Notice of Predetermination is issued if the Enrollee is eligible. Payment will depend on the Enrollee's eligibility and the remaining annual maximum when completed services are submitted to Delta Dental. Predetermining treatment helps prevent any misunderstanding about your financial responsibilities. If you have any concerns about the predetermination, let us know before treatment begins so your questions can be answered before you incur any charges.

  15. Reimbursement Provisions
    1. Filing Your Claims. A Delta Dental Dentist will file the claim for you. You do not have to file a claim or pay the Plan's coinsurance for covered services if provided by a Delta Dental Dentist. Delta Dental of California's agreement with Delta Dental Dentists makes sure that you will not be responsible to the dentist for any money the Plan owes. If the covered service is provided by a dentist who is not a Delta Dental Dentist, you are responsible for filing the claims and paying your dentist. Claims should be filed with Delta Dental of California at P. O. Box 997330, Sacramento, CA 95899-7330 and the Plan will reimburse you. However, if for any reason the Plan fails to pay a dentist who is not a Delta Dental Dentist, you may be liable for that portion of the cost. Payments made to you are not assignable (in other words, we will not grant requests to pay non-Delta Dental Dentists directly).
    2. Services Performed Outside the U.S. Payment for claims exceeding $500 for services provided by dentists located outside the United States may, at Delta Dental's option, be conditioned upon a clinical evaluation at Delta Dental's request (see SECOND OPINIONS). The Plan will not pay Benefits for such services if they are found to be unsatisfactory.

      The Plan does not pay Delta Dental Dentists any incentive as an inducement to deny, reduce, limit or delay any appropriate service. If you wish to know more about the method of reimbursement to Delta Dental Dentists, you may call Delta Dental's Customer Service department for more information.
    3. Payment of Completed Procedures Only. Payment for any Single Procedure that is a Covered Service will only be made upon completion of that procedure. The Plan does not make or prorate payments for treatment in progress or incomplete procedures. The date the procedure is completed governs the calculation of any Deductible (and determines when a charge is made against any Maximum) under your plan. If there is a difference between what your dentist is charging you and what Delta Dental says your portion should be, or if you are not satisfied with the dental work you have received, contact Delta Dental's Customer Service department. Delta Dental may be able to help you resolve the situation. Delta Dental may deny payment of a claim for services submitted more than 12 months after the date the services were provided. If a claim is denied due to a Delta Dental Dentist's failure to make a timely submission, you shall not be liable to that dentist for the amount which would have been payable by the Plan (unless you failed to advise the dentist of your eligibility at the time of treatment).
    4. Claims Processing. The process Delta Dental uses to determine or deny payment for services is distributed to all Delta Dental Dentists. It describes in detail the dental procedures covered as Benefits, the conditions under which coverage is provided, and the limitations and exclusions applicable to the Plan. Claims are reviewed for eligibility and are paid according to these processing policies. Those claims which require additional review are evaluated by Delta Dental's dentist consultants. If any claims are not covered, or if limitations or exclusions apply to services you have received from a Delta Dental Dentist, you will be notified by an adjustment notice on the Notice of Payment or Action. You may contact Delta Dental's Customer Service department for more information regarding Delta Dental's processing policies.
      Delta Dental uses a method called "first-in/first-out" to begin processing your claims. The date Delta Dental receives your claim determines the order in which processing begins. For example, if you receive dental services in January and February, but we receive the February claim first, processing begins on the February claim first.
      Incomplete or missing data can affect the date the claim is paid. If you or your dentist has not provided Delta Dental with all information necessary to complete claim processing, payment could be delayed until any missing or incomplete data is received by Delta Dental. The order in which your claims are processed and paid by the Plan may also impact your annual maximum. For example, if a claim with a later date of service is paid and your annual maximum for the year has been reached then a claim with an earlier date of service in the same calendar year will not be paid.
  16. If You Have Questions About Services From a Delta Dental Dentist. If you have questions about the services you receive from a Delta Dental Dentist, we recommend that you first discuss the matter with your dentist. If you continue to have concerns, call Delta Dental's Quality Assessment department at (415) 972-8300, extension 2700. If appropriate, Delta Dental can arrange for you to be examined by one of our consulting dentists in your area. If the consultant recommends the work be replaced or corrected, Delta Dental will intervene with the original dentist to either have the services replaced or corrected at no additional cost to you or obtain a refund. In the latter case, you are free to choose another dentist to receive your full Benefit.

  17. Second Opinions. Delta Dental obtains second opinions through Regional Consultant members of its Quality Review Committee who conduct clinical examinations, prepare objective reports of dental conditions, and evaluate treatment that is proposed or has been provided. Delta Dental will authorize such an examination prior to treatment when necessary to make a Benefits determination in response to a request for a Predetermination of treatment cost by a dentist. Delta Dental will also authorize a second opinion after treatment if an Enrollee has a complaint regarding the quality of care provided. Delta Dental will notify the Enrollee and the treating dentist when a second opinion is necessary and appropriate, and direct the Enrollee to the Regional Consultant selected by Delta Dental to perform the clinical examination. When Delta Dental authorizes a second opinion through a Regional Consultant, the Plan will pay for all charges for the clinical examination. Enrollees may otherwise obtain second opinions about treatment from any dentist they choose, and claims for the examination may be submitted to Delta Dental for payment. The Plan will pay such claims in accordance with the Benefits of the Plan.

  18. Organ and Tissue Donation. Donating organ and tissue provides many societal benefits. Organ and tissue donation allows recipients of transplants to go on to lead fuller and more meaningful lives. Currently, the need for organ transplants far exceeds availability. If you are interested in organ donation, please speak to your physician. Organ donation begins at the hospital when a person is pronounced brain dead and identified as a potential organ donor. An organ procurement organization will become involved to coordinate the activities.