A. Enrollment and Eligibility
You and any of Your eligible dependents may enroll in this Plan. When You become eligible, You may enroll for dental insurance by completing the required enrollment application and sending the completed form to Us on a timely basis. In order for Your dependent coverage to start, You must also be covered under this Plan. You must enroll for a minimum of 12 months.
Your eligible dependents are Your:
- Spouse; and
- Unmarried dependent child, including:
- A newborn child, natural child, stepchild or a child placed with You for adoption or foster care who is under age 20; and
- A full-time student who is at least age 20 and who is under age 26; and
- A child who is incapable of self-support because of a physical or mental incapacity. A dependent child may remain eligible for dependent benefits past the age limit, subject to the conditions below:
- The condition started before he or she reached the age limit; and
- The child remained continuously covered until he or she reached the age limit; and
- You send Us written proof, and We approve such proof, of the child’s disability and dependence within 31 days from the date he or she reaches the age limit. After the two-year period following the child’s attainment of the age limit, We can ask for periodic proof that the child’s condition continues, but We cannot ask for this proof more than once a year.
In order for Your dependent coverage to start, You must also be covered under this Plan.
If You initially waive dependent dental coverage under this Plan because Your dependent(s) were covered under another dental Plan, You can enroll Your dependent(s) under this Plan if his or her dental coverage will end due to one of the following Qualifying Events:
- Termination of Your Spouse's employment.
- Loss of eligibility under Your Spouse's dental Plan.
- Death of Your Spouse.
- Termination of the other dental Plan.
- Any other event as required by state or federal law.
- However, You must enroll Your dependent(s) under this Plan within 30 days of the Qualifying Event.
B. Your Effective Date
Coverage will begin on the first day of the month following the date Your premium payment is received by Guardian as long as the premium is received on, or before, the 25th day of the preceding month. When You become eligible, You may enroll for dental insurance by completing the required enrollment application and sending the completed form to Us on a timely basis. Incomplete enrollment forms or failure to submit the required initial premium amount will cause a delay in issuance of insurance.
C. How does the Advantage Gold Plan Work?
As long as you meet the Plan’s general eligibility requirements and pay the applicable premium, your acceptance is automatic. In order for Your dependent coverage to start, You must also be covered under this Plan. This Plan helps pay the cost of most dental care services including exams, cleanings, fillings, extractions, crowns, bridges, dentures, implants and orthodontics services for covered dependent children under age 19 years old when the active orthodontic appliance is first placed. You and Your dependents are eligible for dental benefits under this Plan after You and Your dependents complete the service waiting period. Service waiting periods are shown in the Schedule of Benefits.
D. Deductible & Benefit Year Maximums
Your Benefit Year is the 12-month period which starts on Your Plan Effective Date and ends on the 12th month of each year. The Benefit Year Individual Deductible is the amount of covered dental charges incurred by an insured person or on behalf of your insured dependent before Guardian starts paying benefits. The Advantage Gold offers a Benefit Year Individual Deductible of $50 for Preventive, Basic and Major Services. Deductible will be waived for Preventive Services IN NETWORK ONLY. The Benefit Year Maximum is the maximum amount payable for all eligible dental expenses per benefit year, per person. This Plan offers a Graded Benefit Year Maximum. The Year 1 maximum of $1,000 applies during the first 12 months the covered person becomes insured for dental benefits under this Plan. The Year 2 maximum of $1,250 applies during the second 12 month period. The Year 3 maximum of $1,500 applies during the third 12 month period and each 12 month period thereafter. The covered person must have a covered Preventive Service performed during the Benefit Year to move to the next maximum level. If the covered person does not have a covered Preventive Service performed within the Benefit Year, the maximum amount will not be increased.
This Plan provides benefits for orthodontic services for covered dependent children who are under 19 years old when the active orthodontic appliance is first placed. Limited orthodontic treatment, interceptive orthodontic treatment, comprehensive orthodontic treatment: Coverage includes treatment Plan and records, including initial, interim and final records. Coverage also includes fabrication and insertion of Appliances, periodic visits, orthodontic retention and related visits. The Benefit Year Maximum for Orthodontics is $500. The Lifetime Maximum for Orthodontics is $1000. Additionally, there is also $1000 Lifetime Maximum for Implants.
E. Choice of Provider
The Advantage Gold gives you the freedom to receive dental treatment from any dentist You choose. This Plan usually pays a higher level of benefits for covered treatment furnished by a Contracted Dentist. Conversely, it usually pays less for covered treatment furnished by a Non-Contracted Dentist.
Dentists who are contracted in Guardian’s network have agreed to accept a discount for the Covered Services they perform. When You visit one of these Dentists, the discount will lower Your out-of-pocket costs. When You visit a Non-Contracted dentist, Your reimbursement will be based on Guardian’s fee schedule for Your specific Plan or on the 70th percentile of the prevailing fee data for the Dentist’s zip code.
F. Emergency Dental Services
After-hours office visit or emergency palliative treatment: Limited to 1 in a 6-month period. Covered when no other treatment, other than radiographs, is performed in the same visit.
G. Coordination of Benefits
Refer to your certificate of insurance for details. This can be located online at MyDental.GuardianLife.com.
H. Cancellation Policy
Cancellation must have been submitted to us in writing or email only 31 days prior to the cancellation date. Cancellation takes place the last day of the month following receipt date of the cancellation request. If You or Your dependent(s) disenroll in coverage for any reason, a 12-month waiting period will need to be met before You or Your dependent(s) would be eligible to re-enroll in the Plan. The 12-month waiting period starts from the date of cancellation.
I. Limitations and Exclusions for Guardian PPO Plans
The list of dental services illustrated are not exhaustive. Please refer to a certificate of coverage for full Plan description, the list of covered dental services and Plan exclusions and limitations (noted below).
Please refer to a schedule for full Plan description, the list of covered dental services and Plan exclusions and limitations.
This plan does not pay for:
- Any service or treatment method which does not meet professionally recognized standards of dental practice or which is considered to be experimental in nature.
- Educational services, including, but not limited to: (1) oral hygiene instruction; (2)tobacco counseling; or (3) nutritional counseling.
- Any service performed in conjunction with, as part of, or related to a service which is not covered by this Policy.
- Any service furnished solely for cosmetic reasons. This includes, but is not limited to: (1) characterization and personalization of a Dental Prosthesis; (2) bleaching of discolored teeth; and (3) odontoplasty.
- Treatment of congenital or developmental malformations or the replacement of congenitally missing teeth.
- Pulp vitality tests or caries susceptibility tests.
- The localized delivery of antimicrobial agents via a controlled release vehicle into diseased creviculartissue.
- Any service performed on a tooth or teeth with a guarded, questionable or poor prognosis.
- Any restoration, service, Appliance or Dental Prosthesis used solely to: (1) alter vertical dimension; (2) restore or maintain occlusion; (3) treat a condition necessitated by attrition or abrasion; or (4) splint or stabilize teeth for periodontal reasons.
- Replacement of a lost, missing or stolen Appliance or Dental Prosthesis or the fabrication of a spare Appliance or Dental Prosthesis.
- Any service, Appliance, Dental Prosthesis, modality or surgical service intended to treat or diagnose disturbances of the temporomandibular joint (TMJ) that are incidental to, or result from, a medical condition unless required due to state law.
- We will not pay to replace an existing Dental Prosthesis with any Dental Prosthesis unless: (1) it is at least 10 years old and is no longer usable; or (2) it is damaged while in the covered person’s mouth in an Injury suffered while covered and cannot be made serviceable.
- A Dental Prosthesis will not be covered when replacing a tooth or teeth lost or extracted before being covered under this Policy.
J. Grievance Procedures
If you or one of your eligible dependents has a complaint with Guardian or your dentist, you may register a Complaint with Guardian. Grievance forms are available on MyDental.GuardianLife.com or by calling Customer Service at 866-569-9900.