Plan Information

The CapDent Plan NY

A. Eligibility
This plan is available directly to individuals and their families through Dentcare Delivery Systems, Inc (DDS) in New York and through International Healthcare Services, Inc (IHS) in New Jersey. Under family coverage, children are covered to age 26. It is the member's responsibility to provide Dentcare Delivery Systems, Inc. proof of full-time status each semester.

B. Effective Date
If your application and payment information is submitted by the 20th of the month, your coverage will be effective on the 1st of the following month. If it is submitted after the 20th of the month, your coverage will begin on the 1st of the subsequent month.

Once you are enrolled, rates are locked in for 12 months.

C. Payment Information and Cancellation Policy
You must pay for this dental benefit with a valid credit card or ACH account. This is a pre-paid dental insurance plan. DentalInsurance.com will continue to charge your account for all future premiums following your enrollment until such time as you notify DentalInsurane.com that you wish to terminate your policy. Note that enrollment in this program is on an annual basis. You have the right to cancel within the first 30 days after receipt of membership materials and receive a full refund; less a nominal processing fee. After the 30th day, you may not terminate the policy until twelve months from the date you enroll. Declined credit card transactions are subject to a $25 processing fee and will result in a cancellation of coverage.

D. How Does the CapDent Plan Work?
In this managed care program, you and your covered family members select a dentist (one per family) from the CapDent Directory of Participating Providers and receive all treatment from that dentist. Some services are rendered without any cost – others have a minimal copayment that you pay directly to the dentist. First, review the Directory of Participating Dentists and select a provider that is conveniently located for you and your family (all family members must use the same dentist). Then, complete the enrollment form and enter the name and site number of your dentist. Simply call your participating dentist after you receive your ID card and identify yourself as a CapDent Plan member.

E. Annual Deductible & Calendar Year Maximums
There are no annual deductibles or calendar year maximums.

F. Choice of Provider
When you enroll in the CapDent Plan, review the Directory of Participating Dentists and select a provider that is conveniently located for you and your family (all family members must use the same dentist).

G. Specialty Care/Specialist Referrals
Should you require the care of a specialist, you may be treated by any CapDent participating endodontist, periodontist, oral surgeon or orthodontist. In such cases, your copayment will be different than the amounts shown on the Schedule. Services rendered by a participating specialist will be charged to you at 25% less than usual and customary fees. Referral forms are not necessary.

H. Emergency Dental Services
If you have a dental emergency, you will be appointed within 24 hours. Should you be away from home with a dental problem, you will be reimbursed up to $50 for emergency care only.

I. Coordination of Benefits
The CapDent Dental Plan is available as primary coverage and does not coordinate coverage with other dental benefits, if you have them.

J. Termination of Policy
Healthplex reserves the right to amend the plan or rates on an anniversary date, but cannot terminate the plan.

K. Exclusions/Limitations

Exclusions:

  1. Any dental services, which were not rendered or approved by a participating dentist except in cases of out-of-area dental emergency.
  2. A service not furnished by a dentist, unless the service is performed by a licensed dental hygienist under the supervision of a dentist or for an x-ray ordered by a dentist.
  3. Treatment of a disease, defect, or injury covered by a major medical plan, Worker’s Compensation Law, occupational disease law, or similar legislation.
  4. General anesthesia, or analgesia for general services rendered in a hospital environment.
  5. Any dental procedures which are undertaken primarily for cosmetic reasons, or dental care to treat accidental injuries, congenital or developmental malformations.
  6. Restorations, crowns or fixed prosthetics when acceptable results can be achieved with alternative methods or materials. In cases where the selection of a more expensive treatment plan is decided upon, the Plan will allow for the least costly alternative and the patient is responsible for all additional fees charged by the dentist.
  7. Services, which were started prior to the person becoming covered under this plan.
  8. Implants, grafts, precision attachments or other personalized restorations or specialized techniques.
  9. Broken Appointments – If specified by Plan Dentist for appointments not canceled 24 hours in advance, there is a $30.00 charge.
  10. Replacement of any existing crown, bridge or denture, which can be made serviceable according to common dental standards.
  11. Procedures, appliances or restorations (except full dentures) whose main purpose is to: change vertical dimension; diagnose or treat conditions or dysfunction of the temporomandibular joint; stabilize periodontally involved teeth, or restore occlusion.
  12. Treatment of unmanageable children and/or unruly patients. An attempt will be made to treat all patients. However, if a patient is untreatable by virtue of apprehension or any other reason, and is referred to another office for treatment, the responsibility for payment lies with either the patient or with the parents of the patient.
  13. Services not listed in the Schedule of Benefits are not covered.

Limitations:

  1. Oral exams, bitewing x-rays, prophylaxes, scalings and fluoride treatments – Once every 6 months.
  2. Full mouth and panoramic x-rays – Once every 36 months.
  3. Crowns, bridges, dentures and periodontal surgery – Once every 60 months.
  4. Orthodontic treatment of Class II/Class III malocclusions – One 24-month case.
  5. Under family coverage, children are covered to age 26.
  6. These limitations are based on standard dental practice guidelines and are acknowledged by most insurance companies, dental benefit organizations and dental associations.

L. Grievance Procedures
If you have a complaint, contact a Customer Service Representative at Healthplex to obtain a complaint form and a copy of the grievance procedure.