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 most covered services and the maximum reimbursement amounts.

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

• Participating Panel Program (NY and Florida) - 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 2,000 participating dentists. In addition, the Florida PPO Panel consists of over 700 participating dentists throughout the state of Florida. If you use a participating dentist, covered services will be provided at no cost to you, except for those procedures that require a co-payment.

You can search our list of participating dentists online or call the Welfare Fund at 212-539-0539 for more information. 

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 should have an applicable claim 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.

Are benefits provided for General Anesthesia Services?

The Fund only covers general anesthesia charges in conjunction with surgery in accordance with the allowances set forth in its schedule of dental benefits.

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.