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FORD
DENTAL COVERAGE
HOW DENTAL COVERAGE WORKS
The Trust provides dental coverage to you and your eligible Dependents. A Dental Benefits Manager, Delta Dental of Michigan, whose contact information is listed in your Schedule of Benefits, administers this coverage. The specific provisions of the dental coverage, the range of covered services, eligibility rules and so forth may change from time to time. If you have
questions as to whether or not a particular dental service or expense is covered, you should contact the Dental Benefits Manager or have your Dentist submit a treatment plan for expenses
$200 or more before receiving treatment, to insure that you will not incur unexpected expenses for dental treatment.
Under the Traditional Delta Dental PPO Point-of-Service Plan (PPO POS), dental services for you and your eligible dependents are paid at the benefit level outlined under the Dental Benefits At A Glance. You do not have to satisfy a dental Deductible before the Plan covers the
services. Dental benefits are paid up to a maximum of $1,700 per person per calendar year.
Orthodontia services are covered for all Plan participants who are under age 19. Most orthodontic services are covered at 50%, subject to a lifetime maximum of $2,000.
Payments for covered dental services related to the repair of accidental injury to sound natural teeth due to a sudden unexpected impact from outside the mouth are not counted against the annual benefit limit or the lifetime orthodontic limit. Instead, the regular Co-payments under medical coverage provided by the Plan will be required for all such services. Similarly, dental services provided in a hospital are not covered as dental benefits, but may be covered as medical expenses if they qualify for such coverage.
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Dental Benefits At A Glance
PPO
Dentist
Premier
Dentist
Nonparticipating
Dentist
Plan Pays Plan Pays Plan Pays
Class I Benefits
Diagnostic and Preventive
Services - includes exams,
cleanings, fluoride, and space
maintainers
100% 100% 100%
Emergency Palliative Treatment -
to temporarily relieve pain 100% 100% 100%
Class II Benefits
Radiographs - X-rays 100% 90% 90%
Minor Restorative Services -
includes fillings 100% 90% 90%
Periodontic Services - to treat gum
disease 100% 90% 90%
Endodontic Services - includes root
canals 100% 90% 90%
Relines and Repairs - to bridges
and dentures 100% 90% 90%
Other Basic Services - misc.
services 100% 90% 90%
Extractions - removal of teeth 100% 90% 90%
Oral Surgery – extractions and other
dental surgery other than extractions 90% 90% 90%
Major Restorative Services -
includes crowns 90% 90% 90%
Class III Benefits
Prosthodontic Services - includes
bridges and dentures 70% 50% 50%
Class IV Benefits
Orthodontic Services - includes
braces
(treatment must begin prior to age 19 and coverage will continue to the end of treatment or until the maximum has been reached)60% 50% 50%
DENTAL COVERED CHARGES
Your Delta Dental Plan benefits cover a Dentist’s charges that you are required to pay for necessary dental services and supplies, up to the Allowed Amount for such services.
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If you have a dental problem that can be treated in more than one way, the procedure that provides a cost-effective, professionally satisfactory result is covered.
Predetermination of Dental Benefits
If the estimated charge for dental or orthodontic services is less than $200, or if emergency care is involved, your Dentist does not need to obtain a predetermination of benefits. If treatment of planned dental work is expected to cost $200 or more, however, your Dentist should file a predetermination of benefits or “treatment plan” with the Dental Benefits Manager before treatment begins. The Dental Benefits Manager then can authorize payments before your Dentist begins work, and you will know in advance exactly how much your dental coverage will pay. Your Dentist may obtain a form from Delta Dental’s website at www.deltadentalmi.com.
The Dental Benefits Manager will determine what portion of the total expenses will be paid by your dental coverage, taking into account alternate procedures, services or courses of
treatment, based on accepted standards of dental practice. The Dental Benefits Manager will then notify you and your Dentist of the determination.
Class I Services
• Routine oral exams and cleaning and scaling, but not more than twice for each covered person during any calendar year;
• Three cleanings per calendar year if you have a documented history of periodontal disease; a fourth cleaning is allowed during the two calendar years following periodontic surgery;
• Topical application of fluoride, generally limited to two applications per year for patients under age 20;
• Space maintainers to replace prematurely lost teeth for dependent children under age 19 payable one per area per lifetime (coverage will terminate at the end of the day
immediately preceding the dependent child’s 19th birthday);
• Emergency treatment to relieve dental pain; and
• Brush biopsy one per calendar year, subject to Plan standards.
Class II Services
• Dental X-rays, including full mouth X-rays once during each period of five consecutive calendar years, supplementary bitewing X-rays once in any calendar year, and dental X- rays that are required for the diagnosis of a specific treatment;
• Extractions, including those needed for orthodontic treatment;
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• Oral surgery;
• Fillings made of amalgam, silicate, acrylic, synthetic porcelain, and composites on front teeth only, as appropriate, to restore diseased or accidentally injured teeth;
• General anesthetics and intravenous sedation when necessary and used with oral or dental surgery;
• Periodontics and treatment of other gum or mouth tissue diseases including periodontal maintenance cleanings;
• Endodontics, including root canal therapy;
• Injection of antibiotics by the attending Dentist;
• Occlusal guard once in a lifetime;
• Repair or recementing of crowns, inlays, onlays, bridgework and dentures; or relining or rebasing dentures more than six months after installation, but not more than once in any period of 36 consecutive months;
• Inlays, onlays, gold fillings or crown restorations but only when a tooth, as a result of extensive caries or fractures, cannot be restored with the filling materials described above (is there a time limitation?);
• Replacement of crowns more than three (3) years after installation of an initial or
replacement crown if the crown has been damaged and cannot be made serviceable, or if there is recurrent decay under the existing crown or decay at a crown-to-natural-tooth margin that cannot be repaired by a direct-fill restoration.
Class III Services
• Initial installation of fixed bridgework, including inlays and crowns as abutments;
• Initial installation of partial or full removable dentures, including any attachments and adjustments during the six months after installation;
• Replacement of an existing partial or full removable denture or fixed bridgework by a new denture or bridgework, or the addition of teeth to an existing partial removable denture or to bridgework if:
− The replacement or addition of teeth is necessary to replace teeth extracted after the existing denture or bridgework was installed;
− The existing denture or bridgework cannot be made serviceable and at least five years have passed since its installation; and
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− The existing denture is an immediate temporary denture and replacement of a permanent denture occurs within 12 months of the first installation of the immediate temporary denture.
• Cosmetic bonding of eight front teeth for children age eight through the end of the calendar year in which they become age 19 if required because of severe staining, but not more frequently than once in any period of three consecutive years.
Class IV Services
• Orthodontia (teeth straightening), as follows:
− Continuous treatment must begin before the patient reaches age 19;
− Benefits are subject to a $2,000 lifetime maximum per eligible person; and
− Services include preventive and corrective treatment of dental irregularities resulting from injury or the abnormal growth and development of teeth.
THE ENHANCED TRADITIONAL DENTAL PLAN
Your coverage includes an Enhanced Delta Dental Plan, which offers access to two of the nation’s largest networks of participating dentists: Delta Dental PPO and Delta Dental Premier. When you receive services from a Delta Dental PPO network Dentist, your out-of- pocket expenses will be lower than if you received services from a Delta Dental Premier or non- participating Dentist.
Under Delta Dentals PPO POS plan you are free to visit any licensed dentist anywhere, but you will save the most money by visiting one of the 68,000 dentists throughout the United States who participate in Delta Dental PPO. If you go to a non-PPO dentist, you also have access to more than 128,000 dentists nationwide who participate in Delta Dental Premier.
When dentists sign contracts to participate with Delta Dental, they agree to accept Delta Dental’s fee determination as payment in full for covered services. This guaranteed acceptance reduces your copayments and deductibles and eliminates balance billing.
In addition, all dentists who participate with Delta Dental PPO and Delta Dental Premier agree to submit claims on behalf of their patients, making the network easy-to-use and hassle-free.
Contact Delta Dental of Michigan at (800) 524-0149 or go to Delta Dental’s website at www.deltadentalmi.com to find network Dentists, or for additional information about nominating new network Dentists. For dental coverage information, register and log on at Delta Dental’s consumer toolkit at www.toolkitsonline.com.
DENTAL EXPENSE LIMITATIONS
Under the Delta Dental Plan, certain dental services have limitations or exclusions. You will be notified of these limitations and exclusions when your treatment plan is considered or at the
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time you receive the services. If you have any questions about dental limitations and exclusions, please contact the Dental Benefits Manager listed in your Schedule of Benefits. You can find the list of limitations and exclusions at www.deltadentalmi.com, or by calling Delta Dental at 800-524-0149.
DEFINITIONS
Dental Hygienist
A person who is trained and licensed to perform dental hygiene services in the state or country where the services are rendered, such as cleaning of teeth, under the direction of a licensed Dentist, and who acts within the scope of his or her license.
Dentist
A person licensed to practice dentistry in the state or country where the services are rendered;
and acts within the scope of his or her license.
DENTAL EXPENSE EXCLUSIONS
Under the Traditional Dental Plan, certain dental expenses are not covered. These include but are not limited to:
• Benefits payable by your other health care coverages;
• Work not performed by a Dentist, except scaling and cleaning of teeth and topical application of fluoride performed by a licensed Dental Hygienist under a dentist’s supervision;
• Veneers for crowns or pontics on teeth, other than the 10 upper and lower anterior teeth;
• Services or supplies that are cosmetic in nature, including charges for personalization or characterization of dentures;
• Prosthetic devices (including bridges), crowns, inlays, onlays and their fitting, if you were not covered when they were ordered, or if they are not installed or delivered within 60 days after the day your coverage ends;
• Replacement of lost, missing, or stolen prosthetic devices;
• Failure to keep a scheduled visit with the Dentist;
• Replacement or repair of an orthodontic appliance;
• Charges for services that are compensated under Workers’ Compensation or similar laws;
• Charges for services or supplies for which no charge is made that the patient is legally obligated to pay or for which no charge would be made in the absence of dental expense coverage;
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• Charges for services or supplies that are not necessary, according to accepted
standards of dental practice, or that are not recommended or approved by the attending Dentist;
• Charges for services or supplies that do not meet accepted standards of dental practice and that are considered Experimental;
• Services or supplies received as a result of war, declared or undeclared;
• Services or supplies furnished or payable by any government or governmental agency, or any governmental program or law under which you could be covered, unless payment is legally required;
• Duplicate appliances;
• Charges for completion of any insurance forms;
• Sealants and oral hygiene and dietary instruction;
• A plaque control program;
• Implantology;
• Services or supplies for periodontal splinting; and
• Treatment of temporomandibular joint (TMJ) syndrome, except for certain initial
diagnostic procedures. You should submit a treatment plan for expenses related to the treatment of TMJ.
• Services, for correction of congenital or developmental malformations.
• Cosmetic surgery or dentistry for aesthetic reasons.
• Services or appliances started before a person became eligible under this Plan. This exclusion does not apply to orthodontic treatment in progress.
• Prescription drugs (except intramuscular injectable antibiotics), medicaments/solutions, premedications, and relative analgesia.
• Charges for hospitalization, laboratory tests, and histopathological examinations.
• Charges for failure to keep a scheduled visit with the Dentist.
• Specialized techniques.
• Services or supplies that do not meet accepted standards of dental practice or that are investigational or experimental in nature.
• Those benefits excluded by the policies and procedures of the Dental Benefits Manager, including their Processing Policies.
• Services or supplies for which no charge is made, for which the patient is not legally
obligated to pay, or for which no charge would be made in the absence of dental coverage.
• Services or supplies received as a result of dental disease, defect, or injury due to an act of war, declared or undeclared.
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• Services that are covered under a hospital, surgical/medical, or prescription drug program.
• Services that are not within the Plans benefits that have been selected and that are not in the contract.
• Fluoride rinses, self-applied fluorides, or desensitizing medicaments.
• Preventive control programs (including oral hygiene instruction, caries susceptibility tests, dietary control, tobacco counseling, home care medicaments, etc).
• Space maintainers for maintaining space due to premature loss of anterior primary teeth.
• Lost, missing, or stolen appliances of any type and replacement or repair of orthodontic appliances or space maintainers.
• Cosmetic dentistry, including repairs to facings posterior to the second bicuspid position.
• Prefabricated crowns used as final restorations on permanent teeth.
• Appliances, surgical procedures, and restorations for increasing vertical dimension; for altering, restoring, or maintaining occlusion; for replacing tooth structure loss resulting from attrition, abrasion, or erosion; or for periodontal splinting. If orthodontic services are
Covered Services, this exclusion will not apply to orthodontic services as limited by the terms and conditions of the Plan.
• Paste-type root canal fillings on permanent teeth.
• Replacement, repair, relines, or adjustments of occlusal guards.
• Chemical curettage.
• Services associated with overdentures.
• Metal bases on removable prostheses.
• The replacement of teeth beyond the normal complement of teeth.
• Personalization/characterization of any service or appliance.
• Temporary crowns used for temporization during crown or bridge fabrication.
• Posterior bridges in conjunction with partial dentures in the same arch.
• Precision attachments and stress breakers.
• Specialized implant surgical techniques, including a radiographic/surgical implant index.
• Appliances, restorations, or services for the diagnosis or treatment of disturbances of the temporomandibular joint (TMJ).
• Diagnostic photographs, diagnostic casts (study models), and cephalometric films, unless done for orthodontics.
• Myofunctional therapy.
• Mounted case analyses.
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Dental Benefits Manager will make no payment for the following services. Participating Dentists may not charge eligible people for these services. All charges from Nonparticipating Dentists for the following services will be the responsibility of the
eligible person:
• The completion of claim forms.
• Consultations, when performed in conjunction with examinations/evaluations.
• Local anesthesia.
• Acid etching, cement bases, cavity liners, and bases or temporary fillings.
• Infection control.
• Temporary crowns.
• Gingivectomy as an aid to the placement of a restoration.
• The correction of occlusion, when performed with prosthetics and restorations involving occlusal surfaces.
• Diagnostic casts, when performed in conjunction with restorative or prosthodontic procedures.
• Palliative treatment, when any other service is provided on the same date except X-rays and tests necessary to diagnose the emergency condition.
• Post-operative X-rays, when done following any completed service or procedure.
• Periodontal charting.
• Pins and/or preformed posts, when done with core buildups for crowns, onlays, or inlays.
• A pulp cap, when done with a sedative filling or any other restoration. A sedative or temporary filling, when done with pulpal debridement for the relief of acute pain prior to conventional root canal therapy or another endodontic procedure. The opening and drainage of a tooth or palliative treatment, when done by the same Dentist or dental office on the same day as completed root canal treatment.
• A pulpotomy on a permanent tooth, except on a tooth with an open apex.
• A therapeutic apical closure on a permanent tooth, except on a tooth where the root is not fully formed.
• Retreatment of a root canal by the same Dentist or dental office within 24 months of the original root canal treatment.
• A prophylaxis or full mouth debridement, when done on the same day as periodontal maintenance or scaling and root planing.
• An occlusal adjustment, when performed on the same day as the delivery of an occlusal guard.
• Reline, rebase, or any adjustment or repair within six months of the delivery of a partial denture.
• Tissue conditioning, when performed on the same day as the delivery of a denture or the reline or rebase of a denture.
