Coordination of Benefits |
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Anthem Blue Cross and Blue Shield policies all have a coordination of benefits provision. This provision explains that if you are issued an Anthem Blue Cross and Blue Shield Individual Dental Plan policy, and one of the persons covered by your Anthem policy is covered by a dental group plan, the dental group plan will have primary responsibility for the covered expenses of that family member. For any dependent children on your Anthem individual policy who are enrolled under another individual dental plan, the primary policy is the policy of the parent whose birthday (month and day) falls earlier in the calendar year. Parent birth year is not considered.
Eligibility
Individual Dental Plan coverage is available to those who:
- are under age 65, or 65 and older only if enrolled or enrolling in an Anthem Medicare Supplement plan;
- live in the Anthem Blue Cross and Blue Shield service area; and
- are not eligible for any group dental coverage.
Your spouse and dependent children are also eligible to apply. Dependent children must be:
This individual dental policy cannot be used as an employer-provided dental benefit plan. No employer of any person covered under this policy may pay any premium for this coverage, directly or indirectly, including through wage adjustment. "Employer" does not include a trade or business wholly owned by an individual, or individual and spouse, that has no other employees or that does not offer dental benefits to any other employees. Also, as it pertains to this provision, a church may purchase an individual dental policy if only purchasing it for one employee.
Renewability
Your policy is automatically renewed at the option of the Insured, as long as:
- premiums are paid in accordance with the terms of the policy;
- there is no documented pattern of abuse or misuse of our network by you;
- you make no fraudulent or material misrepresentation under the terms of this
coverage, including on your application; and
. the Insured resides in Anthem's service area.
We can refuse to renew this policy if all policies of the same form number are also not renewed. Any such action will be in accordance with applicable state and Federal laws.
Application fee
When you apply for Anthem Individual Dental, you must pay a $25 application fee which is non-refundable upon termination of your application or policy.
Canceling your policy
If you wish to cancel your policy, you must tell us by phone or in writing. Other than the application fee described above, we'll refund any unused premium within 31 days after the cancellation date. Once you cancel your coverage, you cannot reapply for this coverage until 24 months after cancellation or lapse of this policy.
Termination
Coverage ends for a covered spouse upon divorce from the covered person in whose name the dental program was obtained (the Insured). Coverage will end for covered persons:
- if the required Premium is not paid when due, subject to a 31-day grace period;
- if there is a documented pattern of abuse or misuse of our dental network;
- at the Insured's request;
- at the Insured's death (a covered spouse or dependent may continue coverage under the dental program as long as the spouse or dependent contacts us within 31 days of the Insured's death to arrange for continued coverage); or
- when he/she begins active duty with the armed services;
In addition, coverage ends for dependent children:
- at the end of the year a child turns 23 or
- when the child marries.
If the covered child is incapable of earning a living because of a mental or physical handicap, coverage for the child will continue as long as the Insured's coverage is in force.
Limitations
Limitations & Exclusions
Like all dental coverage, this policy has limitations and exclusions.
"Limitations" are preset limits on covered services - for example, limits on the number of times you can receive a certain service over the life of your policy. "Exclusions" means services this policy does not cover. When we say "services," we mean services and supplies. If you have questions about any of these limitations or exclusions or want to clarify the meaning of a dental or medical term stated below, please call your Anthem Sales Representative.
Limitations
Diagnostic Services
. 2 oral or periodontal evaluations (whether emergency or non-emergency) per calendar year
Radiographic Services
- 1 set of bitewing x-rays (not in same year as full mouth series x-rays) per calendar year;
- 1 full mouth series x-rays for covered persons age 5 and over every 3 calendar years; and
- 9 or more bitewing or periapical x-rays taken at one time will be considered a full mouth x-ray series; Up to 4 individual periapical films, but not in the same year as a complete mouth x-ray series, (does not apply when rendered in
conjunction with emergency treatment).
Preventive Services
- 2 dental cleanings, including periodontal cleanings each calendar year;
- 2 fluoride applications for covered persons under age 16 per calendar year;
- 2 space maintainers for covered persons under age 12 per lifetime; and
- 1 sealant for each unrestored permanent first and second molar for covered persons under age 16 per lifetime. There must be a lapse of a least 2 years from the time sealants are placed and the time a restoration is performed on the same tooth and surface for benefits to apply.
Restorative Services
- 1 amalgam or resin restoration (filling) per tooth per surface per calendar year. White-colored composite resin fillings will only be covered on anterior (front) teeth. If composite resin filings are done on back teeth, then you are responsible for the difference between our allowable charge and the dentist's charge for an amalgam filling.
- 1 pin retention per tooth per calendar year; and
- 1 stainless steel crown on each primary (baby) tooth per lifetime.
Endodontic Services
- 1 root canal; anterior, bicuspid or molar per tooth every 3 calendar years;
- 1 retreat of previous root canal; anterior, bicuspid, or molar per tooth per lifetime;
- 1 apicoectomy/periradicular surgery; anterior, bicuspid, molar, or additional root per root or tooth per lifetime;
- 1 retrograde filling per root or tooth per lifetime;
- Root canals are covered only on permanent teeth; and
- Therapeutic pulpotomy is covered only on primary (baby) teeth.
Periodontic Services
- 1 periodontal cleaning (Applies to your 2 cleanings per year) per calendar year;
- 1 periodontal scaling and root planing per quadrant every two
- (2) calendar years;
- 1 gingivectomy or gingivoplasty per quadrant every three (3) calendar years;
- 1 periodontal osseous (bone) surgery per quadrant every three
- (3) calendar years; and
- 1 full mouth debridement per lifetime.
Prosthodontic Services
. Services for bridges, crown, an
dentures are only covered for teeth extracted or missing after the dental policy's effective date, which includes initial placement only, unless for an existing bridge more than 5 years old;
- 1 adjustment or repair to partial or complete dentures per calendar year;
- 1 chairside relining of partial or complete dentures every 2 calendar years;
- 1 onlay, crown or bridge per tooth every 5 calendar years;
- 1 partial or complete denture per arch every 5 calendar years;
- 1 laboratory rebasing or relining of dentures per appliance every 5 calendar years;
- 1 crown repair per tooth perlifetime; and
- 1 crown recementation per tooth per lifetime.
Oral Surgery
- Use of anesthesia only in conjunction with surgical procedures; and
- 1 vestibuloplasty every 3 calendar years.
Adjunctive
- 1 palliative (emergency) treatment per calendar year; and
- Use of anesthesia only in conjunction with surgical procedures.
Exclusions
Anthem Individual Dental Plan does not cover:
- Services not listed or described in your policy as a covered service;
- Dental services that are covered under any other dental benefits plan under which a covered person is enrolled;
- Dental services with respect to congenital or developmental malformation or primarily for cosmetic purposes except as specified in your policy;
- Upgrading of serviceable dentistry;
- .. Services rendered prior to the covered person's effective date, and services rendered on or after the covered person's effective date that are directly related to services received by the covered person before the effective date;
- Services rendered after the date of termination of this policy;
- Dental pit/fissure sealants on other than first and second permanent molars;
- Diagnostic photographs;
- Dietary instruction or other counseling;
- Silicate restorations;
- Sedative fillings;
- Root canal therapy on other than permanent teeth;
- Pulp capping (direct or indirect);
- Separate charges for pulp vitality tests and bases and liners under restorations;
- Therapeutic pulpotomy on other than primary teeth;
- Guided tissue regeneration, including flap entry or re-entry and closure;
- Gingival curettage;
- Separate charges for irrigation or re-evaluation following periodontal therapy;
- Periodontal splinting and occlusal adjustments for periodontal purposes;
- Controlled release of medications to tooth crevicular tissues for periodontal purposes;
- Repositioning appliances or restorations necessary to increase vertical dimensions or restore or correct the occlusion;
- Services rendered for purposes other than to eliminate oral disease and/or replace covered missing teeth (mouth rehabilitation);
- Gold foil restorations;
- Inlays;
- Temporary dentures or temporary crowns, or duplicate dentures;
- Services to replace teeth that were lost or extracted prior to the policy's effective date;
- Services to replace non-functioning teeth;
- Fixed bridges when done in conjunction with a removable appliance in the same arch;
- Precision attachments for dental appliances;
- Tissue conditioning;
- Prefabricated resin crowns;
- Dental implants and associated services in conjunction with implants;
Exclusions cont.
- Consultations (including telephone consultations), charges for failure to keep a scheduled visit, charges for completion of a claim form, or charges for providing information in connection with a claim;
- Occlusal guards and athletic mouth guards;
- Bleaching or whitening of discolored teeth;
- Behavior management or hypnosis;
- Prescription drugs and therapeutic injections;
- Separate charges for infection control procedures and procedures to comply with Occupational Safety and Health Administration (OSHA) requirements;
- Analgesics (nitrous oxide);
- Occlusal analysis;
- Tooth desensitizing treatments;
When coverage is available for the following services, these services require the performance of diagnostic x-rays six months prior to the earlier of (1) the request for predetermination of such services or (2) the date the services were rendered:
- more than one (1) crowns;
- fixed prosthetic devices; or
- surgical extraction of impacted teeth.
If diagnostic x-rays are not preformed as specified here, the services listed are not covered.
- Services that we deem, in our sole discretion, to be experimental/ investigative;
- Services that are not medically necessary as determined by us, in our sole discretion;
- Services of any type rendered in conjunction with the services of an attending Provider whose services are not covered by this policy;
- Services provided by your immediate family or by you; services rendered by a provider or provider's employee to a co-worker;
- Services covered under Federal or state programs (except Medicaid), or under any program to which the government contributes money. These programs include: Veterans Administration (VA) Hospitals; worker's compensation; and occupational disease law. This exclusion applies whether or not you waive your rights to payment. However, we will provide benefits once your benefits are exhausted under government-financed programs;
- Services for, or related to, cosmetic surgery and/or procedures, including routine complications thereof. Cosmetic surgery is a procedure performed to improve a person's appearance;
- Services not prescribed by or performed by or upon the direction of a provider licensed to do so;
- Services received from a dental or medical department maintained by or on behalf of an employer, a mutual association, labor union, trust, or similar person or group;
- Medical or dental services related to temporomandibular joint (TMJ) dysfunction, therapy or surgery, regardless of the reason such services are performed;
- Acupuncture;
- Anesthesia when used other than in conjunction with surgical services; and
- Separate charges for hospital visits or other facility charges.
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