Dental Blue RET - Amendatory Rider

Amendatory Rider

 

This rider modifies the terms of your health plan. Please keep this rider with your Benefit Description for easy reference.

Restorative Services

The benefits described in your Benefit Description for composite resin (tooth color fillings) have been changed.

The benefits described in your Benefit Description for composite resin (tooth color) fillings on front teeth are also provided for composite resin (tooth color) fillings on back teeth (bicuspids and molars).

In addition, Blue Cross and Blue Shield no longer provides benefits only for an amalgam (silver) filling toward the cost of a composite resin (tooth color) filling. Instead, Blue Cross and Blue Shield uses the allowed charge for the composite resin (tooth color) filling to calculate this benefit payment. Except for those instances described in your Benefit Description, you do not have to pay the amount of the dentist’s actual charge that is in excess of the allowed charge for a composite resin (tooth color) filling.

Note: Your Benefits Payable Rider explains the amount of your benefits for these covered services. All other provisions remain as described in your Benefit Description.

Dependent Eligibility

The “Eligible Dependents” section in your Benefit Description is replaced by the following new section:

Eligible Dependents
The subscriber may enroll eligible dependents for coverage in this dental plan under his or her group membership. “Eligible dependents” include the subscriber’s (or subscriber’s spouse’s) children who are under age 26. To be an eligible dependent, a child under age 26 is not required to live with the subscriber or the subscriber’s spouse, be a dependent on the subscriber’s or subscriber’s spouse’s tax return, or be a full-time student. These eligible dependents may include:

  • A newborn child. The effective date of coverage for a newborn child will be the child’s date of birth provided that the subscriber formally notifies the plan sponsor within the time period required to add a new dependent.
  • An adopted child. The effective date of coverage for an adopted child will be the date of placement of the child with the subscriber for the purpose of adoption. The effective date of coverage for an adoptive child who has been living with the subscriber and for whom the subscriber has been getting foster care payments will be the date the petition to adopt is filed.
  • A newborn infant of an enrolled dependent child immediately from the moment of birth and continuing after, until the enrolled dependent child is no longer eligible as a dependent.

If an eligible dependent child is married, the dependent child can enroll for coverage under the subscriber’s group membership. And, as long as that enrolled child is an eligible dependent, his or her children are also eligible for coverage under the subscriber’s group membership. The dependent child’s spouse is not eligible to enroll as a dependent for coverage under the subscriber’s group membership. An eligible dependent may also include the subscriber’s (or subscriber’s spouse’s) child who is:

  • A person under age 26 who is not the subscriber’s (or subscriber’s spouse’s) child but who qualifies as a dependent under the Internal Revenue Code.
  • A child recognized under a Qualified Medical Child Support Order as having the right to enroll for health care coverage.
  • A disabled dependent child age 26 or older. A dependent child who is mentally or physically incapable of earning his or her own living and who is enrolled under the subscriber’s group membership will continue to be covered after he or she would otherwise lose dependent eligibility under the subscriber’s group membership, so long as the child continues to be mentally or physically incapable of earning his or her own living. In this case, the subscriber must make arrangements with Blue Cross and Blue Shield through the plan sponsor not more than 30 days after the date the child would normally lose eligibility. Also, Blue Cross and Blue Shield must be given any medical or other information that it may need to determine if the child can maintain coverage in this dental plan under the subscriber’s group membership. From time to time, Blue Cross and Blue Shield may conduct reviews that will require a statement from the attending physician. This is to confirm that the child is still an eligible disabled dependent child.

All other provisions remain as described in your Benefit Description.

Benefits Payable

This Benefits Payable Rider modifies the terms of your Benefit Description. Please keep this rider with your Benefit Description for easy reference.

Deductible
The deductible amount for your benefits under this dental plan is $0. This means that you will not have to first pay a deductible before you receive benefits for covered services under this dental plan.

All other provisions remain as described in your Benefit Description.

Overall Benefit Maximum
All benefits described in your Benefit Description are subject to a $1,500 calendar year overall benefit maximum for each member. After you reach your overall benefit maximum, no more benefits are provided in that calendar year. In this situation, you must pay all charges. (If you change from a Blue Cross and Blue Shield dental plan to this dental plan, any dollar amount applied toward your calendar year maximum under prior Blue Cross and Blue Shield dental plans will be carried over and applied to the calendar year maximum under this dental plan.)

Note: This overall benefit maximum does not apply to any orthodontic benefits that may be covered under this dental plan.

All other provisions remain as described in your Benefit Description

Services for Members Under 19

The annual benefit maximum as described in your Benefits Payable Rider does not apply for any covered services that are furnished to enrolled eligible dependents who are under age 19.

Note: This rider does not change orthodontic benefits that may be covered under this dental plan.

All other provisions remain as described in your Benefit Description

Under Dental Blue Freedom, your benefits for covered dental services furnished by a dentist who has a Blue Cross and Blue Shield participating provider payment agreement but not a PPO provider contract are provided at the same benefit level that applies when the same covered dental services are furnished by a preferred dentist. Refer to your Benefits Payable Riders and your Orthodontic Endorsement (if you have supplemental orthodontic coverage) for the amount of your benefits and the amounts that you must pay for covered dental services.

All other provisions remain as described in your Benefit Description.

Your Benefits
Under Dental Blue Freedom, your coverage consists of two levels of benefits: in-network benefits; and out-of-network benefits. You will receive in-network benefits when you obtain covered dental services from a dentist who has a written payment agreement to furnish covered dental services to members enrolled under Dental Blue Freedom. When you obtain covered dental services from any other dentist, you will receive out-of-network benefits and your out-of-pocket costs will generally be more. Refer to your Benefit Description for information about how to find an in-network dentist.

Covered Services In-Network Benefits MEMBER’S COST Out-of-Network Benefits MEMBER’S COST
Under Dental Blue Freedom, your benefits will be paid up to an overall benefit maximum in each calendar year for all your in-network and out-of network benefits combined. Until these benefits have been paid, you pay:
Preventive Benefit Group Group 1 Services Nothing* 20% of the allowed charge
Basic Benefit Group – Group 2 Services Not covered; you pay all costs Not covered; you pay all costs
Major Benefit Group – Group 3 Services Not covered; you pay all costs Not covered; you pay all costs
*In some cases, you may have to pay the amount of the dentist’s actual charge that is more than the dentist’s allowed charge. (Refer to your Benefit Description and riders for an explanation of the allowed charge.)

 
All other provisions remain as described in your Benefit Description.

Enhanced Benefits for Members With Oral Cancer

For members who have been diagnosed with oral cancer, this dental plan provides additional coverage for the following dental care services:

  • Dental cleanings (oral prophylaxis or periodontal maintenance cleanings), once each three months. (There must be at least three months between any cleanings covered under your dental plan, including these enhanced benefits.)
  • Fluoride treatment, once each three months.
  • Pre-diagnostic cancer screening, once each six months.

For these benefits, any deductible, coinsurance (for in-network services only) and calendar-year benefit maximum provisions that would otherwise apply for your dental benefits do not apply. (Your out-of-network coinsurance for these benefits will not be more than 20%. In some cases, this coinsurance may be less than 20%. This will happen if the coinsurance amount specified in your Benefits Payable Rider is less than 20%.)

To find out more about these enhanced benefits or how to qualify for these enhanced benefits, you may call the Blue Cross and Blue Shield customer service office at the toll-free telephone number shown on your dental plan identification card.

All other provisions, including your dental benefits for all other covered services, remain as described in your Benefit Description.

Benefit Calculation

The allowed charge for covered dental services furnished by out-of-network dentists has been changed as follows:

For covered dental services furnished by dentists who do not have a payment agreement to furnish these services to members enrolled under Dental Blue Freedom, Blue Cross and Blue Shield calculates your benefits based on the 90th percentile of the Dental Prevailing Healthcare Charges in the zip code region where the covered dental services are furnished. This payment rate is referred to as the provider’s usual and customary charge. The usual and customary charge may sometimes be less than the dentist’s actual charge. If this is the case, you must pay the amount of the provider’s actual charge that is in excess of the provider’s usual and customary charge. This is in addition to the amount you would normally pay for covered dental services (for example, any deductible and/or coinsurance that you owe for that covered dental service). However, if the provider’s actual charge is less than the usual and customary charge, your benefits will be calculated based on the provider’s actual charge.

All other provisions remain as described in your Benefit Description.

Orthodontic Services

This Orthodontic Endorsement modifies the terms of your Benefit Description. Please keep this endorsement with your Benefit Description for easy reference.

Your dental benefits include benefits for the orthodontic services described in this endorsement.

Orthodontic services and supplies are those necessary and appropriate to prevent and correct misalignment of the teeth. The misalignment must be severe enough to interfere significantly with the function of the teeth. The orthodontic services described in this endorsement are covered immediately as of your effective date under this endorsement without waiting periods. (This means that benefits will not be provided for any services you received before your effective date.)

Your Orthodontic Benefits
Under Dental Blue Freedom, your orthodontic coverage consists of two levels of benefits: in-network benefits; and out-of-network benefits. You will receive in-network benefits when you obtain covered orthodontic services from a dentist who has a written payment agreement to furnish covered orthodontic services to members enrolled under Dental Blue Freedom. When you obtain covered orthodontic services from any other dentist, you will receive out-of-network benefits and your out-of-pocket costs will generally be more. Refer to your Benefit Description for information about how to find an in-network dentist.

Orthodontic Services In-Network Benefit Out-of-Network Benefits
Lifetime Benefit Maximum $750 per member (in-network and out-of-network benefits combined)
Covered Services
(first orthodontic exams, limited active care and comprehensive active care)
You pay 50% of the allowed charge up to the benefit maximum.* You pay 60% of the allowed charge up to the benefit maximum.*
Age Limit These benefits are available to members under age 19.
*In some cases, you may have to pay the amount of the dentist’s actual charge that is more than the dentist’s allowed charge. (Refer to your Benefit Description and riders for an explanation of the allowed charge.)

 

Note: Any benefits you received for orthodontic services under prior dental plan(s) administered by Blue Cross and Blue Shield will be applied to the lifetime maximum under this endorsement.

These benefits are provided for:

  • First Orthodontic Exams. This includes your first complete orthodontic exam, models, photographs and radiographs (x-rays), excluding full-mouth radiographs.
  • Limited Active Care. This is care that Blue Cross and Blue Shield determines is of a minor nature and consists of one or more than one of the following services: minor treatment for tooth guidance; minor treatment to control harmful habits; interceptive orthodontic treatment; and orthodontic treatment accomplished solely through the use of functional appliances.
  • Comprehensive Active Care. This is care that Blue Cross and Blue Shield determines is of an extensive nature and is part of a complete course of orthodontic treatment. Comprehensive active care includes active care and services and supplies for orthodontic appliances. This includes the construction and insertion of the appliance.

Treatment Begun Prior to Your Effective Date
If you began orthodontic treatment prior to your effective date under this endorsement, your in-network dentist will be paid on a monthly basis for covered orthodontic services that you receive on or after your effective date under this endorsement. Monthly payments will be made for covered orthodontic services until you complete your treatment. Depending on your stage of treatment at the time you become eligible for orthodontic benefits under this endorsement, the total of these monthly payments may be less than your orthodontic lifetime benefit maximum under this endorsement.

Treatment Begun After Your Effective Date
If you begin orthodontic treatment after your effective date under this endorsement, your in-network dentist will be paid in two installments for your covered orthodontic services. The total of these installments will not be more than your orthodontic lifetime benefit maximum under this endorsement.

Note: No benefits are provided under this endorsement for any services you receive after the termination date of this endorsement.

Pre-Treatment Estimates
Your dentist may submit a Pre-treatment Estimate to Blue Cross and Blue Shield in order to determine the extent of your benefits for orthodontic services. (Refer to your Benefit Description for more information.)

Exclusions
In addition to the exclusions described in your Benefit Description, no benefits are provided under this endorsement for:

  • Surgical services for the correction of congenital anomalies.
  • Replacement of orthodontic appliances for reasons such as theft, abuse, misuse, misplacement, loss, improper fit, allergies, breakage or ingestion.
  • Speech therapy.
  • Instructions for muscle exercises to prevent or correct misalignments of the teeth (myofunctional therapy).