Making care available
Dental Choice
Regence BlueShield of Idaho
Dental health is an important part of physical health. With Regence Dental Choice, you can help your employees get what they need for overall wellness.
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Preventive and restorative care is essential for healthy teeth and gums. Regence Dental Choice allows you to help your employees and their families get the care they need.
Regence offers a wide range of benefits and a network of dentists who agree to help keep costs down.
Good dental health shouldn’t be optional
With today’s technology, no one should have to suffer from tooth decay or dental disease. That’s why Regence is pleased to make Dental Choice coverage available to your employees and their families. By offering this plan, you can make it easier for them to get regular check-ups and needed care. There’s a plan for every need Dental Choice offers flexibility and comprehensive coverage. That makes it affordable for you and practical for your employees. You have a choice among ten packages of dental benefits. All offer flexibility, and any of them can be written either as stand-alone coverage or as a companion plan for your Regence medical coverage. Real benefits for real needs Our ten available packages vary in details, but all of them offer the following coverage: • Two oral exams per calendar year • Two cleanings per calendar year • Bite-wing and full-mouth x-rays • Fluoride and sealants for children 17 and under Seven of the packages offer coverage for major restorative services, including implants. Finally, participating dentists have agreed to charge no more than the current allowable charge for any given service. That means Regence membership protects your employees against balance-billing when they see network providers.
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Idaho Dental Choice
Children need regular check-ups to establish a lifetime of good dental habits. That’s why dental coverage should be available to the whole family.
Employees (including officers, managers, proprietors and partners) and their eligible dependents can be covered under this plan. Eligible employees hired on or after the plan’s effective date will need to meet any probationary period you establish. To be eligible, employees have to meet the following criteria: • They have to be employed on a regular basis for at least 20 hours per week and be eligible for federal and FICA withholding. • They have to be at least 15 years of age. Also, if you offer benefits to retirees, they, too, can be eligible for this coverage. Unmarried dependent children may continue on this plan up to age 23. All applicants will need to submit applications for coverage. Enrollment Coverage will begin for an eligible employee and dependents on the first day of the month after we receive the completed enrollment forms, or on the first day of the month following the end of any probationary period. Newborns and newly adopted children will be covered automatically for the first 60 days after birth or placement for adoption; coverage will continue only if we receive a completed enrollment form before the end of those 60 days. Any unmarried child dependent who is or becomes incapable of self-sustaining employment due to developmental disability or physical handicap prior to age 23 and who is primarily dependent on the enrolled employee for support and maintenance will retain dependent coverage as long as the enrolled employee remains on the plan, the plan remains in force and the dependent’s condition persists. Proof of the dependent’s condition must be provided, in writing, to Regence within 31 days of their 23rd birthday. Regence may require proof of continued eligibility in the future. Coverage will end on the last day of the month in which the member ceases to be eligible. Dependents who lose coverage due to divorce will be covered through the last day of the month in which the divorce decree is entered.
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Who is eligible?
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Idaho Dental Choice
Regence Dental Choice: Designed for small business
We have ten plans available. Choose the one that’s right for you: Deductible
Coinsurance
Package 1*
$50 Class I & II Combined
80% Class I & II
$500
Package 2*
$25 Class I, $50 Class II
80% Class I & II
$500
Package 3
$75 Class I, II & III Combined
80% Class I & II
$1,000
Package 4
$50 Class I & II Combined $75 Class III
80% Class I & II, 50% Class III
$1,000
Package 5
$25 Class I $50 Class II, $75 Class III
80% Class I & II, 50% Class III
$1,000
Package 6
$50 Class I, II & III Combined
100% Class I, 80% Class II, 50% Class III
$1,000
Package 7
$25 Class I, II & III Combined
100% Class I, 80% Class II, 50% Class III
$1,000
Package 8
$0 Class I $50 Class II & III Combined
100% Class I, 80% Class II, 50% Class III
$1,000
Package 9
$0 Class I $25 Class II & III Combined
100% Class I, 80% Class II, 50% Class III
$1,500
Package 10
$0 Class I, II & III Combined
70% Class I & Class II** 50% Class III
$1,000
Incentive Dental (Available to groups of 25 or more enrolled employees)
Out-of-Pocket Maximum
*Please Note: Groups with two to five enrolled employees with no prior group dental coverage are eligible only for Packages 1 and 2 for the first 12 months of coverage.
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**Class I & II services will be paid at 70% of allowable charges during the first calendar year of a member’s coverage. At each successive calendar anniversary date, the percentage payment will be increased by 10% (never exceeding 100% of allowable charges), provided the member obtained covered dental services during the most recently completed calendar year.
Benefits by Class
Class I—Preventive and Diagnostic* • Oral exams (twice per calendar year) • Cleaning (twice per calendar year) • Fluoride for children age 17 and under (twice per calendar year) • Bite-wing x-rays (once every three years) • Sealants for children age 17 and under (once every four years) • Space maintainers for children age 11 and under Class II—Basic Services* • Palliative emergency treatment • Pulp vitality tests • Biopsies of oral tissue • Endodontics • Fillings • Simple extractions • Root canal treatment • Apicoectomy • Extractions • Hemisection • Periodontal infection • Anesthesia • Oral lesions • Mucogingivoplastic surgery Class III—Major Restorative* Prosthodontic services, including: • Dentures (every five years) • Bridgework (every five years) • Repairs to dentures, bridgework, inlays and onlays • Denture relining (every two years) • Crowns, including repairs • Veneer, subject to Regence approval • Onlays, subject to Regence approval • New: Endoseal implants (four per lifetime) *Optional orthodontic benefit
If you have 25 or more enrolled employees, you have the option of purchasing orthodontic coverage. Groups without prior orthodontic coverage will be subject to a 12-month waiting period. Benefits for orthodontic services will be provided at 50% of the allowable charge, subject to a lifetime maximum of $2,000. 0
Idaho Dental Choice
Limitations and exclusions
Benefits will not be provided in any of the following circumstances or for any of the following conditions under the terms of this Policy:
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• Services that are not considered necessary dental care. • Dental services related to congenital malformations or provided primarily for cosmetic or aesthetic purposes, including hypoplasia, fluorosis, discoloration of teeth or deformed teeth, except for newborn children. • Dental services for which the enrolled employee would have no legal obligation to pay in the absence of this or any similar coverage. • Dental care or treatment not specifically listed as covered. • Crowns, inlays, and onlays, except as may be provided under Class III services. • Gold restorations, except as may be provided under Class III services. • Replacement of crowns, gold cast restorations, (including inlays, onlays and veneers) less than five years old, except as may be provided under Class III services). • Temporary crowns, except when used in an out-of-area emergency for shortterm pain control, subject to approval by Regence BSI (except as may be provided under Class III services). • Charges for replacement of lost or stolen items. • Hospitalization, hospital services or supplies provided in connection with covered dental services, or additional fees charged by a dentist for the hospital treatment of an Insured. • Dental work covered under the Workers’ Compensation Code. • Charges that exceed the allowable charge. • Orthodontic treatment, including correction of malocclusion, except as may be provided by endorsement. • Appliances or restorations used for periodontal splinting (except for documented cases of bruxism); increasing vertical dimensions; restoring occlusion; or correcting habits including but not limited to tongue thrusting. • Diagnostic photographs, diagnostic casts and study models. • Duplicate x-rays. • Oral hygiene instruction. • Recontouring restorations. • Replacements of space maintainers; space maintainers used in conjunction with orthodontics to create a space between the teeth. • Temporary dentures, except when replacing anterior (front) teeth accidentally lost less than one month prior to placement of a permanent denture.
• Indirect pulp capping. • Occlusal equilibration and/or treatment for temporomandibular joint (TMJ) disorders. • Nitrous oxide. • Services and supplies provided in connection with implants, except as provided under Class III benefits. • Experimental and investigational dental procedures. • Behavior management (i.e., manipulation of an uncooperative child or adult with severe gag reflex). • Dental services incurred prior to the date the Insured became eligible for such services under this policy. An expense is incurred when: — the impression is taken for dentures or fixed bridgework; — preparation of the tooth is begun for crown work; or — work on the tooth is begun for root canal therapy. • Services provided by a provider who is related to the Insured by blood or marriage or who ordinarily resides in the Insured’s home. • Claims submitted to Regence BSI more than 12 months after the last day on which covered dental services were rendered, unless it can be shown to the satisfaction of Regence BSI that there was unusual and justifiable cause for such late submission.
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Benefits will be limited as follows: • Total benefits paid for root planing and scaling per quadrant shall be limited once every 24 consecutive calendar months. • Total benefits paid for initial oral examinations and periodic oral examinations shall be limited to twice in any calendar year. • Total benefits paid for bitewing x-rays shall be limited to twice in any calendar year. • Total benefits paid for either a complete series or a panoramic x-ray shall be limited to once each three years unless special need is shown. • Total benefits paid for prophylaxis services—including cleaning, scaling and polishing—shall be limited to twice in any calendar year. • Total benefits paid for prophylaxis services for periodontal maintenance shall be limited to once each three months, subject to review for medical necessity. • Total benefits paid for topical application of sodium or stannous fluoride for Insureds age 17 and under shall be limited to twice in any calendar year. • Total benefits paid for topical application of sealant for Insureds age 17 and under shall be limited to once in any four-year period. Coverage shall be limited to permanent teeth. • Total benefits paid for space maintainers, including all adjustments made within six months of installation, shall be limited to Insureds age 11 and under. • Total benefits paid for dental implant crowns and abutment-related procedures shall be limited to once per tooth in a seven-year period. • Total benefits paid for endoseal implants shall be limited to four during an Insured’s lifetime. • Total benefits paid for repair of implant supported prosthesis or abutment shall be limited to once per tooth during an Insured’s lifetime. • If an Insured transfers from the care of one dentist or provider to that of another dentist or provider during the course of treatment, or if more than one dentist or provider renders services for a dental procedure, Regence BSI shall be liable for not more than the amount it would have been liable for had only one dentist or provider rendered the service. • In all cases in which there are optional techniques of treatment carrying different fees, Regence BSI shall be liable only for the treatment carrying the lesser fee.
DC-2007-Policy DC-2007-BK FSDC-2007-BK
DC-1-07 SL
www.id.regence.com
Toll-Free 1 (800) 632-2022 Hearing Impaired (TDD) (208) 798-2074
Regence BlueShield of Idaho Sales Offices Boise (208) 336-2420 Coeur d’Alene (208) 667-2761 Lewiston (208) 746-2671 Pocatello (208) 234-0020 Twin Falls (208) 736-0755
For more information, call toll-free 1 (800) 856-8543.