DENTAL BENEFITS

The Superior Officers Council currently sponsors three dental plans for our active members. The Healthplex Indemnity/PPO Plan and the Healthplex Comprehensive Plan-Dentcare Delivery Systems are open for enrollment.
The Healthplex/Dentcare Buy-Up Dental Plan is an enhanced cost share plan that is only open for enrollment periodically. Open enrollment periods will be announced on our website and through member mailings.

The Healthplex Indemnity/PPO (Preferred Provider Organization) Plan gives our members the flexibility to visit any dentist of their choice in or out of the Healthplex network.

To receive the advantages of In-Network benefits, visit the Healthplex web site at www.healthplex.com to review the Directory of Preferred Providers who participate in the dental plan. The network of participating dentists will treat eligible active members and their eligible dependents with minimal or no out-of-pocket expense for covered services. When services are rendered from participating dentists in the Healthplex PPO Plan, you will only be responsible for the copayment, if any.

Eligible active members and their eligible dependents may receive services from dentists who do not participate in the Healthplex PPO Plan. You are free to receive dental care from any licensed dentist not participating in Healthplex. When services are received from an out-of-network dentist, Healthplex will pay for all covered services according to the Out-of-Network Schedule of Allowances. For the most current Out-of-Network Schedule of Allowances, you can visit the SOC web site. You will be responsible to your dentist for all charges not covered or not paid in full by the plan.

Enrolling
If you wish to enroll in the Healthplex PPO/Indemnity Plan and are:
   • Currently enrolled in the Healthplex Comprehensive (Dentcare Delivery Systems), you must disenroll by submitting the Dentcare Delivery request to Disenroll Form.
Upon completion and submission of the appropriate form, you will automatically be enrolled in the Healthplex PPO/Indemnity Plan (SOC Default Plan).
Dis-enrolling
If you wish to dis-enroll from the Healthplex PPO/Indemnity Plan, you must complete and submit a Healthplex Subscriber Change Form and follow the enrollment instructions for the plan of your choice.

NOTE: Change forms must be completed and returned by the 12th of the month for your new policy to be effective on the first day of the following month. If a member changes dental plans, he/she is required to do so for a minimum of one year.

Your Dental Benefits Program is divided into four segments. You are responsible for any patient co-payments for services rendered by an In-of-Network provider. Out-of-Network Benefits for covered services are provided according to a schedule of allowances. There are no deductibles associated with your dental plan; however there is a $2,000 per family annual (January-December) maximum.

Part I (Basic Dental Benefits): This section of the Dental Benefits Program includes a complete range of basic dental services (examinations, cleanings, fillings, extractions, periodontal, etc.).
Part II (Prosthetics): Most prosthetic services are covered under the plan. Included
under the prosthetic benefits portion of our program is the replacement of full or partial dentures, inlays, crowns or bridges. Replacement of prosthetics is limited to once every five years.
Part III (Orthodontics): Orthodontic services are available for eligible dependent
children only; up to age 22. Coverage is provided for a 24-month case only.
Part IV (Dental Implants): This plan includes implants at 100% patient co-pay. Services include covered ADA codes (6010-6097). This benefit only applies to services received from In-Network Capital PPO providers. There is no Out-of-Network benefit.

Pre-determination of benefits is required for: space maintainers, inlays and restorative crowns as well as endodontic, periodontic, prosthetic and orthodontic services. This system has been instituted to notify you and your dentist of the services covered under the program and the amount the plan will pay.
The pre-determination procedure requires that your dentist fill out a standard claim form as a “Treatment Plan” before treatment is begun. Be sure the dentist includes the patient’s x-rays. This will reduce the processing time. The “Treatment Plan” and x-rays should be sent directly to Healthplex:

Healthplex, Inc.

PO Box 211672

Eagan, MN 11533

Healthplex will process the Treatment Plan and the dentist will receive a pre-determination form that will show those services that are covered by our Program. Services not covered will be indicated on the form. When treatment is completed, the dentist must insert the dates the authorization services were performed and return the pre-determination form for payment.
All claim forms received are screened for completeness, numbered, checked for eligibility, reviewed for coverage and approved or rejected. Both you and, in most instances, your dentist are advised of the approval or rejection of benefits.

Our Dental Benefits Program does not provide benefits for:

  • Dental services received from a dental or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trustee, or similar person or group
  • Dental service for which the subscriber incurs no charge
  • Dental services for which coverage is available to the subscriber, in whole or in part, under any Workers’ Compensation Law or similar legislation whether or not the subscriber claims compensation or receives benefits thereunder and whether or not any recovery is had by the subscriber against a third party for damages resulting from a condition, disease, ailment or accidental injury necessitating dental services
  • Dental service with respect to congenital malformations or primarily for cosmetic or aesthetic purposes
  • Dental services furnished or available to a subscriber in whole or part under the laws of the United States (except Medicaid), or any state or political subdivision thereof, or for which the subscriber would have no legal obligation to pay in the absence of this or any similar coverage
  • Dental services to the extent coverage is available to the subscriber under any contract of a Participating Plan
  • Dental service to the extent that charges for such services exceed the charge that would have been made and actually collected if no coverage existed hereunder
  • Gold foil restorations
  • Dental service not considered within the scope of normal good dental practice that is inconsistent with the highest ethical standards of the dental profession
  • Fissure sealants
  • Bacteriological examinations
  • Dental service other than those specifically listed as Covered Dental Services
  • Loss or theft of dentures or appliances
  • Replacement and/or repair of any appliances furnished under the Orthodontic Treatment Plan
  • Prosthetic services where teeth are restorable by means other than crowns
  • Services involving periodontal, provisional, or temporary splints
  • Temporary crowns, occlusal adjustments, appliances or restorations used solely to increase vertical dimensions

No benefit will be paid under this Contract for any loss, or portion thereof, for which mandatory automobile no-fault benefits are recoverable or recovered.
Payments of benefits for replacement of full or partial dentures, inlays, crowns, and bridges shall be limited to once every five years.

Missing Tooth
For a tooth or teeth to be eligible for replacement, the teeth must either have been extracted or have been replaced by a fixed or removable appliance during the time you were eligible for benefits under your group coverage.
Alternate Benefits
When there is a choice between two professionally acceptable procedures, both of which will achieve the same results, for the replacement of missing teeth or the restoration of teeth, benefits will be provided for the less expensive procedure.

Whenever you visit any dentist listed in the Healthplex PPO Directory, present your Healthplex Identification Card. Your provider will submit a completed Healthplex Claim Form directly to Healthplex, Inc. For services rendered by a participating provider, the member will be responsible for the applicable copayment, if any. Healthplex will pay the participation provider based on the contracted rate for covered services.
When using an out-of-network provider, the provider will submit a claim for service rendered. Covered services will be reimbursed directly to the member based on the reimbursement schedule.

If you disagree with the disposition of a claim, you may request a review. You, or your duly authorized representative, may make the request in writing within 60 days and forward to:

Healthplex, Inc.

PO Box 211672

Eagan MN 11533

 

Be sure to include your identification number and the claim number as well as any pertinent information or comments you wish to make. The claim will be reconsidered taking into account any additional materials you have provided. Upon completion of this review, you will receive written notification of the decision, explaining the basis for upholding or modifying the original disposition of the claim.

The Healthplex Comprehensive Plan (Dentcare Delivery Systems) is a preventive dental program. Covered services can only be rendered by participating dentists. Members must select one participating dentist (per family) to provide general dental services. These primary dentists will provide all covered services according to the Schedule of Benefits/Copayments. Many preventive services are provided at no cost. Other services may require patients to make copayments directly to the dentist. For a copy of the Schedule of Benefits/Copayments, visit www.nypdsoc.com.

    • General covered services can only be rendered by the member’s assigned dentist.
    • Each member selects one participating dentist (per family) to provide general dentist services.
    • Patients must receive referrals from their assigned dentist in order to have services covered for special procedures.
    • Your Dentcare Identification Card will show your assigned participating dental provider.
    • Provider changes can be made by completing and submitting a Dentcare Change Form.

When endodontic, periodontal, surgical or orthodontic treatment is needed by a specialist, the participating primary dentist will refer the case to participating specialists. In the event that participating specialists are not available within 50 miles of your participating primary dentist, you may be entitled to receive a benefit equal to the amount that we would pay a participating specialist.
Members have no benefits when a non-participating general dentist provides treatment or when specialty services are provided without a referral from Dentcare or the participating primary dentist.

There are no deductibles associated with your dental plan; however, there is a $2,000 per family annual (January-December) maximum.

Part I (Basic Dental Benefits): This section of the Dental Benefits Program includes a complete range of basic dental services (such as: examinations, cleanings, fillings, extractions, etc.) plus periodontal services. You are responsible for patient co-payments, if any, when ser-vices are rendered by your assigned provider.
Part II (Prosthetics): You are responsible for patient co-payments, if any, when services are rendered by your assigned provider.
Part III (Orthodontics): See Schedule of Allowances for benefits provided by In-Network and Out-of-Network providers by visiting Healthplex at www.healthplex.com or the SOC web site.

Pre-determination of benefits is required for: space maintainers, inlays and restorative crowns as well as endodontic, periodontic, prosthetic and orthodontic services. This system has been instituted to notify you and your dentist of the services covered under the program and the amount the plan will pay.
The pre-determination procedure requires that your dentist fill out a standard claim form as a “Treatment Plan” before treatment is begun.
Be sure the dentist includes the patient’s x-rays. This will reduce the processing time. The “Treatment Plan” and x-rays should be sent directly to Healthplex, Inc. at:

Healthplex, Inc.

PO Box 211672

Eagan, MN 11533

Healthplex will process the Treatment Plan and the dentist will receive a predetermination form that will show those services that are covered by our Program. Services not covered will be indicated on the form. When treatment is completed, the dentist must insert the dates the authorization services were performed and return the pre-determination form for payment.
All claim forms received are screened for completeness, numbered, checked for eligibility, reviewed for coverage and approved or rejected. Both you, and in most instances your dentist, are advised of the approval or rejection of benefits.

Our Dental Benefits Program does not provide benefits for:

    • Dental services received from a dental or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trustee, or similar person or group
    • Dental service for which the subscriber incurs no charge
    • Dental services for which coverage is available to the subscriber, in whole or in part, under any Workers’ Compensation Law or similar legislation whether or not the subscriber claims compensation or receives benefits thereunder and whether or not any recovery is had by the subscriber against a third party for damages resulting from a condition, disease, ailment or accidental injury necessitating dental services
    • Dental service with respect to congenital malformations or primarily for cosmetic or aesthetic purposes
    • Dental services furnished or available to a subscriber in whole or part under the laws of the United States (except Medicaid), or any state or political subdivision thereof, or for which the subscriber would have no legal obligation to pay in the absence of this or any similar coverage
    • Dental services to the extent coverage is available to the sub-scriber under any contract of a Participating Plan
    • Dental service to the extent that charges for such services exceed the charge that would have been made and actually collected if no coverage existed hereunder; gold foil restorations
    • Dental service not considered within the scope of normal good dental practice that is inconsistent with the highest ethical standards of the dental profession
    • Fissure sealants
    • Bacteriological examinations
    • Dental service other than those specifically listed as Covered Dental Services
    • Loss or theft of dentures or appliances
    • Replacement and/or repair of any appliances furnished under the Orthodontic Treatment Plan
    • Prosthetic services where teeth are restored by means other than crowns
    • Services involving periodontal
    • Provisional or temporary splints
    • Temporary crowns, occlusal adjustments, appliances or restorations used solely to increase vertical dimensions

 No benefit will be paid under this Contract for any loss, or portion thereof, for which mandatory automobile no-fault benefits are recoverable or recovered.
Payments of benefits for replacement of full or partial dentures, inlays, crowns, and bridges shall be limited to once every five years.

Missing Tooth
In order for a tooth or teeth to be eligible for replacement, the teeth must either have been extracted or have been replaced by a fixed or removable appliance during the time you were eligible for benefits under your group coverage.
Alternate Benefits
When there is a choice between two professionally acceptable procedures, both of which will achieve the same results, for the replacement of missing teeth or the restoration of teeth, benefits will be provided for the less expensive procedure.

The member can choose a conveniently located private dental office from a listing of participating providers. For a listing of participating providers, contact Healthplex Customer Service at (800) 468-0600, or visit www.healthplex.com.

If a member wishes to change dental offices, the member must complete a Healthplex Subscriber Change Form and submit it to the SOC Fund Office.

Enrolling
If you wish to enroll in the Healthplex Comprehensive Plan (Dentcare Delivery Systems)
and are:
   • Currently enrolled in the Healthplex Indemnity/PPO Plan, you must complete and submit the Healthplex Subscriber Change Form.
Disenrolling
If you wish to disenroll from the Healthplex Comprehensive Plan (Dentcare Delivery Systems), complete and submit a Healthplex Subscriber Change Form and follow the enrollment instructions for the plan of your choice.
NOTE: Change forms must be completed and returned by the 12th of the month for your new policy to be effective the first day of the following month. if a member changes dental plans, he/she is required to do so for a minimum of one year

Your provider will submit a completed Healthplex Claim Form directly to Healthplex, Inc. at:

Healthplex, Inc.

PO Box 211672

Eagan, MN 11533

For services rendered by a participating provider, the member will be responsible for the applicable co-payment, if any. Healthplex will pay the participating provider based on the contracted rate for covered services. Whenever you visit your assigned dentist or are referred to a participating dentist, present your Healthplex Identification Card.
For questions, claim forms, to view a listing of participating Managed Care Providers in your area, or to request additional ID cards, call Healthplex Customer Service at (800) 468-0600 or visit www.healthplex.com.

The pre-determination procedure requires that your dentist fill out a standard claim form as a “Treatment Plan” before treatment is begun.
Be sure the dentist includes the patient’s x-rays. This will reduce the processing time. The “Treatment Plan” and x-rays should be sent directly to Healthplex, Inc. at:

Healthplex, Inc.

PO Box 211672

Eagan, MN 11533

Healthplex will process the Treatment Plan and the dentist will receive a predetermination form that will show those services that are covered by our Program. Services not covered will be indicated on the form. When treatment is completed, the dentist must insert the dates the authorization services were performed and return the pre-determination form for payment.
All claim forms received are screened for completeness, numbered, checked for eligibility, reviewed for coverage and approved or rejected. Both you, and in most instances your dentist, are advised of the approval or rejection of benefits.

If you disagree with the disposition of a claim, you may request a review. You, or your duly authorized representative, may make the request in writing within 60 days and forward to:

Healthplex, Inc.

PO Box 211672

Eagan, MN 11533

Be sure to include your identification number and the claim number as well as any pertinent information or comments you wish to make. The claim will be reconsidered taking into account any additional materials you have provided. Upon completion of this review, you will receive written notification of the decision, explaining the basis for upholding or modifying the original disposition of the claim.

MEMBERS WILL HAVE THE OPTION TO ENROLL DURING OPEN ENROLLMENT PERIODS. OPEN ENROLMENT PERIODS ARE ANNOUNCED PERIODICALLY

The Healthplex/Dentcare Buy-Up Dental Plan is a member cost share plan. This enhanced dental plan has low monthly premiums paid through an authorized payroll deduction. Some of the highlights of the plan include:

  • No co-payments for covered procedures when utilizing one of Healthplex's National Panel Network Providers.
  • Allows you to visit any dentist in the expanded Healthplex National PPO Network.
  • Utilizes the Healthplex National Network with over 500,000 access points.
  • An annual maximum of $3000 per individual (January to December).
  • Low co-pays for a standard In-Network 24-month Orthodontic case (restrictions apply).

Additional Benefits:
Cosmetic Services:
This plan includes implants at 100% patient co-pay. Services include covered ADA codes (6010-6097). This benefit only applies to services received from In-Network Capital PPO providers. There is no Out-of-Network benefit.
Implant Services:
This plan includes a reduced rate for covered implant services. Patient is responsible for 100% of these reduced rates. Services include covered ADA Codes (610-6097).This benefit only applies to services received from In-Network Capital PPO providers. There is no Out-of-Network benefit.