SRCS Dental Flyer REV 4 - Santa Rosa City Schools

Individual Continuation of Benefits
All benefits shall terminate for any Eligible Person if the
contract is terminated, and Santa Rosa City Schools
Dental Plan is not obligated in such event to provide
continuation of Benefits to any such person.
Benefits will also terminate for any person who ceases to
be eligible under the terms of the Contract. COBRA
would be available for coverage lost by a termination of
employment or reduction in hours.
Reimbursement
Reimbursement may be made to the Eligible Patient for
services performed by a Non-Participating Dentist, upon
submission to Santa Rosa City Schools Dental Plan on a
standard claim form, which is available in most dental
offices or from Santa Rosa City Schools Dental Plan.
Santa Rosa City Schools Dental Plan makes payment for
services performed by a Participating Dentist to the
Dentist, unless otherwise specified.
Facilities
Services may be obtained from any licensed Dentist. To
determine whether any particular Dentist is a
participating provider, a provider list should be
consulted, or you may contact The SSM Group, at (707)
544-1801.
Choice of Physicians & Providers
A person eligible for Benefits may elect the service of
any licensed Dentist. However, if the Dentist is not a
Participating Dentist of Santa Rosa City Schools Dental
Plan, there may be a difference in the amount of his/her
fees that are covered by the Program.
The Eligible Person using the services of a Dentist who
is not a Participating Dentist may also be liable for the
amount of fees in excess of the fees allowed by Santa
Rosa City Schools Dental Plan.
The following options may be offered upon termination of
eligibility:
Approved Leave of Absence
Employees on approved leave of absence may continue their
coverage for themselves and their dependents for a maximum
of one (1) year by remitting a monthly payment check made
payable to the District. The District remits these payments
together with their monthly District payments in one check to
the Administrator and continues to leave the employee on the
monthly billing.
Labor Disputes
Employees who cease work as a result of a labor dispute and
who are eligible when regularly employed have the option of
continuing their eligibility for a maximum of six (6) months
from the date of cessation of work. This option shall be
available only so long as a minimum of 75% of the absent
employees who were eligible as of the date of cessation of work
continue their eligibility for themselves. Employees who
exercise this option shall pay the applicable monthly payment
to the District and/or Employee Association. Eligible
Employees who have lost eligibility as a result of a labor
dispute and who subsequently return to work shall become
eligible on the first day of the month following the return to
work. Such employees shall be considered as newly-hired
employees with respect to the incentive co-payment level and
the maximum. In the vent that the District makes retroactive
payment for all employees who would have been eligible had
there not been a labor dispute, theses employees shall be
considered as continuously eligible. Services provided during
the period such employees were not eligible are not covered.
Arbitration of Dental Disputes
Any party to a dispute, including an Eligible Person, may initiate
arbitration by written notice to each other party to the dispute,
stating the intention to arbitrate and describing the nature of
the dispute, the amount involved, if any, and the remedy
sought, and by filing two copies of such notice with the
Administrator.
Termination of Benefits
Benefits terminate upon termination of the Contract. In
the event of termination, Santa Rosa City Schools Dental
Plan shall not authorize services performed beyond the
date of termination, except for the completion of Single
Procedures (as defined in the Contract) commenced
prior to termination of the Contract which are otherwise
Benefits under the terms of the Contract.
CLAIMS ADMINISTERED BY:
THE SSM GROUP
320 COLLEGE AVENUE, SUITE 340
P.O. BOX 329
SANTA ROSA, CA 95402
(707) 544-1801
www.thessmgroup.com
Santa Rosa
City Schools
Dental Plan
Summary
Benefits and Coverage
The maximum amount payable by Santa Rosa City Schools
Dental Plan for covered Basic and Prosthodontic Benefits
provided to any Eligible Person in any contract year (Dec. 1Nov. 30) or portion thereof is $1,500. The maximum
amount payable for Dental Accident Benefits provided to any
Eligible Person in any contract year shall be $1,500.
Co-Payment
30% of the Dentist’s fees for covered Preventive and Basic
Benefits during the first contract year of patients eligibility,
decreasing to 20%, 10% and 0% respectively during
subsequent contract years of eligibility, provided the patient
has utilized the program during the preceding contract year.
50% of the Dentist’s fees for covered Major Benefits.
Once Santa Rosa City Schools has fulfilled its maximum
obligations, all further charges will be the responsibility of
the patient.
Preventive & Basic Benefits
Diagnostic and Preventive
Procedures to assist the Dentist in determining required
dental treatment. [Prophylaxis (cleaning), fluoride
treatments, exams.]
Oral Surgery
Extractions and certain other surgical procedures, including
pre and post-operative care.
Restorative
Amalgam, synthetic porcelain and plastic restorations for
treatment of carious lesions (visible destruction of hard
tooth structure resulting from the process of dental decay).
(Within limits of program).
Crowns, Jackets and Gold or Cast Restorations
Treatment of carious lesions (visible destruction of hard
tooth structure resulting from the process of dental decay)
which cannot be restored with amalgam, synthetic porcelain
or plastic restorations.
Endodontics
Treatment of the tooth pulp.
Periodontics
Treatment of the gum and bones supporting the teeth.
Major Benefits
Prosthodontic Benefits
Procedures for construction or repair of fixed bridges, partial
or complete dentures.
Limitations
Limitations on Basic
Routine oral examinations and prophylaxis treatments are
limited to four (4) times in any twelve month contract year while
the patient is an Eligible Person under the Santa Rosa City
Schools Dental Plan.
Unless special need is shown, full mouth x-rays are provided
only after three years have elapsed following any prior provision
of full mouth x-rays under the Santa Rosa City Schools Dental
Plan.
Supplementary bitewing (individual) x-rays are provided on
request by your Dentist, but not more than once every six (6)
months while the patient is an Eligible Person under the Santa
Rosa City Schools Dental Plan.
Crowns, jackets, and gold or cast restorations will be replaced
only after five (5) years have elapsed following any prior
provisions under the Santa Rosa City Schools Dental Plan.
Limitations on Prosthodontic
Prosthodontic appliances (including, but not limited to, fixed
bridges and partial or complete dentures) will be replaced only
after five (5) years have elapsed following any prior provisions
under the Santa Rosa City Schools Dental Plan program, except
when the Santa Rosa City Schools Dental Plan determines that
there is such extensive loss of remaining teeth or change in
supporting tissues that the existing appliance cannot be made
satisfactory.
Santa Rosa City Schools Dental Plan will pay the applicable
percentage of the Dentist’s fee for a standard cast chrome or
acrylic partial denture or a standard complete denture, up to a
maximum fee allowance which is at least the Prevailing Fee for a
standard denture. (A “standard” complete or partial denture is
defined as a removable prosthetic appliance provided to replace
missing natural, permanent teeth and which is constructed
using acceptable and conventional procedures and materials.)
Implants- If implants are utilized Santa Rosa City Schools Dental
Plan will allow the cost of a standard bridge, crown or partial
toward the cost of the implants and appliances constructed in
association therewith. Santa Rosa City Schools Dental Plan will
not pay for any replacement within five (5) years thereafter.
General Limitations and Optional Services
If any Eligible Person elects a more expensive plan of treatment
than is customarily provided, or specialized techniques rather
than standard procedure, the Santa Rosa City Schools Dental
Plan will pay the applicable percentage of the lesser fee and the
patient is responsible for the remainder of the Dentist’s fee. For
example: a gold crown where a silver filling would restore the
tooth, or a precision denture where a standard denture would
suffice.
Exclusions
Services for injuries or conditions which are
reimbursed under Worker’s Compensation or
Employer’s Liability Laws; services which are
provided to the Eligible Person by any Federal or
State Government Agency or are provided without
cost to the Eligible Person by any municipality,
country or other political subdivision, except MediCal benefits.
Services with respect to congenital (hereditary) or
developmental (following birth) malformations or
cosmetic surgery or dentistry for purely cosmetic
reasons; including but not limited to: cleft palate,
maxillary and mandibular malformations, enamel
hypoplasia (lack of development), fluorosis
(discoloration of teeth), and anodontia (congenitally
missing teeth).
Services for restoring tooth structure lost from wear,
for rebuilding or maintaining chewing surfaces due
to teeth out of alignment of occlusion, or for
stabilizing the teeth. Such services include, but are
not limited to, equilibration and periodontal
splinting.
Prosthodontic services or devices (including crowns
and bridges) or any Single Procedure started prior to
the date the person became eligible for such
services under this program.
Prescribed drugs, premedication or analgesia, such
as nitrous oxide.
Experimental procedures.
All hospital costs and any additional fees charged by
the Dentist for hospital treatment.
Charges for anesthesia, other than general
anesthesia administered by a licensed Dentist in
connection with covered oral surgery services.
Extra oral grafts (grafting of tissue from outside the
mouth to oral tissue).
Services with respect to any disturbances of the
temporomandibular joints (jaw joints).
Orthodontic services (treatment of malalignment of
teeth and/or jaws) including orthodontic surveys.
Services performed for cosmetic reasons.
Composite Restorations (posterior teeth only).
Sealants.