Delta Dental Benefits - Questions and Answers

Below, please find common Questions and Answers relating to the Dental Benefits covered under Delta Dental Insurance. If you have any other questions, please contact Delta Dental at 1 (800) 932-0783.

 

 

DO I HAVE DENTAL COVERAGE ?

Yes, Delta Dental is the insurance carrier of your dental plan. This is a traditional plan in which teachers may choose any dentist they desire and the dentist submits your claim(s) to the Delta Dental insurance company. Dentists are reimbursed directly following submission of claims. 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 26.

 

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 dentists who participate in the Delta Dental network and those dentists who do not.

 

Both in-network (Click Here) and out-of-network (Click Here) tables are available to view.

 

 

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.

 

 

WHAT PERCENTAGE OF MY DENTAL BILLS WILL BE COVERED ?

Delta Dental does not pay a percentage of what you are charged. Allowances are paid in accordance with the in-network and out-or network status of your dentist.

 

The maximum dental benefit payable per person per calendar year is $1,600.00 for teacher members and $960.00 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. 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.

 

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 Delta Dental 1 (800) 932-0783.

 

 

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, Delta Dental will co-ordinate with the spouse’s insurance carrier. Delta Dental uses the standard “Birthday Rule” when determining which insurance company will be the children’s primary (first to pay) carrier. Delta Dental 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. Delta Dental 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”. Delta Dental will never pay more than 100% of the covered charges.
 

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).
 
COBRA
Teachers and/or their dependents may be able to extend their dental benefits when coverage would otherwise cease. Such circumstances would include the death or retirement of a teacher, or a dependent child who reaches the age of 23. Call the SBF for details. (716) 881-5462.
 

How to File a Claim

All claims will be submitted to DELTA DENTAL by your dentist. Provide the information represented on your DELTA DENTAL membership ID card prior to or at the time of your appointment.