Dental Benefits

Dental Plan

The following information has been mailed to all members and communicated in the New York Teacher. The Red Apple is in the process of being updated and will be reflected in the appropriate website sections.

Effective February 1, 2012, we have adjusted our dental schedule to include some new copays which reflect the need to keep our participating providers, and keeping a wide array of dental care benefits available for all members and their dependents.

Members can access the new schedule here.


Guide to Dental Benefits

Dental Plan

Scheduled benefit plan

Members may choose to access either

  • a panel dentist through SIDS — Self- Insured Dental Services (NY Area) or the Florida PPO Panel (Florida Area), with little or no out-of-pocket cost;
  • or may choose any dentist and submit for reimbursement according to the UFT Welfare Fund Schedule of Covered Dental Expenses.

Dentcare (HMO)

For members who want no out-of-pocket expenses for covered dental services, Dentcare, a dental HMO is available. Members may select a participating dentist for each family member. The Primary dentist makes specialist referrals, if needed.

Florida dental discount plan

Available upon retirement if you are a year-round Florida resident.

Who is covered?

All eligible members and eligible dependents, as defined in the General Information section, are covered for dental benefits.

What dental benefit programs are available?

The UFT Welfare Fund offers benefits through a choice of three (3) types of dental programs as follows:

  1. A "fee-for-service" plan under which members may receive their dental services from a panelist (with little or no out-of-pocket costs). This is known as the UFT Welfare Fund Scheduled Benefit Plan.
  2. Non-participating dentist whereby a member will be reimbursed directly according to the UFT Welfare Fund’s schedule of covered dental expenses.
  3. A Dental HMO plan under which comprehensive dental services are covered with no out-of-pocket expenses, known as Dentcare.

Note: A Florida plan is available upon retirement if you are a year-round Florida resident. This plan is known as the Florida Dental Discount Plan (Healthplex America).

Dental benefits are provided only to the extent that the services, supplies, and the course of treatment are necessary and appropriate, and that they meet professionally recognized standards of quality. Necessity and appropriateness are determined after taking into account the total current oral condition of the patient.

How do I enroll in one of the dental plans?

Upon enrolling in the UFT Welfare Fund, a member and his/her covered dependent(s) are automatically enrolled in the Scheduled Benefit Plan. If you wish to select the Dental HMO (Dentcare), or the Florida Discount Dental Plan, the UFT Welfare Fund’s Dental Transfer Form (DTF) must be completed within sixty (60) days of employment. There is also a Dental Open Enrollment Period every year in the fall [from September 1 – October 15] during which time you may change plans by completing the UFT Welfare Fund’s Dental Transfer Form (DTF).

Your dental coverage remains unchanged when you move from in-service to retiree status.

Note: If you elect to receive dental coverage through the dental HMO, you may not receive reimbursement through the Scheduled Benefit Plan.

What are the benefits under the Scheduled Benefit Plan?

This plan provides benefits for covered services under a reimbursement schedule, called the “Schedule of Covered Dental Expenses" which lists all covered services and the maximum reimbursement amounts.

Within the Scheduled Benefit Plan there are two (2) options available:

  • Participating Panel Program (NY Area) - provided by Self Insured Dental Services (SIDS). Or in Florida - Florida PPO Panel.
  • Direct Reimbursement (using a non-participating dentist).

What is the Participating Panel Program?

Within the Scheduled Benefit Plan there is a dental panel option available consisting of over 700 participating dentists. In addition, the Florida PPO Panel consists of over 1,600 participating dentists throughout the state of Florida. If you use a participating dentist, the reimbursable services will be provided at no cost to you, except for a $150 co-payment for crowns, bridges, dentures, root therapy; a $200 co-payment for certain treatment appliances; a $15 co-payment for exams, fillings, routine extractions and for each month of active orthodontic treatment; and a $50 co-payment for surgical extractions, osseous surgery and covered anesthesia.

A list of participating dentists is available on our website or by calling the Welfare Fund at 212-539-0539.

Panelists:

New York Area: SIDS, Inc.
P.O.Box 9005
Lynbrook, NY 11563-9005
866-679-SIDS (7437) or 516-394-9408
www.uftdental.com
Directory of participating dentists >>

Florida Area: Florida PPO Panel
c/o CIGNA
800-577-0576
www.uftwf.org

What is the Direct Reimbursement Program?

When you utilize a non-participating dentist, you may be required to pay for the full cost of the service and then submit a claim for payment. Reimbursement is made according to the scheduled amount or the actual charge, whichever is less.

What is a Pre-Treatment Estimate and when is it required?

A pre-treatment estimate is an advance notice of dental treatment that should be submitted before treatment is commenced in order to determine what benefits are available. A pre-treatment estimate is required for inlays or onlays, crowns, laminate veneers, bridgework, dentures, periodontal surgery or when expenses for services provided in a ninety (90) day period will exceed $500.

What is an Alternate Course of Treatment?

For Covered Dental Expenses under this plan, when more than one Dental Service could provide suitable treatment based on professional and customary dental standards, the Fund’s dental plan administrator, CIGNA, will determine the Dental Service on which payment will be based. You are free to apply this benefit payment to the treatment of your choice; however, you are responsible for the expenses incurred which exceed Covered Expenses. For this reason, CIGNA strongly recommends the use of pretreatment estimate as described above, when major dental services are needed, so that you know in advance what the benefit plan will cover before any treatment begins. Under no circumstances will an alternate benefit be applied to services that are not Covered Dental Expenses.

How are benefits obtained under the Scheduled Benefit Plan?

The UFT Scheduled Benefit Plan is administered by Connecticut General Life Insurance Company (CIGNA), P. O. Box 182531, Chattanooga, TN 37422-7531 800-577-0576 mycigna.com

You can obtain benefit payments for services rendered by participating or non-participating dentists only if you file the required dental claim form with Connecticut General Life Insurance Company (hereinafter referred to as “CIGNA”) as described below.

  1. Dental Claim Form
    The UFT Welfare Fund Dental Claim Form is used for two different purposes. Indicate by checking the appropriate box on the form whether it is a Pre-Treatment Estimate or a Payment Claim.
    You should take a dental form with you when you first visit the dentist, and for each new course of dental treatment. Participating dentists will have their own form.
  2. Using the Dental Claim Form
    1. Submission of Form

      When submitting the Dental Claim Form, you must complete all relevant items in the Member Information section. If not applicable, disregard patient and spouse information. The Authorization to Release Information must always be signed whether the form is a Pre-Treatment Estimate or a Payment Claim (unless there is a signature on file).

      The dentist completes the Dentist Information section, including patient name. The dentist must sign the form. In lieu of completing this form, the dentist may attach his or her own standardized form to the UFT Welfare Fund Dental Form, provided that all required information, including the procedure codes, and the dentist's signature appear.
    2. Assignment of Benefits

      The benefits to which you are entitled will be paid to you unless you assign them. Sign the “Authorization to Assign Benefits” line if you wish payment to be sent directly to your dentist (payment to SIDS and the Florida PPO participating dentists is automatically assigned.) If you assign benefits, you will be notified of the payments made so that you know the portion of the bill not covered by this plan.
    3. Pre-Treatment Estimate

      A Pre-Treatment Estimate (which is an Advance Notice of Dental Treatment) is required when the dental course of treatment includes one or more of the following:
      1. Periodontal Surgery
      2. Inlays or Onlays
      3. Crowns
      4. Bridgework
      5. Dentures
      6. Laminate veneers
      7. The expense for services provided in a ninety (90) day period would exceed $500.

      The Pre-Treatment Estimate Form must be submitted along with Pre-Treatment X-rays and must include all services to be provided in the course of treatment within a ninety (90) day period.

      In order to determine what benefits are available, as well as the reimbursement, you and your dentist should submit a Pre-Treatment Estimate Form to CIGNA, prior to the commencement of treatment.

      You and your dentist will each receive an Explanation of Benefits (EOB) from CIGNA delineating the services authorized.

      Note: The Pre-Treatment Estimate only authorizes the work to be performed. To obtain benefits, a Payment Claim must be submitted after the work has been performed listing dates of service. No payment will be made if the patient is not eligible when services are rendered.

    4. Periodic Submission of Claims

      Upon completion of treatment, a complete Payment Claim Form must be submitted to CIGNA with appropriate X-rays. If treatment continues over a long period of time, your dentist may wish payment as the work progresses. To be reimbursed on an on-going basis your dentist can periodically file a Payment Claim Form, indicating the work that has been performed to date, and the charges. This process can be repeated during the duration of treatment.
    5. Important Information Regarding the Claim Form

      The Payment Claim Form must be submitted within one (1) year of the date of service. Be sure to sign the claim form. Remember, it is the member's responsibility to ensure that all claims are submitted in a timely manner. Claims submitted more than one (1) year after completion of treatment will not be honored for payment.

      Be sure to inspect the claim before it is submitted to ensure that the listed services were actually performed. Please be advised that your signature authorizes reimbursement for all dental procedures listed.

      Note: Pre- and post-treatment X-rays must be submitted with the Payment Claim Form for root canal therapy and non-routine extractions.

What if I have questions regarding the status of a claim or payment?

If you have any questions regarding your claim, please contact CIGNA at 800-577-0576 or the Fund Office.

How are payments made?

All payments for benefits under the Plan are made by CIGNA. You will receive a check from CIGNA unless you have assigned the benefit to the dentist. If you have assigned the benefit, payment will be made by CIGNA directly to the dentist.

Will I receive an Explanation of Benefits (EOB)?

Yes. You will receive a statement from CIGNA, delineating the specific services performed and amount(s) paid; regardless of to whom payment was made. Please review this for accuracy. Report any discrepancies to the UFT Welfare Fund.

Are benefits provided for the replacement of, or addition to, prosthetics?

Benefits are provided for the replacement of, or addition to prosthetic appliances only under the following circumstances:

  1. when replacement of an existing partial or full removable denture, or fixed bridgework replaces missing natural teeth by a new partial or full removable denture, or by addition of teeth to an existing partial removable denture; or
  2. when replacement of existing fixed bridgework replaces fixed bridgework, or by the addition of teeth to existing fixed bridgework; or
  3. when replacement of an existing partial denture, which replaces missing natural teeth by new fixed bridgework but only when, as a result of the existing condition of the oral cavity, a professional result can be achieved only with bridgework.

    Otherwise, the Covered Dental Expenses for the replacement of an existing denture are limited to the Covered Dental Expenses for a new denture.

    With regard to 1, 2 and 3 above, satisfactory evidence must be presented that:
    1. the replacement or addition of teeth is required to replace one (1) or more missing natural teeth extracted or accidentally lost after the existing denture or bridgework was placed and while the family member was covered under the plan; and
    2. the existing denture, bridgework, or crown was placed at least five (5) years prior to its replacement, whether or not benefits were paid for it by this Dental Plan, and that the existing denture or bridgework cannot be repaired, duplicated, or made serviceable; and
    3. the existing denture is an immediate temporary denture that cannot be made permanent, and its replacement by a permanent denture takes place within twelve (12) months from the placement of the immediate temporary denture.
  4. when, in the case of replacement of an existing free standing crown, evidence satisfactory to CIGNA is presented that the existing crown cannot be repaired or made serviceable, whether or not benefits were paid for it under this Dental Plan, and was placed at least five (5) years prior to its replacement.

What is not covered under the Scheduled Benefit Plan?

  1. Charges made by a practitioner other than a dentist. Exception: a licensed dental hygienist may perform cleaning or scaling of teeth, if such treatment is rendered under the supervision and direction of the dentist.
  2. Charges for services and supplies that are partially or wholly cosmetic in nature, including charges for personalization or characterization of dentures.
  3. Charges for crowns, inlays, onlays, dentures, bridgework, or other prosthetic appliances, and the fitting thereof, which (a) were ordered under the plan, or (b) which were ordered while the individual was covered under the plan, but are finally installed or delivered to such individual more than thirty (30) days after termination of coverage.
  4. Charges for the replacement of a lost or stolen prosthetic device.
  5. Charges for any services or supplies that are for the correction or modification of an occlusion, including orthodontic treatment, except to the extent those benefits are provided for in the “Schedule of Covered Dental Expenses”.
  6. Charges for any duplicate prosthetic device, or other duplicate device or appliance.
  7. Charges for dentures, crowns, inlays, onlays, or bridgework intended to increase vertical dimension, or to diagnose or treat TMJ dysfunction or stabilize periodontally involved teeth.
  8. Charges for precision or other elaborate attachments or features for dentures, bridgework, or any other dental appliances.
  9. Charges for any services or supplies that are not specifically included as Covered Dental Expenses.
  10. Charges that would not have been made if no benefit plan existed, or charges that neither you nor any of your dependents are required to pay.
  11. Charges for services or supplies that are furnished, paid for, or otherwise provided for by reason of the past or present service, of any person in the armed forces of a government.
  12. Charges for services or supplies which are paid for, or otherwise provided for under law of a government (national or otherwise), except where the payments or the benefits are provided under a plan specifically established by a government for its civilian employees and their dependents.
  13. Charges for any dental treatment, services or supplies that are not recommended and approved by the attending dentist.
  14. Charges for services or supplies which do not meet professionally recognized standards of quality, are not necessary for treatment of existing disease or injury, or are not appropriate treatment, taking into account the total currently existing oral condition.
  15. Charges in excess of the allowances authorized by the Fund.
  16. Charges for specialty orthodontic or interim appliances.

Dental HMO PLAN – Dentcare

If you elect to receive dental coverage through the Dentcare HMO, the Welfare Fund's Scheduled Benefit Plan is not applicable. Dentcare would provide all covered services.
Dentcare HMO
333 Earl Ovington Blvd., Suite 300
Uniondale, NY 11553-3608
800-468-0600; 516-542-2700

What are the benefits under the Dental HMO Plan (Dentcare)?

The Dentcare HMO is a pre-paid program of comprehensive dentistry with no deductibles, co-payments or other out-of-pocket expenses when provided or authorized by your primary Dentcare dentist. There are no annual or lifetime maximums and they offer 100% coverage on all covered dental services without having to file claim forms.

How do I enroll in the Dentcare HMO plan?

Enrollment in the Dentcare HMO is strictly voluntary. If you wish to select Dentcare you must complete the UFT Welfare Fund’s Dental Transfer Form (DTF) during the Fall Dental Open Enrollment Period. The Dental Transfer Form is also available by calling the UFT Welfare Fund Forms Hotline at 212-539- 0539. Once enrolled, you and your family will continue to be enrolled in Dentcare until the next Fall Dental Open Enrollment Period when you are permitted to change plans.

Can each family member have a different dental plan?

No. If you enroll in Dentcare, your entire family must also be enrolled in Dentcare.

How do I obtain benefits under the Dentcare plan?

You must choose your dentist from Dentcare’s list of participating providers. That dentist will perform all necessary work or will refer you to one of Dentcare’s specialists.

Your primary dentist must refer you to specialists. There is no coverage without the proper referral.

It is not necessary for the entire family to have the same dentist. Each family member, including children, may choose from the list of Dentcare’s participating dentists.

Specific questions about the level of benefits or about participating dentists may be directed to Dentcare at 800- 468-0600.

Once enrolled, Dentcare will send you an ID card indicating your primary dentist. Dentcare will also notify the dentist that you are a Dentcare patient. You may call your Dentcare dentist anytime after the effective date of your coverage.

UFT Florida Dental Discount Plan

Administered by Healthplex America Member Services 888-200-0322 Plan S200

Who is eligible for the Florida Dental Discount Plan?

Retirees who are year-round Florida residents. If you elect to receive dental coverage through the Florida Dental Discount Plan [schedule of benefits], the Welfare Fund’s Scheduled Benefit Plan is not applicable. All covered services would be provided by Healthplex America.

What are the benefits?

Healthplex America is a pre-paid program of comprehensive dentistry with various levels of co-payments, depending on the work being done.

How many times a year can I visit my dentist?

You are encouraged to visit your dentist regularly. With your Healthplex America dental plan, you are not limited to a specific number of visits per year.

Can I change participating dentists?

Yes. You may see any dentist in the Healthplex America provider directory. However, UFT members who elect to participate in the UFT Florida Dental Discount Plan may only change their dental plan option during the Fall dental open enrollment period.

Is there any maximum coverage limitation?

There are no limitations on benefits.

How do I pay for services?

If your visit is for covered preventive care, like a routine exam, cleaning or x-ray, there is no charge for the procedure. The dentist is prepaid by the Healthplex America program. For other procedures, a co-payment may be required. See your Schedule of Benefits for amounts. You pay co-payments directly to the dentist.

What if I need a specialist?

When treatment by a specialist is required and you visit a Healthplex America participating specialist, the co-pay will be on your Schedule of Benefits.

What if I go to a non-participating dentist?

You will not be eligible for benefits. You must receive treatment from a participating Healthplex America dentist.

My wife and I spend the winter in Florida and the summer in New York (snowbirds). Can we join the Florida Dental Discount Plan?

No. This plan is designed for year-round Florida residents only. Participating dentists do not exist outside of Florida so you would have no dental coverage in any other area of the country. Transfers in or out of other dental plans are allowed only during the Fall Dental Open Enrollment Period.

Special Coordination of Dental Benefits

(For members and their spouse/domestic partner who are also UFT Welfare Fund members.)

A. Scheduled Benefit Plan

Members and their spouse or domestic partner who are also members are entitled to Special Coordination of Benefits (SCOB) when the Scheduled Benefit Plan covers both.

SCOB can significantly increase reimbursement for dental work. If you utilize the services of a non-participating dentist whose charges are above the schedule of allowances, you will be eligible for additional reimbursement under your spouse’s/domestic partner’s coverage. You are covered for up to twice the fee schedule, not to exceed the dentist’s actual charges.

SCOB is applicable to panel dentists. If you utilize the services of a panel dentist, you would generally have no out-of-pocket costs. You will not be charged co-payments that are listed on our dental schedule. The Fund will pay the dentist for the applicable co-payments. However, payments for upgraded or non-convered services will still be the responsibility of the member.

SCOB does not extend limitations on time or frequency of treatment. For example, one (1) exam every six (6) months does not become one (1) exam every three (3) months; but the reimbursement for the exam could be higher.

To obtain the special coordinated dental benefit, check the box on top of the form to indicate special coordination of coverage and submit it directly to CIGNA.

Note: Do not assign these benefits to your dentist. Assignment will interfere with the Welfare Fund's ability to administer your coordinated benefits.

B. SIDS/Florida PPO Panel

SCOB is applicable to panel dentists. If you utilize the services of a panel dentist, you would generally have no out-of-pocket costs. You will not be charged co-payments that are listed on our dental schedule. The Fund will pay the dentist for the applicable co-payments. However, payments for upgraded or non-covered services will still be the responsibility of the member.

C. Dentcare & Scheduled Benefit Plan

  1. You may also elect to have your family covered under Dentcare and the Scheduled Benefit Plan. One member enrolls in Dentcare and the other member stays in the Scheduled Benefit Plan. Under this option, you and your family members may use either a Dentcare dentist or a non-Dentcare dentist. Services rendered by the non-Dentcare dentist would be reimbursed according to the Scheduled Benefit Plan.
  2. SCOB (additional reimbursement as explained in Part A above) would no longer be applicable.
  3. Out-of-pocket costs incurred under the Scheduled Benefit Plan are not reimbursable through Dentcare.
  4. Only one member or spouse/domestic partner is permitted to enroll in Dentcare.

D. Florida Dental Discount Plan & Scheduled Benefit Plan

  1. You may also elect to have your family covered under the Florida Dental Discount Plan and the Scheduled Benefit Plan. One member enrolls in the Florida Dental Discount Plan and the other member stays in the Scheduled Benefit Plan.

    Under this option, you and your family members may use either a Florida Dental Discount Plan dentist or a non-Florida Dental Discount Plan dentist. Services rendered by the non-Florida Dental Discount Plan dentist would be reimbursed according to the Scheduled Benefit Plan.
  2. SCOB (additional reimbursement as explained in Part A above) would no longer be applicable.
  3. Out-of-pocket costs incurred under the Scheduled Benefit Plan are not reimbursable through the Florida Dental Discount Plan.
  4. Only one member or spouse/domestic partner is permitted to enroll in the UFT Florida Dental Discount Plan.
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