Dental Blue Enhanced
A. Enrollment and Eligibility
You and your enrolling dependents must be permanent, legal residents of the United States. You and your enrolling spouse must be age 64 ¾ or younger.
Eligible dependents include:
- the subscriber’s lawful spouse
- any unmarried child (of the subscriber or the enrolled spouse) under age 19
- any unmarried child (of the subscriber or the enrolled spouse) ages 19 to 23, who qualifies as a dependent for federal income tax purposes
- the subscriber’s or enrolled spouse’s child, who continues to be both incapable of self-support due to continuing mental retardation or physical handicap, and who is at least one-half dependent on the subscriber or enrolled spouse for support
B. Your Effective Date
Policy effective dates are always the FIRST of the month. If the enrollment form and payment information are received by DentalInsurance.com by the 25th of the month, coverage will become effective on the FIRST of the following month. Incomplete enrollment forms, or failure to submit the required initial premium amount may cause an initial delay in issuance of insurance. Do not cancel any other insurance or assume you are insured under the Policy until you receive your certificate of insurance.
C. How does the plan work?
As long as you meet the plan’s general eligibility requirements and pay the applicable premium, your acceptance is automatic. There are no waiting periods for cleanings, exams and X-rays; a six – month waiting period for Basic services and 12 months for major services/orthodontics. This plan pays the cost of exams, cleanings and x-rays.
D. Annual Deductible & Calendar Year Maximums
The annual deductible is the amount of covered dental charges incurred by an insured person or on behalf of your insured dependent before Dental Blue starts paying benefits. The annual deductible of $50 will apply to each insured person. The deductible is waived for in-network diagnostic and preventive services. The Calendar Year Maximum is the maximum amount the plan will pay for all eligible dental expenses in any calendar year. The Calendar Year Maximum for this policy is $1250.
E. Choice of Provider
Dental Blue allows you to choose from over 18,000 dentist locations in our network. Whether you choose a Dental Blue Basic or Dental Blue Enhanced plan , you have the power to visit any dentist or specialist in the Dental Blue 100 network. You also have the freedom to visit a dentist outside of our Dental Blue network altogether if you want. If you choose to see a dentist who is not part of the dental network, your claim allowance is based upon a fee schedule. Keep in mind, however, you will usually save the most money when you visit a dentist within the Dental Blue network you selected.
F. Specialty Care/Specialty Referrals
Specialty Care can be utilized and the benefits will be applied based on the type of service needed, provided the waiting periods have been satisfied.
G. Emergency Dental Services
Except for palliative emergency treatment, there is no specific code tied to emergency services and no special limitation or exclusion for services which are emergency vs. non-emergency.
H. Coordination of Benefits
There is no coordination of benefits for this plan.
I. Cancellation Policy
If you wish to cancel your policy, the cancellation will become effective the first of the month following our receipt of your written notice to cancel or the paid to date, whichever comes first.
J. Termination of Policy
Coverage ceases under the plan when: You do not pay the premium when due, subject to the grace period; the spouse is no longer married to the principal insured; a child fails to meet the previously listed eligibility requirements; any member becomes enrolled in any other Blue Cross of California/BC Life & Health Insurance Company non-group coverage; any covered member resides in a foreign country for more than six consecutive months or is absent from California for more than six consecutive months. You must notify BC Life & Health Insurance Company of all changes affecting any member’s eligibility.
Services not specifically listed in the “Covered Services” section of this Policy.
Procedures not yet recognized by the American Dental Association as indicated with a specific procedure code designation, or procedures which are considered experimental or investigative in nature or which are not widely accepted as proven and effective procedures within the organized dental community.
Any condition for which benefits are recovered or can be recovered, either by any workers’ compensation law or similar law even if you do not claim those benefits. If there is a dispute or substantial uncertainty as to whether benefits may be recovered for those conditions pursuant to workers’ compensation law or similar law, we will provide the benefits of this plan for such conditions, subject to the right to a lien or other recovery under section 4903 of the California Labor Code or other applicable law.
Any services you actually received that were provided by a local, state, county or federal government agency including any foreign government, except when payment under this Policy is expressly required by federal or state law. This Policy will not cover payment for these services if you are not required to pay for them or they are given to you for free. Veterans Administration Hospitals and Military Treatment Facilities will be considered for payment according to current legislation.
Any services for treatment of illness or injury that occurs as a result of any act of war, declared or undeclared.
Any services for treatment of injuries sustained or illnesses resulting from participation in a riot or civil disturbance, or while committing or attempting to commit an assault or felony (unless otherwise required by law). Services, treatments or other care required while incarcerated in a federal, state or local penal institution or required while in custody of federal, state or local law enforcement authorities, including work release programs.
Services For Which You Are Not Legally Obligated To Pay: Services for which no charge is made to you in the absence of insurance coverage.
Expenses Before Coverage Begins or After Coverage Ends: Services received before your Effective Date or services received after your coverage ends.
Professional services received from a person who lives in the Insured’s home or who is related to the Insured by blood, marriage or adoption.
Cosmetic Dentistry: Any services performed for cosmetic purposes (including but not limited to external bleaching, bleaching of non-vital discolored teeth, composite restorations, veneers, crowns on teeth not exhibiting pathology and facings on crowns on posterior teeth). *
Excess Amounts: Any amounts in excess of the dental benefit maximums and yearly Maximum Benefit stated in this Policy. The Covered Expense for all Covered Services includes the administration of any local anesthesia and the provision of infection control procedures as required by state and federal mandates. If billed separately, such charges will be denied. *
Procedures requiring Appliances or restorations (other than those for replacement of structure loss from tooth decay) that are necessary to alter, restore or maintain occlusions. These include but are not limited to:
- Changing the vertical dimension.
- Replacing or stabilizing lost tooth structure by attrition, abrasion, abfraction, erosion or bruxism.
- Realignment of teeth.
- Gnathological recording.
- Occlusal equilibration.
- Periodontal splinting.
Harmful Habit Appliances: Fixed and removable Appliances to inhibit thumb sucking.
Replacement of an existing fixed or removable prosthesis for which benefits were paid if replacement occurs within seven (7) years of the original placement, unless the prosthesis is being used during the healing period for recently extracted anterior teeth.
Replacement of crowns, inlays, onlays and laboratory-fabricated restorations if replacement occurs within seven years of the original placement. Benefits will not be provided for a pontic or an abutment if a fixed or removable partial, crown, or onlay was placed on the affected tooth/teeth in the last seven (7) years.
Lost or Stolen Dentures or Appliances. Replacement of existing full or partial dentures or Appliances which have been lost or stolen.
Charges for any duplicate prosthetic device or Appliance, or for a “spare” set of dentures or any other duplicate Appliance. *Prescribed drugs, pre-medication or analgesia including charges for nitrous oxide or any similar local anesthetic when the charge is made separately from a Covered Service.
Replacement of existing fillings for any purpose other than restoring active decay. The extraction of immature erupting third molars and nonpathologic, asymptomatic third molars is excluded. Third molar extractions are not covered under age 16.
Histopathological exams (examination of cells by microscope) and/or the removal of tumors, cysts, and foreign bodies.
Charges for tobacco counseling, oral hygiene instruction, dietary planning, or behavior management.
Diagnosis or Treatment of the Joint of the Jaw and/or Occlusion: Services, supplies or appliances provided in connection with any treatment to alter, correct, fix, improve, remove, replace, reposition, restore or otherwise treat the joint of the jaw (temporomandibular joint) or associated musculature, nerves and other tissues for any reason or by any means; or
Treatment of congenital or developmental malformations including but not limited to cleft palate, maxillary and mandibular malformations, enamel hypoplasia, fluorosis, and anodontia.
Personalization or characterization of dentures or teeth. Precision attachments and the replacement of part of a precision attachment.
Overdentures and related services, including root canal therapy on teeth supporting an overdenture.
Maxillofacial prosthetics that repair or replace facial and skeletal anomalies, maxillofacial surgery, orthognathic surgery or any oral surgery requiring the setting of a fracture or dislocation.
Prosthetics for Insureds under 16 years of age including but not limited to fixed bridges, dentures, removable partials, crowns, inlays and onlays.
Denture adjustments, repairs, relines and rebase are not covered for a period of six (6) months from initial placement if the denture(s) were paid for under this Policy.
Fixed Prosthodontics are not a Covered Service when all molars are missing on one or both sides of an arch. Benefits are provided for the replacement of an existing bridge if it is seven (7) years old or older and cannot be made serviceable.
Temporary and interim prosthetics (temporary crowns, bridges, partials, dentures, etc.). Temporary services are considered an integral part of the final services rather than a separate service, and are therefore not eligible for benefits.
Implants: Materials implanted into or on bone or soft tissue and all adjunctive services (including but not limited to surgery, prosthetics placed on implants, cleanings, maintenance, etc.) performed in conjunction with the placement or removal of implants.*
Occlusal guards, occlusal adjustments (complete or limited) and occlusal analysis.
All hospital costs and any additional fees charged by the Dentist for hospital treatment.
Professional visits for house/extended care facility, office visits after regularly scheduled hours, and case presentations.
Teeth lost prior to coverage under this Policy are not eligible for prosthetic replacement unless the prosthetic replacement replaces one or more eligible natural teeth lost during the term of this coverage.
Services or treatments that are not Medically Necessary. Medically necessary services or treatments are those which are ordered by the attending Dentist for the direct care and treatment of a covered condition. They must be standard dental practice where received for the condition being treated and must be legal in the United States.
If more than one treatment plan would be considered Medically Necessary for a dental condition, any amount exceeding the cost of the least expensive professionally acceptable treatment plan is not covered.
Charges for missed or cancelled appointments.
Orthodontic services, cephalometric film, braces, appliances and all related services including surgery necessary in conjunction with orthodontic treatment.
Transfer of care: If a Policyholder transfers from the care of one Dentist to that of another Dentist during the course of treatment, or if more than one Dentist renders services for one dental procedure, BC Life & Health shall be liable only for the amount it would have been liable for had one Dentist rendered the services.
Services for treatment of malignancies and neoplasms. Complications of Non-Covered Services:
Complications arising from non-Covered Services and supplies. Examples of Non-Covered Services include, but are not limited to: cosmetic surgery, or operations and procedures which are determined to be experimental or investigational.
Claims received after 12 months from the date service was rendered.
Osseous grafts if the following procedures have been performed on the affected tooth or site on the same date of service or within the previous 12 months:
- Retrograde Filling
- Root canal therapy
Fixed Bridges are covered only when:
- The bridge is replacing teeth that were extracted after the Insured’s Effective Date; and
- The total units required to replace all missing teeth is six units or less in an arch (arch means maxilla or mandible); and
- The bridge or bridges consist of no more than six (6) units total in an arch. (Each abutment is a unit and each pontic is a unit in a bridge.) Coverage for fixed bridgework that includes more than a total of six (6) units is limited to the amount this Policy would pay for a removable partial denture.
* Even though these services are not covered as part of the dental plan, discounted fees for these services are available from in-network dentists.
L. Grievance Procedures
If you have a complaint about services from BC Life or your health care provider, please call us first toll free at (888) 209-7852 or write to us at:
BC Life & Health Insurance Company
P.O. Box 9066
Oxnard, California 93031-9066
This is a general group summary of the features of this plan. When you purchase the plan you will receive a Certificate of Insurance that details your rights and obligations, as well as those of the insurance company.
This website provides a very brief description of some of the important features of this plan. It is not the insurance contract, nor does it represent the insurance contract. A full description of benefits, exceptions and limitations is contained in the Certificate of Insurance.