Kalamazoo College, G-1013
Benefit Description – Dental Plan Limits
- Benefit Year – January 1 through December 31
- Deductible per Benefit Year – $50/employee; $150/employee plus one or more dependents
Benefit Percentage
- Type I – Preventive Dental Services – 100%; deductible waived (0% coinsurance)
- Type II – Minor Restorative Dental Services – 80% after deductible (20% coinsurance)
- Type III – Major Restorative Dental Services – 50% after deductible (50% coinsurance)
- Type IV – Orthodontic Services (for dependent children under age 19 only) – 50% after deductible (50% coinsurance)
Maximum Benefit Paid per Covered Person per Benefit Year for Types I, II, and III Dental Services – $1,200
Lifetime Maximum Benefit Paid per Dependent Child for Type IV Orthodontic Services – $1,000
Special Eligibility Provision for Working Spouses and Domestic Partners
A participant’s spouse or domestic partner who is eligible for dental benefits coverage under his or her own employer’s group health plan must enroll for that coverage. Coverage under the spouse or domestic partner’s own employer’s group health plan will be considered his or her primary coverage, and this Plan will be the secondary coverage. A participant’s spouse or domestic partner who is eligible for dental coverage under his or her own employer’s group health plan, but who declines to take that other coverage will not be eligible to enroll in or participate in the Plan unless one of the exceptions noted below applies.
The participant is obligated to immediately report to the Plan Administrator any change that would affect his or her spouse or domestic partner’s eligibility under this Plan (i.e., the spouse or domestic partner changes employers or the spouse or domestic partner’s employer offers its employees a dental plan for the first time). If it is found that a spouse or domestic partner who is eligible for coverage under his or her own employer’s group health plan has not enrolled for his or her own employer’s group health plan as required by this provision, benefits for the spouse or domestic partner may be terminated. Coverage may not be retroactively rescinded except as permitted by law (e.g., in cases of fraud or intentional misrepresentation). Notice that coverage will be retroactively rescinded must be provided 30 days before proceeding with the termination process. Otherwise, coverage will be terminated prospectively once the error is discovered.
The following exceptions to this provision shall apply:
- A participant, spouse, or domestic partner who is an employee of Kalamazoo College and who is married to or in a domestic partner relationship with an individual who is also an employee of Kalamazoo College will not be penalized for declining to enroll separately as individual participants in this Plan.
- A spouse or domestic partner who is required to pay at least 50% or more of the total cost for dental coverage under his or her employer’s group health plan will not be subject to this provision and can enroll for primary / sole dental coverage under this Plan.
Special Provision for Injuries Arising Out of Automobile Accidents
The following special coordination rule applies regarding automobile insurance. If a covered person has automobile insurance (including, but not limited to no-fault) that provides benefits, the automobile insurance shall be the primary plan and this Plan shall be the secondary plan for purposes of paying benefits.
Summary of Dental Procedures
Services – Special Limitations
Type I: Preventive Dental Services
A. Oral Examination – Limited to two times in any 12-consecutive-month period.
B. Dental Prophylaxis (cleaning teeth) – Limited to two times in any 12-consecutive-month period.
C. Complete Series or Panorex X-Rays – Limited to one time in any 36-consecutive-month period.
D. Occlusal, Extraoral, and Individual Periapical X-Rays – None.
E. Bite-Wing X-Rays – Limited to two times in any 12-consecutive-month period.
F. Bacteriologic Cultures – None.
G. Fluoride Treatment – Dependent children up to age 16 only. Limited to one time in any 12-consecutive-month period.
H. Palliative Treatment – Paid as a separate benefit only if no other service, except x-rays, was rendered during the visit.
I. Sedative Fillings – Paid as a separate benefit only if no other service, except x-rays, was rendered during the visit.
J. Sealants – Dependent children up to age 16 only.
K. Space Maintainers – None.
L. Emergency Treatment – Exams only.
Type II: Minor Restorative Dental Services
A. Periodontal Exams – Limited to one time in any three-consecutive-month period.
B. Periodontal Prophylaxis – Limited to one time in any three-consecutive-month period.
C. Diagnostic Casts – Limited to one time in any 24-consecutive-month period.
D. Stainless Steel Crowns – None.
E. Re-cement Inlays, Onlays, Crowns, and Bridges – None.
F. Pulpotomy and Osseous Surgery – None.
G. Root Canal Therapy – None.
H. Apicoectomy and Retrograde Filling – None.
I. Scaling and Root Planing – Limited to two times per quadrant of the mouth in any 12-consecutive-month period.
J. Temporary Splinting – None.
K. Periodontal Appliance – Limited to one appliance in any 36-consecutive-month period.
L. Repairs to Full Dentures, Partial Dentures, and Bridges – Limited to repairs or adjustments done more than 12 months after the initial insertion.
M. Relining Dentures – Limited to relining done more than 12 months after the initial insertion and then not more than one time in any 24-consecutive-month period.
N. Simple Extraction – None.
O. Surgical Extraction of Impacted Teeth – Not covered as a dental expense if covered under the employer’s medical plan.
P. Alveoplasty – Not covered as a dental expense if covered under the employer’s medical plan.
Q. Gingivectomy – Not covered as a dental expense if covered under the employer’s medical plan.
R. Vestibuloplasty – Not covered as a dental expense if covered under the employer’s medical plan.
S. Root Recovery – None.
T. Incision and Drainage – None.
U. Local and General Anesthesia – None.
V. Amalgam Restorations (fillings) – Multiple restorations on one surface will be treated as a single filling.
W. Silicate, Plastic, and Composite Restorations (fillings) – None.
X. Pin Retention – Limited to two pins per tooth.
Y. Gingival Curettage – None.
Z. Osseous Graft – None.
AA. Frenectomy – None.
BB. Occlusal Adjustment – None.
CC. Bite Splint Appliances – Limited to one appliance in any five-consecutive-year period.
Type III: Major Restorative Dental Services
A. Gold Inlays and Onlays – Covered only when the tooth cannot be restored by silver fillings. An expense is considered incurred at the time the tooth or teeth are initially prepared.
B. Porcelain Restorations – None.
C. Crowns – Covered only if the tooth cannot be restored by a filling or by other means. An expense is considered incurred at the time the tooth or teeth are initially prepared.
D. Post and Core – None.
E. Replacement of Teeth to Bridges and Dentures – None.
F. Full or Partial Dentures – None.
G. Fixed Bridges – An expense is considered incurred at the time the tooth or teeth are initially prepared.
H. Dental Implants – None.
Type IV: Orthodontic Services (Dependent Children Under Age 19 Only)
Orthodontic Diagnostic Procedures, Surgical Therapy, and Appliance Therapy – None.
This brochure represents only a summary of your group health benefits Plan as it applies to all eligible employees and dependents. This brochure is not the Plan Document or the Summary Plan Description for ERISA purposes and shall not be relied upon to establish or determine eligibility, benefits, procedures, or the content or validity of any section or provision of the Dental Benefits Plan. Please refer to the Plan Document for specific information regarding Plan provisions.