Plan Design

• Preventive 100%, Basic 80%, Major 50%, Orthodontics 50%, $1000 Annual Maximum, $1000 Lifetime Orthodontic Maximum, $50/%150 Deductible, Endodontics & Periodontics are in Major services.
• 12 Month waiting period applies to Major and Orthodontic services. With proof of coverage and effective dates from the company’s prior carrier – the employee’s waiting period for Major, and Orthodontic services, if covered by the company’s previous dental plan, will be reduced by the number of months the employee was covered by the prior carrier.
• Monthly Administration Fee is $2.00 per employee to a maximum of $20.00.
• All rates are subject to change.

 

Underwriting Guidelines

• A minimum of 2 eligible persons must enroll.
• Contributory plans: Require the employer to contribute 50% of the single premium and 75% of all eligible employees enroll on the plan
• Voluntary plans: Groups with 2-20 eligible require 25% of eligible employees to enroll on the plan. Groups with 21+ eligible require a minimum of 5 eligible employees to enroll on the plan.
• All dual option plans must be quoted.
• The following industries must be quoted: Schools and Education Services, and Legal/Law firms, Public Administration and Municipalities, Financial Institutions, Accountants, Medical, Insurance Companies and Agencies.
• Dental offices and dental related industries are not eligible for coverage.
• Rates will be separate by geographical area (by employer).
• Groups with 10% or more of eligible employees residing outside of the approved state are subject to underwriting review.
• Eligible employees must be considered full time and work at least 30 hours per week for a contributory plan, and 20 hours for a voluntary plan.
• All employees and dependents must enroll within 30 days from the time the employee becomes eligible.
• Groups currently enrolled with Dental Select or that have been quoted by Dental Select are ineligible to use manual rates.

 

Utah Plan Design

• Voluntary plans:In Network: Preventive 100%, Basic 80%, Major 50%, Orthodontics 50%. Out of Network: Preventive 80%, Basic 70%, Major 50%, Orthodontics 50%.
• $1000 Annual Maximum, $1000 Lifetime Orthodontic Maximum, $50/%150 Deductible, Endodontics & Periodontics are in Major services.
• Contributory plans: Preventive 100%, Basic 80%, Major 50%, Orthodontics 50%, $1000 Annual Maximum, $1000 Lifetime Orthodontic Maximum, $50/%150 Deductible, Endodontics & Periodontics are in Major services.
• 12 Month waiting period applies to Major and Orthodontic services. With proof of coverage and effective dates from the company’s prior carrier – the employee’s waiting period for Major, and Orthodontic services, if covered by the company’s previous dental plan, will be reduced by the number of months the employee was covered by the prior carrier.
• Monthly Administration Fee is $2.00 per employee to a maximum of $20.00.
• All rates are subject to change.

 

Utah Underwriting Guidelines

• A minimum of 2 eligible persons must enroll.
• Contributory plans: Require the employer to contribute 50% of the single premium and 75% of all eligible employees enroll on the plan
• Voluntary plans: Groups with 2-20 eligible require 25% of eligible employees to enroll on the plan. Groups with 21+ eligible require a minimum of 5 eligible employees to enroll on the plan.
• All dual option plans must be quoted.
• The following industries must be quoted: Schools and Education Services, and Legal/Law firms, Public Administration and Municipalities, Financial Institutions, Accountants, Medical, Insurance Companies and Agencies.
• Dental offices and dental related industries are not eligible for coverage.
• Rates will be separate by geographical area (by employer).
• Groups with 10% or more of eligible employees residing outside of the approved state are subject to underwriting review.
• Eligible employees must be considered full time and work at least 30 hours per week for a contributory plan, and 20 hours for a voluntary plan.
• All employees and dependents must enroll within 30 days from the time the employee becomes eligible.
• Groups currently enrolled with Dental Select or that have been quoted by Dental Select are ineligible to use manual rates.

 

Dental Limitations

Plan Limitations

The services covered by our co-insurance dental plans are subject to limitations and exclusions. A partial list of these limitations and exclusions is shown below. For a complete list of your plan’s specific covered services, and the limitations and exclusions that apply to those services, refer to your Policy or contact Us.

1. Routine exams and cleanings – two per year (in conjunction with all other exams).
2. Topical Fluoride – up to age 15 – 2 per calendar year.
3. Panoramic (age 6 and older) or full mouth series x-rays (age 11 and older) – limited to one every 36 months.
4. Bitewing x-rays – 8 total per year (ages 2 and over).
5. Occlusal x-ray – 1 upper and 1 lower every 24 months.
6. Sealants – repair/ replacement is not covered within 36 months of application. Limited to permanent bicuspids and molars without decay or restorations for children up to age 15.
7. Space maintainers – to preserve space between teeth for premature loss of a primary baby tooth. This does not include use for orthodontic treatment. Up to age 15.
8. Fillings – Repair or replacement is not covered within 24 months of initial placement.
9. Full mouth debridement – limited services available on same date of service. Limited to one per 60 months.
10. Periodontal scaling/root planing – limited to once per quadrant in any 24 month period.
11. Periodontal maintenance – two per year in lieu of preventive cleaning.
12. Stainless steel crowns – one per 24 months.
13. Occlusal guards for bruxism – one every 24 months.
14. Crowns, bridges, inlays, onlays, dentures and gold fillings – every 60 months (age restrictions may apply; additional lab fee may be charged by provider for higher metals and porcelain that is not covered by the plan).
15. Dentures – relining or rebasing of removable dentures – once per 12 months.
16. General anesthesia, including intravenous sedation – Age 7 & under: Once per calendar year up to $150; Age 8 & older: for the extraction of impacted teeth, based on necessity and not for anxiety management, up to $150 per year.

 

Orthodontia Services Limitations (only included if indicated on Summary of Benefits)

No coverage or limited coverage for orthodontic treatment which began prior to the effective date of coverage.

 

Alternate Benefit

If a less expensive, alternate procedure, service, or course of treatment can be performed in place of the proposed treatment to correct a dental condition, and the alternative treatment will produce a professionally satisfactory result, then the maximum allowed will be the charge for the less expensive treatment.

 

Dental Exclusions

Plan Exclusions

Limitations and Exclusions may vary by state. Refer to your Policy or contact Us.

Exclusions – Coverage is not provided for expenses incurred:

EXPENSES NOT COVERED:  No benefits will be paid for expenses incurred:

1. for services and supplies not listed in the Coverage Schedule, not recognized as essential for the treatment of the condition according to accepted standards of practice or considered experimental.
2. for services related to, performed in conjunction with, or resulting from a non-covered procedure.
3. for charges in excess of the contracted Fee-for-Service schedule or the Usual and Customary rate, whichever applies.
4. for any treatment program which began prior to the date the Insured is covered under the Policy.
5. for crowns, inlays and onlays on teeth that can be restored by direct placement materials.
6. for the replacement of crowns, bridges, dentures, inlays or onlays that can be restored to normal function.
7. for the replacement of crowns, bridges, inlays, onlays or prosthetic appliance within 5 years from the date of last placement.
8. for service or supplies payable under any medical expense plan.
9. for any condition covered under any Worker’s Compensation Act or similar law.
10. for services applied without cost by any municipality, county or other political subdivision or for which there would be no charge in the absence or insurance.
11. during any Waiting Period We require.  This exclusion applies to employer-sponsored adult coverage only.  When You voluntarily end Your insurance without a Qualifying Event and re-enroll at a later date, Your Waiting Period is 2 years and begins on the date Your coverage first ended.
12. for services that are applied toward the satisfaction of a Deductible, if any.
13. for services subject to a Waiting Period that were incurred during the Waiting Period.
14. for charges resulting from changing from one provider to another while receiving treatment, or from receiving treatment from more than one provider for one dental procedure to the extent that the total charges billed exceed the amount incurred if one provider had performed all services.
15. for hospital facility charges for any dental procedure, including but not limited to: emergency room charges, surgical facility charges, hospital confinement.
16. for drugs or the dispensing of drugs.
17. for oral hygiene instruction; plaque control; acid etch; prescription or take-home fluoride; broken appointments; completion of a claim form; OSHA/Sterilization fees (Occupational Safety & Health Agency); or diagnostic photographs (except for orthodontic purposes).
18. for orthodontia, unless included within the Coverage Schedule.
19. for cosmetic procedures, including but not limited to veneers and bleaching of teeth and procedures performed primarily for cosmetic reasons.
20. for implants (unless included in the Covered Services); myofunctional therapy; athletic mouthguards; precision or semi-precision attachments; treatment of fractures, cysts, tumors, or lesions; maxillofacial prosthesis; orthognathic surgery; TMJ dysfunction; cleft palate; or anodontia.
21. for services to replace teeth that were missing (extracted or congenitally) prior to the effective date of coverage on Our Plan. This limitation ends after 36 months of continuous coverage on the Plan. Abutment teeth will be reviewed for eligibility of prosthetic benefits.
22. for composite, resin, or white fillings on posterior primary teeth.  Benefits will be reduced to that of an amalgam or silver filling.
23. for the replacement of a filling within 24 months of placement, unless for specific health reasons.
24. for the replacement of retainers.
25. for sealants not applied to a permanent bicuspid or molar; applied at age 15 or older; applied 3 years from a previous sealant application; applied to a decayed tooth.
26. for lab fees for higher metals or porcelain crowns, bridges, inlays, or onlays.
27. during travel or activity outside the United States.
28. to replace lost or stolen appliances.
29. for any procedure begun after the Policy terminates; or for any prosthetic dental appliances installed or delivered more than 90 days after the Insured’s coverage terminates.
30. for appliances, restorations, or procedures to: (a) alter vertical dimension; (b) restore or maintain occlusion; or (c) splint or replace tooth structure lost as a result of abrasion or attrition.
31. for initial placement of any prosthetic crown, appliance, or fixed partial denture unless such placement is needed because of the extraction of one or more teeth while the Insured is covered under this Policy.  But the extraction of a third molar (wisdom tooth) will not qualify under the above.  Any such prosthetic crown, appliance, or fixed partial denture must include the replacement of the extracted tooth or teeth.

 

This information is a brief description of the important features of this insurance plan. It is not an insurance contract. Insurance benefits are underwritten by ACE American Insurance Company. Coverage may not be available in all states or certain terms may be different where required by state law. Chubb NA is the U.S.-based operating division of the Chubb Group of Companies, headed by Chubb Ltd. (NYSE:CB) Insurance products and services are provided by Chubb Insurance underwriting companies and not by the parent company itself.