RFP_26_041_Attachment 2_PPO Premier 11426 summary.pdf
PDF 83 KB Posted
- Attached to
- Multiple Option Dental Program
- Solicitation number
- RFP 680 26-041/DJ 5
- Issued by
- Palm Beach County, Florida
About this file
This document is a Summary of Benefits for the Premier DPPO 2 Dental PPO plan offered to the Palm Beach County Board of County Commissioners in Florida, effective October 1, 2021. The plan provides comprehensive dental coverage through a network of preferred providers with out-of-network options available at reduced benefit levels. Coverage includes preventive and diagnostic services (periodic evaluations, radiographs, cleanings, fluoride treatments, and sealants), basic restorative services (fillings and simple extractions), and major services (oral surgery, periodontics, endodontics, implants, crowns, dentures, and bridges). Orthodontic services are also covered, limited to 24 months of treatment with specific payment structures. The plan features an annual calendar year deductible of $50 per individual and $150 per family, with no deductible for out-of-network coverage. Network providers are paid based on negotiated discounted fees, while out-of-network benefits are based on the 90th percentile of usual and customary charges.
The plan establishes a maximum annual benefit of $3,500 per person for both network and out-of-network coverage, with a separate lifetime orthodontic maximum of $2,000 per person. Network preventive and diagnostic services are covered at 100 percent, basic services at 80 percent, major services at 50 percent, and orthodontic services at 50 percent. Out-of-network coverage is reduced to 90 percent for preventive services, 70 percent for basic services, 40 percent for major services, and 50 percent for orthodontic services. The plan includes multiple limitations and exclusions, including frequency restrictions on services such as cleanings (limited to two per 12-month period), sealants (limited to one per 36 months for patients under 16), and denture replacements (limited to one per 60 months). The plan is underwritten by Solstice Benefits, Inc., a life and health insurer pursuant to the Florida Insurance Code, and is offered exclusively to the Palm Beach County Board of County Commissioners.
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Premier DPPO 2
Dental PPO Summary of Benefits Effective 10/1/2021
NETWORK NETWORK OUT-OF-NETWORK
Individual Annual Calendar Year Deductible $50 $50 $0 $0
Family Annual Calendar Year Deductible $150 $150 $0 $0
No (In Network) No (Out-of-Network)
No
No
COVERED SERVICES NETWORK PLAN PAYS*
OUT-OF-NETWORK PLAN
PAYS**
Periodic Oral Evaluation 100% 90%
Routine Radiographs 100% 90%
Non-Routine - Complete Series Radiographs 100% 90%
Prophylaxis (Cleanings) 100% 90%
Fluoride Treatment 100% 90%
Sealants 100% 90%
Space Maintainers 100% 90%
Palliative Treatment 100% 90%
Restorations (Amalgam or Composite) 80% 70%
Simple Extractions 80% 70%
MAJOR SERVICES
Oral Surgery (includes surgical extractions) 50% 40%
Periodontics - Surgical 50% 40%
Endodontics 50% 40%
Anesthetics 50% 40%
Adjunctive Services 50% 40%
Implants 50% 40%
Inlays/Onlays/Crowns 50% 40%
Dentures and other Removable Prosthetics 50% 40%
Fixed Partial Dentures (Bridges) 50% 40%
ORTHODONTIC SERVICES
Underwriting Exhibit For Agent Use Only and/or Not For Use with General Public
**Out of-Network benefits are based on the 90th Percentile of Usual and Customary Charge.
The above Summary of Benefits is for informational purposes only and is not an offer of coverage. Please note that the above table provides only a brief, general description of coverage and does not constitute a contract. For a complete listing of your coverage, including exclusions and limitations relating to your coverage, please refer to your Certificate of Coverage or contact your benefits administrator. If differences exist between this Summary of Benefits your Certificate of Coverage/benefits administrator, the Certificate of Coverage/benefits administrator will govern. All terms and conditions of coverage are subject to applicable state and federal laws. State mandates regarding benefit levels and age limitations may supersede plan design features.
Offered and Underwritten by Solstice Benefits, Inc., a Life and Health Insurer pursuant to the Florida Insurance Code.
Diagnose or correct misalignment of the teeth or bite 50% 50% Limited to no more than twenty-four (24) months of treatment, with the initial payment of 20% at banding and remaining payment prorated over the course of treatment.
*The network percentage of benefits is based on the discounted fees negotiated with the provider.
General Anesthesia: When clinically necessary or when administered in conjunction with an approved bony extraction (D7230/40/41) of a 3rd molar..
Limited to one (1) time per tooth per consecutive sixty (60) months.
Full Denture/Partial Denture: Limited to one (1) per consecutive sixty (60) months.
No additional allowances for precision or semi precision attachments.
Bridges: Limited to one (1) time per tooth per consecutive sixty (60) months
Subject to separate Lifetime Maximum of $2,500
BASIC SERVICES
Multiple restorations on one (1) surface will be treated as a single filling.
Limited to one (1) time per tooth per lifetime.
Extractions: Limited to one (1) time per tooth per lifetime.
Periodontal Surgery: Limited to one (1) quadrant or site per consecutive thirty-six
(36) months per surgical area.
Scaling and Root Planing: Limited to one (1) time per quadrant per consecutive twenty-four (24) months.
Periodontal Maintenance: Limited to two (2) periodontal maintenance in any twelve (12) consecutive months, to a maximum of two (2) total prophylaxis and periodontal maintenance procedures in any twelve(12) consecutive months.
Periodontics - Non Surgical 40%50%
Limited to Covered Persons under the age of sixteen (16) years, and to one (1) time per consecutive twelve (12) months.
Limited to Covered Persons under the age of sixteen (16) years, and to one (1) time per first or second unrestored permanent molar every consecutive thirty-six (36) months.
Limited to Covered Persons under the age of sixteen (16) years, one (1) time per consecutive sixty (60) months. Benefit includes all adjustments within six (6) months of installation.
Covered as a separate benefit only if no other service, other than exam and radiographs, were done during the visit
PREVENTIVE & DIAGNOSTIC SERVICES
Limited to two (2) times per consecutive twelve (12) months.
Bitewings: Limited to one (1) series of films per consecutive twelve (12) months.
Complete Series/Panorex: Limited to one (1) time per consecutive thirty-six (36) months.
Limited to (2) prophylaxis in any twelve (12) consecutive months, to a maximum of
(2) total prophylaxis and periodontal maintenance procedures in any twelve (12) consecutive months.
Annual deductible applies to preventive and diagnostic services
Solstice BenefitsBooster Included (Increasing Calendar Year Maximum Benefit)
Preventive Waiver Saver Included (P&D Services Do Not Accumulate Towards Annual Maximum)
Orthodontic eligibility requirement Adults and Children
BENEFIT GUIDELINES
Dental Plan Exclusively for PBC Board of County Commissioners
NON-ORTHODONTICS ORTHODONTICS
OUT-OF-NETWORK
Maximum (the sum of all Network and Out-of-Network benefits will not exceed Maximum Benefits)
$3500 per person per Calendar Year
$3500 per person per Calendar Year
$2000 per person per Lifetime $2000 per person per Lifetime
Limitations, Non-Covered Services, and Exclusions General Limitations Non-Covered Services Exclusions
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2. 1. Illness, accident, treatment or medical condition arising out of:
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Underwriting Exhibit For Agent Use Only and/or Not For Use with General Public
SEDATIVE FILLINGS are covered as a separate benefit only if no other service, other than X-rays and exam, were performed on the same tooth during the visit.
Any charges related to infection control, denture duplication, oral hygiene instructions, radiograph duplication, charges for claim submission, equipment or technology fees, exams required by a third party, personal supplies, or replacement of lost or stolen appliances.SPACE MAINTAINERS are limited to Covered Persons under the age of sixteen (16) years, one (1) time per consecutive sixty (60) months. Benefit includes all adjustments within six (6) months of installation. Any Dental Services or Procedures not listed in the Schedule of Benefits.
Offered and Underwritten by Solstice Benefits, Inc., a Life and Health Insurer pursuant to the Florida Insurance Code.
REPLACEMENT of missing natural teeth lost prior to the effective date of coverage are covered only after the patient has been eligible under the plan for twelve (12), continuous months.
Acupuncture, acupressure, and other forms of alternative treatment, whether or
Services for which the Copayments and/or the Deductibles are routinely waived by the provider.
SEALANTS are limited to Covered Persons under the age of sixteen (16) years and to one (1) time per first or second unrestored permanent molar every consecutive thirty-six (36) months.
Crowns, inlays, cast restorations, or laboratory prepared restorations when the tooth/teeth may be restored with an amalgam or composite resin filling.
SCALING AND ROOT PLANING is limited to one (1) time per quadrant per consecutive twenty-four (24) months. Localized delivery of antimicrobial agents via controlled release vehicle into diseased crevicular tissue, per tooth, by report, is not covered when performed on the same day as root planing and scaling.
Inlays, cast restorations, or other laboratory prepared restorations when used primarily for the purpose of splinting.
Any charges related to histological review of diagnostic biopsy, material, or specimens submitted to a pathologist or pathology lab.
Prosthodontic restoration that is fixed or removable for complete oral rehabilitation. Procedures related to the reconstruction of a patient’s correct vertical dimension of occlusion (VDO).
PERIODONTAL MAINTENANCE is limited to two (2) periodontal maintenance in any twelve (12) consecutive months, to a maximum of two (2) total prophylaxis and/or periodontal maintenance procedures in any twelve (12) consecutive months.
Attachments to conventional removable prosthesis or fixed bridgework. This includes semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature.
PERIODONTAL SURGERY – Hard tissue and soft tissue periodontal surgery is limited to one (1) time per quadrant or site per consecutive thirty-six (36) months.
PIN RETENTION is limited to two (2) pins per tooth; not covered in addition to Cast Restoration.
POST AND CORES are covered only for teeth that have had root canal therapy.
Incision and drainage of abscess, if the involved tooth is extracted on the same date of service.RELINING, REBASING AND TISSUE CONDITIONING DENTURES are limited to relining/rebasing performed more than six (6) months after the initial insertion.
Thereafter, limited to one (1) time per consecutive thirty-six (36) months.
REPAIRS TO FULL DENTURES, PARTIAL DENTURES, BRIDGES are limited to repairs or adjustments performed more than twelve (12) months after the initial insertion.
Limited to one (1) time per consecutive six (6) months.
Occlusal guards used as safety items or for sports-related activities.
Placement of fixed or partial dentures for the sole purpose of achieving periodontal stability.
Dental Services otherwise Covered under the plan but rendered after the date individual Coverage under the plan terminates, including Dental Services for dental conditions arising prior to the date individual Coverage under the plan terminates.
REPLACEMENT of crowns, bridges, and fixed or removable prosthetic appliances, if inserted prior to plan coverage, are covered after the patient has been eligible under the plan for twelve (12) continuous months.
EXTRAORAL RADIOGRAPHS are limited to two (2) films per consecutive twelve (12) months.
Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.
FLUORIDE TREATMENTS are limited to Covered Persons under the age of sixteen (16) years, and to one (1) time per consecutive twelve (12) months. Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.
Treatment provided in a government hospital; benefits provided under Medicare or other governmental program (except Medicaid), any State or Federal workers' compensation, employers' liability or occupational disease law; benefits to the extent provided for any loss or portion thereof for which mandatory automobile no-fault benefits are recovered or recoverable; services rendered and separately billed by employees of hospitals, laboratories or other institutions; services performed by a member of the Covered Person's immediate family; and services for which no charge is normally made;
FULL OR PARTIAL DENTURES are limited to one (1) time every consecutive sixty (60) months. No additional allowances for precision or semi-precision attachments. Treatment of benign neoplasms, cysts, or other pathology involving benign lesions, except excisional removal.
FULL-MOUTH DEBRIDEMENT is limited to one (1) time per consecutive thirty-six (36) months.
Treatment of malignant neoplasms or Congenital Anomalies of hard or soft tissue, including excision.
GENERAL ANESTHESIA, IV SEDATION are covered when necessary for one of the following reasons; toxicity to local anesthesia, mental retardation, Alzheimer's, spastic muscle disorders.
If previously submitted for payment under the Plan within sixty (60) months of initial or subsequent placement, replacements of: (a) complete or partial dentures, (b) fixed bridgework, or (c) crowns. This includes retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances.
Services provided while the Covered Person is outside the United States, its possessions or the countries of Canada and Mexico are not Covered unless required as an Emergency Service.
MAJOR RESTORATIONS – Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays previously submitted for payment under the plan is limited to one (1) time per consecutive sixty (60) months from initial or subsequent placement.
If damage or breakage was directly related to provider error, replacements of: (a) complete or partial dentures, (b) fixed bridgework, or (c) crowns. This type of replacement is the responsibility of the Dentist. If replacement is Necessary because of patient non-compliance, the patient is liable for the cost of replacement.
ILLEGAL OCCUPATION: Solstice shall not be liable for any loss to which a contributing cause was your commission of or attempt to commit a felony or to which a contributing cause was you being engaged in an illegal occupation.OCCLUSAL GUARDS are limited to one (1) guard every consecutive sixty (60) months and only if prescribed to control habitual grinding.
6. INTOXICANTS AND NARCOTICS: Solstice shall not be liable for any loss sustained or contracted in consequence of your being intoxicated or under the influence of any narcotic unless administered on the advice of a physician.
ORAL EVALUATIONS - Periodic Oral Evaluation limited to two (2) times per consecutive twelve (12) months. Comprehensive Oral Evaluation limited to one (1) time per dentist per consecutive thirty-six (36) months, only if not in conjunction with other exams. Temporomandibular joint (TMJ) services; upper and lower jaw bone surgery, including that related to the TMJ; and orthognathic surgery, or jaw alignment.
ORTHODONTIC SERVICES – When Orthodontic Services are covered under the plan, orthodontic services are limited to twenty-four (24) months of treatment, with the initial payment at banding of 20% and remaining payment prorated over the course of the treatment.
Charges for failure to keep a scheduled appointment without giving the dental office twenty-four (24) hours notice.
Expenses for dental procedures begun before enrollment under the plan.
PALLIATIVE TREATMENT is covered as a separate benefit only if no other service, other than exam and radiographs, were done during the visit.
ALTERNATE BENEFIT – Your dental plan provides that where two or more professionally acceptable dental treatments for a dental condition exist, your plan bases reimbursement on the least costly treatment alternative. If you and your dentist agreed on a treatment which is more costly than the treatment on which the plan benefit is based, you will be responsible for the difference between the fee for service rendered and the fee covered by the plan. In addition, a pre-treatment estimate is recommended for any service estimated to cost over $300; please consult your dentist.
The following are NOT covered under the plan: This Policy excludes Coverage for Dental Service, unless otherwise specified in the Schedule of Benefits or a Rider, as follows:Dental Services that are not Reasonable and/or Necessary.
Hospital or other facility charges.
Reconstructive surgery to the mouth or jaw. war or act of war (whether declared or undeclared); participation in a felony, riot or insurrection;Any Procedures not directly associated with dental disease.
Any Dental Procedure not performed in a dental setting. service in the Armed Forces or units auxiliary thereto;
Procedures that are considered Experimental, Investigational or Unproven. This includes pharmacological regimens not accepted by the American Dental Association (ADA) Council on Dental Therapeutics. The fact that an Experimental, Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Coverage if the procedure is considered Experimental, Investigational or Unproven in the treatment of that particular condition.
suicide, attempted suicide or intentionally self-inflicted injury;
BASIC RESTORATIONS – Multiple restorations on one (1) surface will be treated as a single filling.
BITEWING RADIOGRAPHS are limited to one (1) series of films per consecutive twelve
(12) months.
iv. aviation, other than as a fare-paying passenger on a scheduled or charter flight operated by a scheduled airline; and, COMPLETE SERIES OR PANOREX RADIOGRAPHS are limited to one (1) time per consecutive thirty-six (36) months.
with respect to blanket insurance, interscholastic sports.
DENTAL PROPHYLAXIS (CLEANINGS) are limited to Cosmetic surgery, except that cosmetic surgery shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered dependent child which has resulted in a functional defect.
(2) prophylaxis in any twelve (12) consecutive months, to a maximum of (2) total prophylaxis and periodontal maintenance procedures in any twelve (12) consecutive months.
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