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Dental Information


Below, please find important highlights and common Questions and Answers relating to the Dental Benefits covered under the Buffalo Teachers Federation Supplemental Benefit Fund. If you have any other questions, please contact the Supplemental Benefit Fund Office at (716) 881-5462.

 

There are a few important highlights teachers should keep in mind when using the dental program:

1. There is no deductible for Single Coverage.

2. There is a $40.00 deductible for family coverage per calendar year.

3. The life-time (per person) maximum allowance for periodontal services is as follows:

a. 21 years or less of service, $2,500.00

b. 21 years or more of service, $3,000.00

c. 26 years or more of service, $3,500.00

d. 31 years or more of service, $4,000.00

4. The life-time (per person) maximum allowance for orthodontic services is $850.00.

5. The maximum allowance for teacher members per calendar year (not including periodontal & orthodontic services) is $1,000.00.

6. The maximum allowance for dependents per calendar year (not including periodontal & orthodontic services) is $600.00.

7. The SBF uses the impression date for all reimbursement purposes on prosthodontics (dentures), restorative (crowns), and bridgework services.

8. Teachers having crowns, dentures & bridgework replaced need to check with the SBF to be certain they are eligible for reimbursement.

9. The SBF will cover only bridgework, dentures and crowns once every five years.

10. COBRA may extend dental eligibility of teachers and or their dependents when coverage otherwise would cease. Call the SBF for details.

Remember, any bill submitted for reimbursement must be submitted within 6 months of the date of service.

 


 

DO I HAVE DENTAL COVERAGE ?

Yes, the BTF has a self insured indemnity plan called the SBF Dental Plan. This is a traditional dental plan in which teachers may choose any dentist and are reimbursed following submission of claims. Payment is based on the SBF schedule of allowances. Any difference between the scheduled allowance and the dentist’s charge is the teacher’s responsibility.

 

WHEN DOES MY DENTAL COVERAGE BEGIN ?

Your dental coverage begins on the first day of your employment. Coverage ends on the last day you are compensated by the Board, except for retired teachers whose coverage continues for 60 days from the day they retire.

 

WHO IS ELIGIBLE ?

1. Buffalo Public School teachers working 15 hours or more a week.

2. Your spouse, unless legally divorced.

3. Unmarried dependent children under the age of 23.

No person is a dependent if they are eligible for the plan as a member.

NOTE: If your child is mentally challenged or physically handicapped when his/her dental coverage would terminate from the age rule, said child may be eligible to continue coverage under certain circumstances. For complete information call the SBF.

 

WHAT ARE COVERED DENTAL CHARGES ?

Covered dental charges are charges incurred for any service, supply or treatment included in the Schedule of Dental Procedures in this plan. A list of the most common dental procedures and the maximum amount paid for each is shown on subsequent pages.

For any operative dental procedure not specified in the Schedule of Dental Procedures, the SBF will, subject to the provisions of the Plan, pay an amount of benefits consistent with the amounts appearing on the provided schedule.

 

IS THERE A DEDUCTIBLE ?

There is a $40.00 family deductible. This applies to teachers submitting claims for a spouse or other eligible dependents. This deductible is subtracted from the actual benefits paid. There is no deductible for single teachers (with no dependents). A teacher who qualifies for family coverage may choose individual coverage and avoid the $40.00 deductible. Call the SBF for complete information.

 

WHAT IS AN ELIGIBILITY PERIOD ?

An eligibility period is the period of time during which an insured person is eligible for benefits. It begins January 1st or the first day of your employment and ends December 31st or the date the insurance terminates, whichever comes first. Should a family not incur charges in excess of their deductible amount by December 31st, expenses incurred during the last three months (October, November, December) will be applied toward the deductible for the following year.

 

WHAT PERCENTAGE OF MY DENTAL BILLS WILL BE COVERED ?

The SBF does not pay a percentage of what you are charged. Reimbursement during an eligibility period for covered dental, charges in excess of the deductible will be the maximum amount shown in the schedule of dental procedures.

The maximum dental benefit payable per person per calendar year is $1,000.00 for teacher members and $600.00 for dependents. Benefits for orthodontic and periodontal services are not included in calculating the maximum per year. See the following rate schedule for these services.

 

IS THERE ANY DEADLINE FOR SUBMITTING MY CLAIMS ?

Yes, you must submit your claim for benefits within six months of the date the services were performed. This includes services applied to the deductible. In other words, if you go to the dentist on February 16th you must submit your claim for benefits by August 16th of that same year. It is the responsibility of all teachers to see that their dentist has submitted that claim within the six-month period.

 

WHAT IS NOT COVERED ?

1. Expenses for services, supplies and treatment unless they were prescribed by a dentist or a physician.

2. Expenses for services, supplies and treatment incurred in a Veterans’ Administration Hospital, or which in absence of insurance would have been furnished without cost, or which are furnished under conditions which the insured person has no obligation to pay, or if the expense is reimbursable by any local or other government agency.

3. Expenses for services, supplies and treatment incurred on account of war, declared or undeclared, including armed aggression.

4. Expenses for services, supplies and treatment for cosmetic purposes, including the alteration or extraction and replacement of sound teeth to change appearance.

5. Expenses for services, supplies and treatment due to loss or theft of dentures or bridgework originally covered by the SBF, unless a period of at least five years has elapsed since the expense was incurred.

6. Expenses for services, supplies and treatment incurred on account of replacement or alteration of full or partial dentures or fixed bridgework originally covered by the SBF, unless such charge is required due to one of the following events:

a. An accidental injury requiring oral surgery

b. Oral surgery involving the repositioning of muscle attachments, or the removal of a tumor, cyst, torus or redundant tissue

c. The lapse of 5 years

Replacement or alteration must be completed within 12 months of the events listed in a & b.

 

WHAT ARE EXTENDED BENEFITS ?

If a person’s insurance terminates before the completion of dental work which began before such termination, benefits will be payable with respect to covered dental charges incurred for such unfinished dental work, as though they had been incurred while insured.

Those charges shall include services requiring more than one visit.

In no event shall such benefits be payable for covered dental charges incurred more than one month after the dental insurance terminates.

 

WHAT IF BOTH SPOUSES ARE BUFFALO TEACHERS ?

There is a dual coverage policy for those individuals so situated. For complete information call the SBF office.

 

GENERAL INFORMATION

Non-duplication of Benefits

If an insured person is entitled to any medical and dental care or major medical benefits or services from another source (excluding and individual insurance policy), such benefits under this plan may be reduced to an amount, which, together with all such other benefits, will not exceed 100% of any necessary, reasonable and customary item of expense covered under this plan or any such other plan. (Any item or expense covered under Medicare will be considered in calculating benefits only if a portion of the cost of this item is also covered under a plan other than Medicare).
 

Co-ordination of Benefits & The “Birthday Rule”

If a teacher member’s spouse also has dental benefits, the SBF will co-ordinate with the spouse’s insurance carrier. The SBF uses the standard “Birthday Rule” when determining which insurance company will be the children’s primary (first to pay) carrier. The SBF will always be the primary carrier for the teacher member. The spouse’s insurance carrier will always be the spouse’s primary carrier. The “birthday rule” comes into play only when considering which insurance company is the primary carrier for the dependent children. The “Birthday Rule” simply states that the insurance company that represents the person whose birthday comes first in the calendar year will be the primary carrier for the dependent children. Example: Mrs. Doe is a Buffalo teacher whose birthday is March 1st. Her husband, Mr. Doe also has dental insurance and his birthday is April 1st. The SBF will be the primary carrier for Mrs. Doe’s children because her birthday comes first within the calendar year. It is only the dependent children who are affected by the “birthday rule”. The SBF will never pay more than 100% of the covered charges. Call the SBF for further explanation.
 

When Insurance Terminates

Your dental insurance terminates when you leave the employment of the Buffalo Board of Education, when you are no longer eligible or when the group policy terminates, whichever happens first. A dependent’s insurance terminates when your insurance terminates or when he/she is no longer an eligible dependent, whichever happens first. In some cases COBRA allows you and your dependents to continue coverage for varying periods of time (see below).
 

How to File a Claim

Dental claims forms may be downloaded by Clicking Here. You may also get them from your Building Delegate or by calling the SBF. (716) 881-5462.

When completing the dental form read the instructions carefully and answer all of the questions. If any attachments are required (x-rays) be sure they are included when you return the form. All completed forms must be returned to the SBF office. After your claim has been processed you will be notified in writing if any benefits are denied (in whole or in part), or if any additional information is required by the SBF.

 

Dental Payment Schedule


Below please find the most frequently used procedures covered under the BTF-SBF Dental Plan. To receive a copy of the payment schedule in its entirety, please contact the Supplemental Benefit Fund office at (716) 881-5462.

 

DIAGNOSTIC   
  Clinical Oral Examinations
                  00120 Periodic Oral Examination                       $ 20.00
    00150 Comprehensive Oral Evaluation                            $ 20.00
           
  Radiographs
    00210 Intraoral – Complete Series (including bitewings)   $ 40.00
    00220 Intraoral – Periapical – first film   $ 8.00
    00230 Intraoral – Periapical – each additional film   $ 6.00
    00272 Bitewings – two films   $ 17.00
    00274 Bitewings – four films   $ 25.00
    00330 Panoramic film   $ 35.00
    00340 Cephalometric film   $ 30.00
           
PREVENTIVE
  Dental Prophylaxis
    01110 Prophylaxis – adult   $ 30.00
    01120 Prophylaxis – child 12 years or younger   $ 25.00
           
  Fluoride Treatments
    01203 Topical application of fluoride (prophy not included) – child   $ 15.00
    01204 Topical application of fluoride (prophy not included) – adult   $ 18.00
    01351 Sealant per tooth   $ 18.00
           
RESTORATIVE
Amalgam Restorations (including polishing)
    02140 Amalgam – one surface, permanent $ 40.00
    02150 Amalgam – two surface, permanent $ 45.00
    02160 Amalgam – three surface, permanent $ 50.00
    02161 Amalgam – four or more surfaces, permanent   $ 60.00
           
  Resin Restorations
    02330 resin – one surface, anterior   $ 45.00
    02331 resin – two surface, anterior   $ 50.00
    02332 resin – three surface, anterior   $ 60.00
    02335 resin - four or more surfaces or involving inscisal angle, ant.   $ 75.00
           
  Inlay/Onlay Restorations
    02644 onlay – porcelain/ceramic – four or more surfaces   $300.00
           
  Crowns – Single Restorations Only
    02740 crown – porcelain/ceramic substrate   $340.00
    02750 crown – porcelain fused to high noble metal   $340.00
    02751 crown – porcelain fused to predominantly base metal   $325.00
    02752 crown – porcelain fused to noble metal   $325.00
    02790 crown – fused to cast high noble metal   $340.00
           
  Other Restorative Services
    02920 recement crown   $ 25.00
    02930 prefabricated stainless steel crown – primary tooth   $ 50.00
    02940 sedative filling (to relieve pain)   $ 30.00
    02950 core buildup, including any pins   $ 85.00
    02951 pin retention – per tooth, in addition to restoration   $ 13.00
    02952 cast post & core in addition to crown   $100.00
    02954 prefabricated post & core in addition to crown   $100.00
    02962 labial veneer (porcelain laminate) – laboratory   $260.00
    02970 temporary crown (fractured tooth)   $ 75.00
           
ENDODONTICS
  Pulp Capping & Therapy Procedures
    03110 pulp cap – direct (excluding final restoration)   $ 20.00
    03120 pulp cap – indirect (excluding final restoration)   $ 15.00
    03220 therapeutic pulpotomy (excluding final restoration)   $ 40.00
    03310 anterior endodontic therapy (excluding final restoration)   $ 240.00
    03320 bicuspid endodontic therapy (excluding final restoration)   $ 275.00
    03330 molar endodontic therapy (excluding final restoration)   $ 350.00
           
PERIODONTICS 
  Surgical Services
    04211 gingivectomy or gingivoplasty – per tooth   $ 50.00
    04249 clinical crown lengthening – hard tissue   $150.00
    04260 osseous surgery (including flap entry/closure) per quad   $400.00
    04263 bone replacement graft – first site quadrant   $225.00
           
  Adjunctive Periodontal Services
    04341 periodontal scaling and root planing – per quadrant   $ 50.00
    04355 full mouth debridement to enable evaluation & diagnosis   $ 40.00
    04381 localized delivery of chemotherapeutic agents   $ 60.00
           
  Other Periodontal Services
    04910 periodontal maintenance (active therapy)   $120.00
           
PROSTHODONTICS (REMOVABLE)
  Complete Dentures (including Routine Post – Delivery Care)
    05110-20 complete denture - maxillary or mandibular   $350.00
    05130-40 immediate denture – maxillary or mandibular   $375.00
           
  Partial Dentures (including Routine Post – Delivery Care)
    05213 maxillary partial denture – cast metal frame   $275.00
    05214 mandibular partial denture – cast metal framework   $275.00
           
  Repairs to Partial Dentures
    05610 repair resin denture base   $ 40.00
    05640 replace broken teeth – per tooth   $ 40.00
    05650 add tooth to existing partial denture   $ 55.00
           
PROSTHODONTICS (FIXED PARTIAL DENTURE)
  Fixed Partial Denture
    06240 pontic – porcelain fused to high noble metal   $250.00
           
  Fixed Partial Denture Retainers – Crowns
    06750 crown – porcelain fused to high noble metal   $340.00
    06751 crown – porcelain fused to predominantly base metal   $340.00
    06752 crown – porcelain fused to noble metal   $340.00
    06790 crown – full cast high noble metal   $325.00
    06930 recement fixed partial denture   $ 40.00
           
ORAL & MAXILLOFACIAL SURGERY
  Extractions (including Local Anesthesia, Suturing & Routine Care)
    07110 single tooth extraction   $ 45.00
    07120 each additional tooth extracted   $ 45.00
    07130 root removal – exposed roots   $ 40.00
    07210 surgical removal of erupted tooth   $ 70.00
    07220 removal or impacted tooth – soft tissue   $ 75.00
    07230 removal of impacted tooth – partial bony   $ 100.00
    07240 removal of impacted tooth – completely bony   $ 110.00
    07250 surgical removal of residual tooth roots (cutting procedure)   $ 80.00
    07310 alveoplasty in conjunction with extractions – per quad.   $ 80.00
    07510 incision and drainage of abscess – intraoral soft tissue   $ 40.00
           
ORTHODONTICS
THE SBF ALLOWS THE MAXIMUM LIFETIME BENEFIT OF $850.00 PER PERSON FOR AN
ORTHODONTIC APPLIANCE OR PROCEDURE AS PER THE SBF SCHEDULE. CALL THE SBF AT
(716) 881-5462 FOR DETAILS.
           
ADJUSTED GENERAL SERVICES
  Unclassified Treatment
    09110 palliative (emergency) treatment of dental pain minor procedure   $ 30.00
           
  Anesthesia
    09220 general anesthesia – first 30 minutes   $ 75.00
    09230 analgesia (including nitrous oxide)   $ 35.00
    09241 intravenous sedation   $ 100.00
           
  Professional Consultation
    09310 consultation – (diagnostic service provided by dentist)   $ 25.00
           
  Professional Visits
    09440 office visits – after regular hours   $ 10.00
           
  Miscellaneous Services
    09910 application of desensitizing medicament   $ 15.00
    09940 occlusal guard/ bruxism appliance   $ 120.00
    09951 occlusal adjustment – limited   $ 50.00
    09970 enamel micro abrasion   $ 10.00

How to Submit a Dental Claim


The Supplemental Benefit Fund (SBF) is not an insurance company and does not participate with any dentist. However, most dentists will handle the claims and paperwork for you. If you need to file a claim yourself, please see below for submission details.

 

If you do need to file a claim form:

  1. Download and print the form below. Claim forms are also available in your school or by calling the SBF Officer at (716) 881-5462.
    • Supplemental Benefit Fund Dental Claim Form
  2. Complete the patient and subscriber information on the claim form.
  3. Attach a copy of the dentist's Statement of Treatment, including the dentist's name, complete phone number, and a description of each service that the dentist performed.
    • Please see the “Important note” below.
  4. Make a copy for your records.
  5. Mail the original copies to the address printed on the form.

We usually process claims within six (6) weeks unless additional information is required from you or the dentist.

Important Note: A Statement of Treatment or similar document you receive from your dentist may not include enough information for us to process the claim. It is best to ask a dental office staff member for the dentist and treatment information and to enter it directly onto the claim.

In addition to the dentist's name, address and phone number, and a description of each service, its procedure code and fee, we also need the Tax Identification Number (TIN) and the State License Number.

S5 Box

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