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Select
Your Dental Benefits The Employees’ Group
Dental Insurance Plans are designed to encourage preventive dental
care and provide financial assistance for various types of dental
services and supplies. Dental Plan coverage, available to you and
your eligible family members, can be the key to maintaining your
family's dental health.
You can choose from two Dental Preferred Provider
Organization (PPO) plans--CIGNA Standard Dental
PPO and CIGNA Premier Dental PPO--and one dental HMO (DHMO).
The Board pays 80 percent of the cost of coverage.
Your contribution is made through convenient payroll deductions.
The cost for the Premier Plan is $3.50 biweekly for self-only coverage
and $9.87 biweekly for family coverage. The cost for the Standard
Plan is $2.34 biweekly for self-only coverage and $6.62 biweekly
for family coverage. The cost for the DHMO is $1.71 biweekly for self-only coverage and $4.28 biweekly for family coverage.
PPO
The following chart compares the
benefits for the two CIGNA Dental PPO Plans. Covered percentages
are based on reasonable and customary charges. Any charges in excess
of reasonable and customary, annual, and/or lifetime maximums, or
charges for services not covered by the Plan, are the participant's
responsibility.
| Benefits |
Premier
Plan
Passive PPO
In-Network |
Premier
Plan
Passive PPO
Out-of-Network |
Standard
Plan
Passive PPO
In-Network |
Standard
Plan
Passive PPO
Out-of-Network |
Calendar Year Maximum
(Class I, II, III expenses)
Combined in- and out-of-network
Excludes Orthodontia and Class VII Oral Surgical procedures. |
$3,000 |
$3,000 |
$1,000 |
$1,000 |
Annual Deductible
• Individual
• Family
Carry-over deductible is not applicable. |
None |
None |
$25 per person
$50 per family
|
$25 per person
$50 per family |
Class I - Preventive &
Diagnostic Care
• Oral Exams (Two per calendar year)
• Full Mouth X-rays (One complete set every three calendar
years)
• Bitewing X-rays (Two per calendar year)
• Panoramic X-ray (One complete set every three calendar
years)
• Prophylaxis--cleaning and scaling (Two per calendar year)
• Fluoride Application (One per calendar year for persons
under 19)
• Sealants (Limited to posterior tooth for persons to age
15; one treatment per tooth every three calendar years)
• Oral Hygiene & Dietary Instructions
• Space Maintainers (Limited to non-orthodontic treatment)
• Emergency Care to Relieve Pain |
100% No deductible |
100% No deductible |
100% No deductible |
100% No deductible |
Class II - Basic Restorative
Care
• Fillings
• Periodontal Scaling and Root Planing
• Gingivoplasty (per quadrant)
• Osseous Surgery
• Equilibration-Oclussal Adjustment (entire mouth)
• Root Canal Therapy
• Pulp Capping
• Pulpotomy
• Denture Adjustments and Repairs
• Incision and Drainage of Abcess
• Bruxism and Occlusal Guards
• Oral Surgery
- Routine extraction per tooth
- Surgical removal per tooth
- Alveolectomy per quadrant
• Anesthetics |
90% No deductible |
90% No deductible |
70% After deductible |
70% After deductible |
Class III - Major Restorative
Care
• Crowns (stainless steel and porcelain)
• Dentures
• Bridges
• Repairs to Crowns and Inlays/Onlays |
60% No deductible |
60% No deductible |
50% After deductible |
50% After deductible |
| • Implants |
60% No deductible |
60% No deductible |
Not covered |
Not covered |
Class IV - Orthodontia
Lifetime Maximum |
50% No deductible $2000
children and adults |
50% No deductible
$2000
children and adults |
Not covered |
Not covered |
Class VII - Oral Surgery
Surgical Removal of Impacted Tooth
• Soft tissue impaction per tooth
• Partially bony impaction per tooth
• Completely bony impaction per tooth |
90% No deductible
Not subject to calendar year
maximum |
90% No deductible
Not subject to calendar year
maximum |
70% After deductible
Not subject to
calendar year
maximum |
70% After deductible
Not subject to calendar year
maximum |
All plan deductibles and maximums (dollar and occurrence)
cross-accumulate between in-network and out-of-network unless otherwise
noted.
Waive Missing Tooth Limitation.
Replacement of bridge, crown, or denture, after original installation, is not
subject to five-year waiting period. (If not repairable.)
Alternate Benefit Provision
When more than one dental service could provide suitable
treatment based on common dental standards, CIGNA will determine
the dental service on which payment will be based and the expenses
that will be included as covered expenses. Benefits will be provided
for treatment rendered in accordance with accepted dental standards
for adequate and appropriate care. You and your dentist are free
to apply this benefit payment to the treatment of your choice; however,
you are responsible for the expenses incurred that exceed covered
expenses. For this reason, CIGNA strongly recommends the use of
predetermination of benefits when major dental services are needed
so that you and your dentist know in advance what the benefit plan
will cover before any treatment begins.
Predetermination of
Benefits
Predetermination of benefits is a review by CIGNA
of a dentist's description of planned treatment and expected charges,
including those for diagnostic x-rays. This review should be made
whenever extensive dental work is proposed. The information should
be sent to CIGNA before the dental work is started. If there is
a major change in the treatment plan, a revised plan should be sent
to CIGNA. Pretreatment review is suggested when dental work in excess
of $300 is proposed.
CIGNA Dental PPO Exclusions and Limitations
Covered expenses will not include, and no payment
will be made for, expenses incurred for the following:
- services performed solely for cosmetic reasons;
- replacement of a lost or stolen appliance;
- any replacement of a bridge, crown, or denture
that is, or can be, made useable according to common dental standards;
- procedures, appliances, or restorations (except
full dentures) whose main purpose is to
- change vertical dimension,
- diagnose or treat conditions or dysfunction of the temporomandibular
joint,
- stabilize periodontally involved teeth, or
- restore occlusion;
- porcelain or acrylic veneers of crowns or pontics
on or replacing the upper and lower first, second, or third molars;
- bite registrations, precision or semi-precision
attachments, or splinting;
- dental services that do not meet common dental
standards;
- services that are deemed to be medical services;
- services and supplies received from a hospital; or
- services for which benefits are not payable according
to the "General Limitations" section.
General Limitations
No payment will be made for the following expenses
incurred by you or any one of your dependents:
- for or in connection with an injury arising out of,
or in the course of, any employment for wage or profit;
- for or in connection with a sickness that is covered
under any workers' compensation or similar law;
- for charges made by a hospital owned or operated
by, or which provides care or performs services for, the U.S.
government, if such charges are directly related to a condition
connected with military service;
- to the extent that payment is unlawful where the
person resides when the expenses are incurred;
- for charges that the person is not legally required
to pay;
- to the extent that they are more than either the
applicable contracted fee, applicable reasonable or customary
charges, or applicable scheduled amount;
- for charges for unnecessary care, treatment, or
surgery;
- to the extent that you or any of your dependents
is in any way paid or entitled to payment for those expenses by
or through a public program other than Medicaid; or
- for or in connection with experimental procedures
or treatment methods not approved by the American Dental Association
or the appropriate dental specialty society.
No payment will be made for expenses incurred by
you or any one of your dependents to the extent that benefits are
paid or payable for those expenses under the mandatory part of any
auto insurance policy written to comply with a "no-fault"
insurance law or an uninsured motorist insurance law. Connecticut
General Life Insurance Company will take into account any adjustment
option chosen under such part by you or any one of your dependents.
The information provided is a summary
of your benefits. It does not contain all of the details described
in the official plan document. If there is a discrepancy between
the plan summaries and the official plan document, the plan document
will govern. The Federal Reserve has the right to change, amend,
or terminate any or all of the plans at any time. This summary sheet
is not a contract, and participation in the plans does not guarantee
employment.
DHMO
Participants in the DHMO can choose a primary dentist from the CIGNA dental care network of participating providers with no deductibles, claim forms, or annual dollar maximums. More complex procedures might require a fee (listed on the patient charge schedule).
DHMO Charge Schedule (85 KB PDF)
Learn Who Is Eligible
Learn When Coverage Is Effective
Understand Coverage Cost
When you are done, return to the "Stay
Healthy" page, to complete an enrollment form and/or enroll
in another health benefit program.
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