Dental Benefit

Dental Fee Schedule/Schedule of Allowance

Covered members and enrolled dependents are eligible for dental benefits. Covered claims will be paid up to the scheduled allowance for dental work furnished while you or an enrolled dependent is covered, up to the maximum for the procedure listed in the dental schedule. In addition, if one of the participating dentists is used, then the fees listed in the dental schedule will be accepted as payment in full for covered services.

The following conditions must be met for benefits to be payable:

The claimant must be eligible for benefits at the time expenses are incurred;
The expense is incurred when the service is performed, except in the case of:
dentures - when the final impression is taken;
crown or fixed bridgework - when preparation of the tooth is begun;
root canal therapy - when work on the tooth is completed;
No changes have been made in the Plan prior to the performance of the service that would change the allowance;
Total benefit payments for all treatment of a patient must not exceed the Plan maximums;
The allowance may be reduced by coordination of benefits as applicable.

MAXIMUM AMOUNTS PAYABLE

The maximum amount payable for each covered active member and retiree on a self-pay plan, and his or her enrolled dependents for covered dental services, will be $3,250 in any plan year (September 1 to August 31) exclusive of orthodontic, implant, and periodontic services which have separate maximums. The yearly maximum per person for covered periodontic work is $2,000. The lifetime maximum per person for implants is $4,000 ($2,000 for the first and $2,000 for the second).

Note: All plan maximums are based on the Fund’s Schedule of Allowance (linked above).

The maximum for covered retirees in the Basic Plan is $500 per plan year (September 1 to August 31) for the retiree and his or her eligible dependents combined.

PRE-DETERMINATION OF BENEFITS

If your course of treatment is expected to cost more than $1,000, your dentist is required to complete a pre-determination request on the dental claim form and submit it with a properly mounted set of x-ray films for review by the Fund’s Consultant Dentist. Pre-determination by the Fund’s Consultant Dentist is limited to the approval of the course of treatment proposed; it does not include approval of payment for services not covered under the Dental Plan, the patient’s eligibility, or guaranteed payment. Completed treatment amounting to $1,000 or more may require examination of the patient by the Fund’s Consultant Dentist before payment is made. Your dentist should be familiar with this procedure. This process assures that both you and your dentist will know in advance what services are covered and which parts of the dentist’s charges the FA Benefit Fund would pay.

Pre-determination is not intended to interfere with your dentist’s professional judgment or to delay your dental care. Rather, this process permits a review of the proposed treatment in advance and allows for the resolution of any questions before, rather than after, the work has been done.

The FA Benefit Fund has the right to request that a patient undergo an oral examination to verify the treatment that is recommended in the pre-determination review.

Failure to comply with the pre-determination rules will result in forfeiture of benefits.

ALTERNATE BENEFIT PROVISION

When more than one dental service would provide suitable treatment, your benefits will be based on the treatment determined by the Fund’s Consultant Dentist to be best suited to your condition by accepted standards of dental practice. If two services would both provide satisfactory results according to accepted standards of dental practice and one service is less expensive than the other, the FA Benefit Fund will reimburse up to the scheduled allowance of the less expensive treatment.

The attending dentist and the patient may still proceed with the original treatment plan regardless of the FA Benefit Fund’s determination. However, reimbursement will be made at the level of the alternative.

For example, payment for a crown may not be made if an acceptable professional result can be obtained by filling the tooth. Payment will then be made as if the tooth were filled.

OBTAINING THE BENEFIT

In order to obtain benefits, request the necessary dental claim form from the Fund Office. Upon completion of treatment, have the dentist complete his or her portion of the claim form. You should then complete your portion of the claim form and mail it to the Third Party Administrator. If prolonged dental treatment is required, you should periodically submit claim forms to the Third Party Administrator for that portion of the treatment which has been completed. Payment of the claim will be made directly to you unless you use a participating dentist, then the payment will be made to the dentist.

PARTICIPATING DENTIST PROGRAM

The FA Benefit Fund provides for free choice of dentists. However, the FA Benefit Fund has made arrangements with many dentists who accept the fees listed in the dental schedule as payment in full when the FA Benefit Fund is the primary carrier. If you use a participating dentist and the FA Benefit Fund is the primary carrier, you will not have to pay for any services listed in the schedule up to the Plan maximums. Payments will be made by the FA Benefit Fund directly to the dentist.

Participating dentists may charge you for services not covered by the plan if the annual maximum has been reached or the frequency limitation has been exceeded.

Dentists who specialize in orthodontics, periodontics, endodontics, or oral surgery are listed separately from general dentists. This list will be revised from time to time by the FA Benefit Fund.

The list provides the names, addresses, and telephone numbers of the dentists who are currently participating with the FA Benefit Fund’s dental plan. These dentists have agreed to provide covered dental procedures at no out-of-pocket expense to covered members and their enrolled dependents. The list is provided as an informational service only for the convenience of covered members and eligible dependents. The FA Benefit Fund does not recommend the services of any particular dentist. The participating providers have been selected because they have agreed to accept the Fund’s fee schedule as payment in full for covered services.

If you or your eligible dependents are charged for any covered services by a participating provider, do not pay the charge and contact the Fund Office immediately. The FA Benefit Fund requests that you report any irregularities, including rudeness, unsanitary conditions, and difficulty in obtaining appointments at convenient hours, to the Fund Office.

LIMITATIONS AND EXCLUSIONS

Covered dental expenses shall not include expenses incurred for

Instruction for plaque control;
Oral hygiene instruction;
Bite registrations;
Experimental or investigational dental services;
Any services, supplies, or treatment unless prescribed by a legally qualified dentist or physician;
Services rendered prior to the patient becoming eligible for benefits;
Any dental procedure performed wholly or substantially for cosmetic reasons or without respect to congenital mouth form;
Replacement of existing denture or partial denture more than once every five years;
Placement of existing crown or fixed bridge more often than once every five years;
Crowns, inlays, dentures, bridgework, or other prosthetic appliances installed or delivered more than 30 days after termination of coverage;
Charges for crowns, inlays, dentures, bridges, or other appliances to increase vertical dimension or reduce occlusion;
Charges for multiple abutting of teeth or crowns, or teeth installed for clasping purposes only, or crowns and/or inlays installed as multiple abutments and splints to augment periodontal treatment;
Duplicate prosthetic appliances;
A prosthetic appliance, fixed or removable, used as an adjunct to periodontal care, unless it replaces a missing tooth;
Charges for temporary crowns (unless tooth is fractured and only on anterior teeth), implants and bridges or dentures involving implants, or for temporary dental services which will be considered an integral part of the final dental service rather than a separate service;
Dental service performed by a dentist in which the FA Benefit Fund experiences an instance of unsatisfactory documentation or recording of services which are deemed detrimental to the FA Benefit Fund or the patient;
Most inclusive periodontal service includes all other services performed on the same date, in the same area and payment will be make for the all-inclusive service only; e.g., osseous surgery (ADA code 4260) and gingivectomy (ADA code 4210) performed on the same date, payment will be made for the all-inclusive osseous surgery only;
Any benefit that is claimed after a period that exceeds one year from the completion of the dental services;
Replacement of a lost or stolen appliance;
Dental supplies or services for which benefits are provided at a Veteran’s Administration Hospital or Clinic, or for dental supplies or services related to injury or disease covered by any Workers’ Compensation law, or charges for expenses which are reimbursable through “no fault” automobile insurance;
Dental supplies or services furnished by or for the United States Government or any other local governmental agency or where reimbursement is made elsewhere;
Services where a charge is not incurred or payment is not required;
Services performed by a member of your or your spouse’s immediate family unless proof of payment is provided for those services.
Dental services or supplies not listed or not consistent with the Schedule of Allowance unless the FA Benefit Fund reviews the services and accepts the expenses as covered dental expenses. The covered dental expense for such services will be determined by the FA Benefit Fund and will be consistent with those listed in the Schedule of Allowance.

SCHEDULE OF ALLOWANCES

The Plan year is from September 1 to August 31. The Schedule of Allowance is located at the top of this page, or you can call the Fund Office for a print copy.