A. Application and Eligibility
Coverage is offered to you, and your eligible dependents. Our dental plans have no age limit requirement, so even those covered by Medicare can apply.
Dependents: Eligible dependents are your lawful spouse (or domestic partner in CA, domestic partner or civil union partner in NJ, domestic partnership established under OR law, civil union partnership established under VT law, or regional domestic partners in WA) and eligible children (or reciprocal beneficiary in HI). Eligible children must be unmarried and under 26 years of age at time of application.
B. Your Effective Date
The effective date will be the later of: the 1st of the following month; or two business days after the date received by Golden Rule Insurance Company.
C. How does the Dental Primary plan work?
Taking care of your teeth is an important part of your overall health. We can help keep your smile healthy and happy with our Dental Primary plan. More dentists in our network means you are more likely to keep the same dentist you use today and also have complete coverage available when traveling. Our network provides access to many dental providers. If you use an out-of-network dentist, Dental Primary plan pays benefits based on the network negotiated rate. An out-of-network dentist can bill a patient for any remaining amount up to the billed charge
- Preventive care covered at 100% after $25 copay with NO deductible or waiting period.
- Basic Services* have a $50 calendar-year deductible per covered person, with a maximum of 3 individual $50 deductibles per family – so if you have a family of 4, 5, 6 or even more, you’re only responsible for $150 in deductibles for the whole family!
- Waiting periods apply.
- Plan pays 70% for Basic Services like cavity fillings and simple (nonsurgical) extractions after the initial six-month waiting period is exhausted and the deductible is met.
- There is no coverage for Major Services
D. Calendar Year Maximums
There is a calendar-year maximum benefit of $1,000 per covered person. This means your dental insurance plan would pay up to $1,000 of covered expenses after the calendar-year deductible.
E. Choice of Provider
You get the best benefits if you use a network dentist.
You have the freedom to see any dentist of your choice. Utilizing network dentists reduces costs for covered expenses. If you use an out-of-network dentist, Dental Primary plan pays benefits based on the network negotiated rate — which is usually less than the reasonable and customary charge. After benefits have been paid under the policy, an out-of-network dentist can bill a patient for any remaining amount up to the billed charge.
F. Emergency Dental Services
Emergency treatment to ease dental pain is covered under Basic services after six-month waiting period.
G. Cancellation Policy
You may cancel your policy by notifying the insurance carrier within 30 days after you received it.
After the 30-day free look period has been exhausted, cancellations are taken any time via written request or by contacting the insurance carrier.
H. General Dental Exclusions and Limitations
No benefits will be paid for any services not identified or included as covered expenses under the policy. You will be fully responsible for payment for any services which are not covered expenses, nor part of the insurance policy.
No benefits are payable for:
- Any expense or service related to that expense: incurred prior to the effective date, during the waiting period, or after the termination date of the policy; which exceeds the non-network provider reimbursement; for a dental service that is not rendered or that is not rendered within the scope of the dentist’s license; for dental services, including braces for any medical or dental condition, surgery and treatment for oral surgery, except as expressly provided for in the policy; or billed for incision and drainage if the involved abscessed tooth is removed on the same date of service.
- Any dental services for which benefits are payable under a medical policy issued by us. Not applicable in CA.
- Major services for the Dental PrimarySM plan. This includes all procedures or services related to endodontics, periodontics, major restorative services (crowns, inlays, onlays, and veneers), dental implants, prosthetics (bridges and dentures, fixed or removable), and oral surgery.
- Charges for dental services that are not documented in the dentist records, not directly associated with dental disease, or not performed in a dental setting.
- Hospital or other facility charges and related anesthesia charges, analgesia, or conscious sedation.
- Oral hygiene instructions; plaque control; charges completing dental claim forms; photographs; any dental supplies, including but not limited to, take-home fluoride; prescription and non-prescription drugs, with or without a prescription, unless they are dispensed and utilized in the dental office during your or your covered dependents’ dental visit, except we will pay for injection of antibiotic drugs at the time of initial treatment; sterilization fees; diagnostic casts; treatment of halitosis and any related procedures; lab procedures.
- Removal of sound functional restorations (not applicable in CA); temporary crowns and temporary prosthetics; provisional crowns and provisional prosthesis.
- Acupuncture, acupressure, and other forms of alternative treatment.
- Telephone consultations or for failure to keep a scheduled appointment.
- Bone grafts, guided tissue regeneration, biologic materials to aid in soft and osseous tissue regeneration when performed in edentulous (toothless areas, ridge augmentation or preservations).
- Any dental services which result from intoxication, as defined by applicable state law in the state where the loss occurred, or under the influence of illegal narcotics or controlled substance, unless administered or prescribed by a doctor. Not applicable in CA, MD, MI, NV, OR, SD, or WA.
- In CT, for any dental service incurred by voluntary use of any controlled substance as defined in Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, as now hereafter amended, unless administered or prescribed by a doctor.
- Any dental services in relation to, or incurred in conjunction with, investigational treatment.
- Any dental service which results from or in the course of your employment for wage or profit. Applicable in FL and SD, if services are paid by workers’ compensation.
- In CT, as the result of an injury or illness arising out of, or in the course of, employment for wage or profit, if the covered person is insured, or is required to be insured, by workers’ compensation insurance pursuant to applicable state or federal law. If you enter into a settlement that waives a covered person’s right to recover future medical benefits under a workers’ compensation law or insurance plan, this exclusion will still apply. This exclusion does not apply to a corporate officer of a corporation whether or not the officer is covered by workers’ compensation.
- Any dental service which results from war, participation in a riot, intentionally self-inflicted bodily harm (whether sane or insane — insane is not applicable for MO and MT), or participation in a felony — whether or not charged. (In IA, only if charged, in NV, only if convicted. In OR, whether or not charged does not apply.) In MD, the exclusions for participation in a riot or felony do not apply.
- Any dental service which would be free of charge without insurance, unless provided by Medicaid, the Veterans Administration, or the Maryland Department of Health and Mental Hygiene for non-service related dental services and which by law we are required to pay.
- Any dental service provided by a family member or by someone who ordinarily resides with you or your covered dependent. Not applicable in TX; In NE and NJ, must be immediate family member.
- Any dental service received outside of the United States, except for a dental emergency.
- Jaw or joint problems or malposition of jaw bones, except as provided for under the policy (does not apply in MN).
- Any dental service relating to teeth that can be restored by other means; for purposes of periodontal splinting; to correct abrasion, erosion, attrition, bruxism, abfraction, or for desensitization; or teeth that are not periodontally sound or have a questionable prognosis.
- Orthodontia, braces, cosmetic dentistry, or dental implants.
- Oral surgery, except as expressly provided for in the policy.
- Orthognathic surgery, changing vertical dimension, restoring occlusion, bite analysis, or congenital malformation.
- Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.
- Treatment of malignant or benign neoplasms, cysts, or other pathology, except excisional removal.
- Mouthguards, precision or semi-precision attachments, occlusal guard, replacement of orthodontic retainers, treatment splints, bruxism appliance, duplicate dentures, harmful habit appliances, replacement of lost or stolen appliances, sleep disorder appliance, and gold foil restorations (except as provided for in the policy).
I. Grievance Procedures
If you wish to dispute the decision on a claim, you may register a complaint by writing to us at the address listed on the back of your Explanation of Benefits.