Dental

Your Summary of Benefits

Mahoning County School Employees Insurance Consortium
Anthem Dental Complete

WELCOME TO YOUR DENTAL PLAN!

This benefit summary outlines how your dental plan works and provides you with a quick reference of your dental plan benefits. For complete coverage details, please refer to your employee benefits booklet.

Dental coverage you can count on.

Your Anthem dental plan lets you visit any licensed dentist or specialist you want - with costs that are normally lower when you choose one within our large network.

Savings beyond your dental plan benefits - you get more for your money.

You pay our negotiated rate for covered services from in-network dentists even if you exceed your annual benefit maximum.

YOUR DENTAL PLAN AT A GLANCE	In-Network	Out-of-Network
Annual Benefit Maximum(Calendar Year)
Per insured person	$1,500	$1,500
D&P applies to Annual Maximum	No	No
Annual Maximum Carryover	Yes	Yes
Orthodontic Lifetime Benefit Maximum
Per eligible insured person	$1,500	$1,500
Annual Deductible does not apply to Orthodontic Services
Per insured personCalendar Year	$25	$25
Family Maximum4th Quarter Deductible Carryover Applies	3X Individual	3X Individual
Deductible Waived for Diagnostic/Preventive Services	Yes	Yes
Out-of-Network Reimbursement Options:	90th percentile

Dental Services	In-Network Anthem Pays:	Out-of-Network Anthem Pays:	Waiting Period
Diagnostic and Preventive Services	100% Coinsurance	100% Coinsurance	No Waiting Period
Periodic oral exam Teeth Cleaning (prophylaxis) Bitewing X-rays:2X per 12 months Intraoral X-rays
Basic Services	80% Coinsurance	80% Coinsurance	No Waiting Period
Amalgam (silver-colored) Filling Front composite (tooth colored) Filling Back composite Filling, Covered as Composites Simple Extractions
Endodontics	80% Coinsurance	80% Coinsurance	No Waiting Period
Root Canal
Periodontics	80% Coinsurance	80% Coinsurance	No Waiting Period
Scaling and root planting
Oral Surgery	80% Coinsurance	80% Coinsurance	No Waiting Period
Surgical Extractions
Major Services	50% Coinsurance	50% Coinsurance	No Waiting Period
Crowns
Prosthodontics	50% Coinsurance	50% Coinsurance	No Waiting Period
Dentures Bridges Dental implants, Standard - covered
Prosthetic Repairs/Adjustments	80% Coinsurance	80% Coinsurance	No Waiting Period
Orthodontic Services
Adults & Dependent Children	60% Coinsurance	60% Coinsurance	No Waiting Periods

This is not a contract; it is a partial listing of benefits and services. All covered services are subject to the conditions, limitations, exclusions, terms and provisions of your employee benefits booklet. In the event of a discrepancy between the information in this summary and the employee booklet, the employee booklet will prevail.

Emergency dental treatment for the international traveler

As an Anthem dental member, you and your eligible, covered dependents automatically have access to the International Emergency Dental Program.**
With this program, you may receive emergency dental care from our listing of credentialed dentists while traveling or working nearly anywhere in the world.

** The International Emergency Dental Program is managed by DeCare Dental, which is an independent company offering dental-management services to Anthem Blue Cross Life and Health Insurance Company.

Promoting healthy mouths for members who are pregnant or living with diabetes

If you are pregnant or living with diabetes, you can sign up to receive one additional dental cleaning or periodontal maintenance procedure per year.

Finding a dentist is easy.
To select a dentist by name or location:

Go to anthem.com/mydentalvision or the website listed on the back of your ID card.
Call the toll-free customer service number listed on the back of your ID card.

TO CONTACT US:

Call

Refer to the toll-free number indicated on the back of your plan ID card to speak with a U.S.-based customer service representative during normal business hours. Calling after hours? We may still be able to assist you with our interactive voice-response system.

Write

Refer to the back of your plan ID card for the address.

Limitations & Exclusions

Limitations – Below is a partial listing of dental plan limitations when these services are covered under your plan. Please see your certificate of coverage for a full list.

Diagnostics and Preventive Services
Oral evaluations (exam) Limited to two per Calendar Year
Teeth cleaning (prophylaxis) Limited to two per Calendar Year
Intraoral X-rays, single film Limited to four films per 12-month period
Complete series X-rays (panoramic or full-mouth) Coverage Every 3 Years
Topical fluoride application Limited to once every 12 months
Sealants Limited to one per tooth every 36 months; sealants may be covered under Preventive Services

Basic and/or Major Services
Crowns Limited to once per tooth in a five-year period Fixed or removable prosthodontics - dentures, partials, bridges Covered once in a five-year period; benefits are provided for the replacement of an existing bridge, denture or partial for members
Inlays/Onlays Limited to once per tooth in a five-year period

Reline/Rebase of Dentures Covered every 36 months.

Brush Biopsy Standard - Covered

ADDITIONAL LIMITATION FOR ORTHODONTIC SERVICES
Orthodontia Limited to one course of treatment per member per lifetime

Exclusions – Below is a partial listing of noncovered services under your dental plan. Please see your certificate of coverage for a full list.

Services provided before or after the term of this coverage

Services received before your effective date or after your coverage ends, unless otherwise specified in the employee benefits booklet

Orthodontics (unless included as part of your dental plan benefits) Orthodontic braces, appliances and all related services

Cosmetic dentistry Services provided by dentists solely for the purpose of improving the appearance of the tooth when tooth structure and function are satisfactory and no pathologic conditions (cavities) exist

Drugs and medications Intravenous conscious sedation, IV sedation and general anesthesia when performed with nonsurgical dental care

Analgesia, analgesic agents, anxiolysis nitrous oxide, therapeutic drug injections, medicines or drugs for nonsurgical or surgical dental care except that intravenous conscious sedation is eligible as a separate benefit when performed in conjunction with complex surgical services.

Extractions - Surgical removal of third molars (wisdom teeth) that do not exhibit symptoms or impact the oral health of the member

The in-network dental providers mentioned in this communication are independently contracted providers who exercise independent professional judgment. They are not agents or employees of Anthem Blue Cross Life and Health Insurance Company.

Choice of dentists
While your dental plan lets you choose any dentist, you may end up paying more for a service if you visit an out-of-network dentist.

Here's why:

In-network dentists have agreed to payment rates for various services and cannot charge you more. On the other hand, out-of-network dentists don’t have a contract with us and are able to bill you for the difference between the total amount we allow to be paid for a service – called the “maximum allowed amount” – and the amount they usually charge for a service. When they bill you for this difference, it’s called “balance billing.”

How Anthem dental decides on maximum allowed amounts
For services from an out-of-network dentist, the maximum allowed amount is determined in one of the following ways.

Out-of-network dental fee schedule/rate developed by Anthem, which may be updated based on such things as reimbursement amounts accepted by dentists contracted with our dental plans, or other industry cost and usage data
Information provided by a third-party vendor that shows comparable costs for dental services
In-network dentist fee schedule

Here's an example of higher costs for out-of-network dental services

This is an example only. Your experience may be different, depending on your insurance plan, the services you receive and the dentist who provides the services.

Ted gets a crown from an out-of-network dentist, who charges $1,200 for the services and bills Anthem for the amount.
Anthem's maximum allowed amount for this dental service is $800. That means there will be a $400 difference, which the dentist can "balance bill" Ted.

Since Ted will also need to pay $400 coinsurance, the total he'll pay the out-of-network dentist is $800.
Here's the math:

Dentist's charge: $1,200
Anthem's maximum allowed amount: $800
Anthem pays 50%: $400
Ted pays 50% (coinsurance): $400
Balance Ted owes the provider: $1,200 - $800 = $400
Ted's total cost: $400 coinsurance + $400 provider balance = $800

In the example, if Ted had gone to an in-network dentist, his cost would be only $400 for the coinsurance because he would not have been “balance billed” the $400 difference.