2022 GROUP DENTAL PLANS - Blue Cross of Idaho
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2022 GROUP DENTAL PLANS Form No. 15-022 (07-21)
The Value of Blue Cross of Idaho Dental Plans
Health and Wellness
Good oral health improves overall health and reduces risk of chronic conditions.Our dental plans have been
structured to optimize healthy outcomes by increasing access to care, reducing cost for services that treat
disease, and align covered services to support overall health and utilization of medically necessary services.
Access to Dental Care
Our robust network increases access to dental care. Members have access to more than 1,600 in-network
Idaho providers. We have added two additional partnerships to the national Dental GRID, expanding our
network to 131,000 providers in 2022.
Administrative Ease
Our dental and other ancillary products enhance our medical benefit options. With one card and consolidated
billing, we are your one-stop-shop for all your health benefit needs.
GROUP DENTAL PLAN TYPES
• PPO and Traditional (TRAD) Plans – Five plan options
• Managed Care Plans – Four plan options
• Affordable Care Act (ACA)-Qualified Plans – Two plan options
OPTIMAL DENTAL PLAN: PREFERRED DENTAL:
This plan offers the highest benefit maximum at the Preferred Dental delivers lower premiums and
lowest premium. Optimal Dental is the highest value out-of-pocket expenses. Covered members save
for you and your employees. when they see a provider in our large PPO network.
OPTIMAL DENTAL PREFERRED DENTAL
Group Dental Plans
In-Network Out-of-Network In-Network Out-of-Network
Deductible $50 $25 or $50
(Per person, three family member maximum)
Benefit Period Maximum $2,000 $1,000, $1,250 or $1,500
(Per person)
Dental Provider Network PPO PPO
Preventive Dental Services Member pays 20% of
100% after
(Includes oral exams, X-rays and 20% after deductible Member pays nothing. allowed amount
$20 copay
cleaning and fluoride treatments) after deductible.
Member pays 20% Member pays 30% of
Basic Dental Services 20% after deductible 50% after deductible of allowed amount after allowed amount
(Includes fillings, extractions deductible. after deductible.
and oral surgery)
Optional 6-month waiting period. Optional 6-month waiting period.
Member pays 50% of Member pays 60% of
50% after deductible 60% after deductible allowed amount allowed amount
Major Dental Services after deductible. after deductible.
(Crowns, bridges and dentures, inlays/onlays,
repairs to bridges and dentures,
crown repair and dental implants)
Optional 12-month waiting period. Optional 12-month waiting period.
Orthodontia Member pays 50% of allowed amount. Member pays 50% of allowed amount.
(For groups with 20 or more enrolled contracts) (Lifetime maximum of $1,000, $1,250 or $1,500.) (Lifetime maximum of $1,000, $1,250 or $1,500.)
Please Note: These plans do not meet the ACA coverage requirement for those under age 19.
This brochure describes the general features of our dental plans. It is not a contract. All the provisions of the Policy issued to the group apply.
The benefits of the Policy are governed primarily by the laws of the State of Idaho.
2Blue Cross of Idaho | Dental Plans for Groups
EXPANDED PREFERRED DENTAL:
Expanded Preferred Dental provides flexibility for groups with employees who live outside of Idaho, by
expanding the same in-network benefits as the Preferred Dental plan, to out of network benefits as well.
HEALTHY REWARDS DENTAL:
When members visit a dentist every year, plan payments increase 10 percent each year up to 100 percent
for preventive and basic dental services, both in and out of network. Benefit payments start at 70 percent. It
decreases by 10 percent each year, to a minimum of 70 percent, if a member does not visit a dentist.
VOLUNTARY DENTAL:
Voluntary Dental lets your employees decide whether or not they want dental coverage. Available to
group with three or more employees, and at least one employee must elect coverage. Employer contribution
is optional.
EXPANDED HEALTHY VOLUNTARY DENTAL
Group Dental Plans PREFERRED REWARDS
DENTAL DENTAL1 In-Network Out-of-Network
Deductible $25 or $50 No Deductible $25 or $50 $50 or $75
(Per person, three family member maximum)
Benefit Period Maximum $1,000, $1,250 or $1,500 $1,000, $1,250 or $1,500
(Per person)
Dental Provider Network Traditional Traditional or PPO PPO
Member pays 30%
of allowed amount
Preventive Dental Services Member pays Member pays 30%
for 1st year;
(Includes oral exams, X-rays and Member pays nothing. nothing after $20 of allowed amount after
20% for 2nd year;
cleaning and fluoride treatments) copayment per visit. deductible.
10% for 3rd year;
nothing in 4th year.
Member pays 30%
Member pays 20% of of allowed amount
allowed amount after for 1st year; Member pays 20% Member pays 50%
deductible. 20% for 2nd year; of allowed amount after of allowed amount after
Basic Dental Services 10% for 3rd year; deductible. deductible.
(Includes fillings, extractions and oral surgery)
nothing in 4th year.
Optional 6-month waiting Optional 6-month waiting 6-month waiting period.
period. period.
Member pays 50% of Member pays 50% of Member pays 60% of
Major Dental Services Member pays 50%
allowed amount after allowed amount after allowed amount after
(Crowns, bridges and dentures, inlays/onlays, of allowed amount.
deductible. deductible. deductible.
repairs to bridges and dentures,
crown repair and dental implants)
Optional 12-month waiting period. 12-month waiting period.
Member pays 50% of allowed amount. (Lifetime Maximum
Orthodontia Member pays 50% of allowed amount. of $1,000, $1,250 or $1,500.)
(For groups with 20 or more enrolled contracts) (Lifetime Maximum of $1,000, $1,250 or $1,500.)
24-month waiting period.
Footnotes: 1Healthy Rewards Dental: Member must have at least one covered dental service per benefit period for incentive level to increase.
Please Note: These plans do not meet the ACA coverage requirement for those under age 19.
This brochure describes the general features of our dental plans. It is not a contract. All the provisions of the Policy issued to the group apply.
The benefits of the Policy are governed primarily by the laws of the State of Idaho.
bcidaho.com
3DENTAL BLUE CONNECT
Willamette Dental Group, the Northwest’s largest multi-specialty group dental practice, is the exclusive
provider network for our managed care plan, Dental Blue Connect. Our partnership and plan offers extensive
in-network dental coverage with:
• No deductibles Each Willamette Dental Group dentist works with
• No annual maximum patients to promote long-term dental health. With
more than 50 locations throughout the Pacific
• No waiting periods Northwest, there’s likely a Willamette Dental Group
• No claim forms office in your neighborhood.
Dental Blue Connect offers your employees managed This plan provides limited benefits for services by
care with predictable, low, out-of-pocket costs for non-Willamette dental providers.
covered dental services, low copayments and low Dental Blue Connect may be offered as Voluntary,
monthly premiums. Orthodontic coverage is included standalone, or as a dual option, with our Blue Cross
for children and adults. of Idaho PPO or Traditional plans.
Groups 2-99
Groups 100+
Highland Hills Valley Pathfinder All Groups
In-Network In-Network In-Network In-Network Out-of-Network
Annual Maximum No annual maximum N/A
Deductible No deductible N/A
Waiting Period No waiting period N/A
Office Visit Member pays Member pays Member pays
Customized
We reimburse your
Copayment $15 copayment $20 copayment $25 copayment employee $10 per visit.
Diagnostic and
Preventive Services We reimburse
Covered with office Covered with office Covered with office Covered with office
(i.e., routine/emergency exams, your employee
visit copayment visit copayment visit copayment visit copayment
X-rays, cleanings, fluoride, $10 per visit.
periodontal charting)
Restorative We reimburse
Dentistry Copayment varies Copayment varies Copayment varies Copayment varies your employee
(Crowns and fillings) $10 per visit.
We reimburse
Prosthodontics Copayment varies Copayment varies Copayment varies Customized your employee
(Dentures and bridges)
$10 per visit.
Endodontics and We reimburse
Copayment varies Copayment varies Copayment varies Customized your employee
Periodontics $10 per visit.
We reimburse
Oral Surgery Covered with office Covered with office Covered with office
Customized your employee
(Routine extraction) visit copayment visit copayment visit copayment
$10 per visit.
Comprehensive We reimburse
Member pays $2,000 Member pays $2,200 Member pays $2,500
Orthodontia copayment copayment copayment
Customized your employee
Treatment $10 per visit.
Local Anesthesia, We reimburse
Covered with office Covered with office Covered with office Covered with office
your employee
Dental Lab Fees visit copayment visit copayment visit copayment visit copayment
$10 per visit.
We reimburse
Member pays Member pays Member pays
Nitrous Oxide $40 copayment $40 copayment $40 copayment
Customized your employee
$10 per visit.
Please Note: These plans do not meet the ACA coverage requirement for those under age 19.
Out-of-Network: If your employee visits an out-of-network dentist, we reimburse them $10 per visit.
This brochure describes the general features of our dental plans. It is not a contract. All the provisions of the Policy issued to the group apply.
The benefits of the Policy are governed primarily by the laws of the State of Idaho.
4Blue Cross of Idaho | Dental Plans for Groups
ACA-QUALIFIED PLANS FOR SMALL GROUPS (2-50 EMPLOYEES)
Our group ACA-qualified dental plans, Dental Choice and Dental Choice Plus, offer coverage for the whole
family. Services for children under the age of 19 are not subject to waiting periods and are available day one.
UNDER AGE 19
Small Group Dental DENTAL CHOICE DENTAL CHOICE PLUS
Plans
(2-50 EMPLOYEES) In-Network Out-of-Network In-Network Out-of-Network
$50 per member, $100 per member, $25 per member, $100 per member,
Individual Deductible per benefit period per benefit period per benefit period per benefit period
Annual Out-of-Pocket $350 Individual/
$10,000/Individual
$350 Individual/
$10,000/Individual
Maximum $700 Two or more $700 Two or more
Benefit Period None None None None
Maximum
Preventive Dental
Services Member pays 50% of allowed Member pays 50% of allowed
Member pays $30 Member pays $20
(No waiting period. Includes exams, amount after deductible. amount after deductible.
X-rays, cleaning and fluoride.)
Basic Dental Member pays 50% of Member pays 20% of
Services Member pays 50% of allowed Member pays 50% of allowed
allowed amount allowed amount
(Includes fillings, extractions, amount after deductible. amount after deductible.
after deductible after deductible
and oral surgery)
Major Dental Services
(Crowns, bridges and dentures, Member pays 50% of Member pays 50% of
Member pays 50% of allowed Member pays 50% of allowed
inlays/onlays, repairs to bridges and allowed amount allowed amount
amount after deductible. amount after deductible.
dentures, crown repair and dental after deductible after deductible
implants)
Member pays 50% of Member pays 50% of
Member pays 80% of allowed Member pays 80% of allowed
allowed amount after allowed amount after
amount after deductible. amount after deductible.
deductible deductible
Orthodontia
Orthodontia (for non-cosmetic orthodontia in accordance with Orthodontia (for non-cosmetic orthodontia in accordance with
Blue Cross of Idaho’s medical policies; medically-necessary, Blue Cross of Idaho’s medical policies; medically-necessary,
non-cosmetic treatment; prior authorization required). non-cosmetic treatment; prior authorization required).
AGE 19 AND OLDER
Small Group Dental DENTAL CHOICE DENTAL CHOICE PLUS
Plans
(2-50 EMPLOYEES) In-Network Out-of-Network In-Network Out-of-Network
Individual $75 per member, $100 per member, $60 per member, $100 per member,
Deductible per benefit period per benefit period per benefit period per benefit period
Annual Out-of-Pocket None None None None
Maximum
Benefit Period $1,000 $1,000
Maximum
Preventive Dental
Services Member pays 50% of allowed Member pays 50% of allowed
Member pays $35 Member pays $25
(No waiting period. Includes exams, amount after deductible. amount after deductible.
X-rays, cleaning and fluoride.)
Basic Dental Member pays 50% of allowed Member pays 50% of allowed Member pays 20% of allowed Member pays 50% of allowed
Services amount after deductible. amount after deductible. amount after deductible. amount after deductible.
(Includes fillings, extractions
and oral surgery) 6-month waiting period for members age 19 and older. 6-month waiting period for members age 19 and older.
Major Dental Services Member pays 50% of allowed Member pays 50% of allowed Member pays 50% of allowed Member pays 50% of allowed
(Crowns, bridges and dentures, amount after deductible. amount after deductible. amount after deductible. amount after deductible.
inlays/onlays, repairs to bridges and
dentures, crown repair and dental
implants) 12-month waiting period for members age 19 and older. 12-month waiting period for members age 19 and older.
Orthodontia No Benefit No Benefit No Benefit No Benefit
This brochure describes the general features of our dental plans. It is not a contract. All the provisions of the Policy issued to the group apply.
The benefits of the Policy are governed primarily by the laws of the State of Idaho.
bcidaho.com
5EXCLUSIONS & LIMITATIONS
In addition to the exclusions and limitations listed elsewhere in this Policy, the following exclusions and limitations apply to the entire Policy, unless otherwise specified.
I. GENERAL EXCLUSIONS AND LIMITATIONS O. Temporary dental services. Charges for motorist provision, or other first party or no fault
temporary services are considered an integral part provision of any automobile, homeowner’s or other
There are no benefits for services, supplies, drugs
of the final dental services and are not separately similar policy of insurance, contract or underwriting
or other charges that are:
payable. Provisional services will be considered plan;
A. Procedures that are not included in the permanent and will have standard replacement In the event Blue Cross of Idaho for any reason
Closed List of Dental Covered Services; or that are frequencies applied. makes payment for or otherwise provides benefits
not Medically Necessary for the care of an Insured’s
P. Any service, procedure or supply for which excluded by this provision, it shall succeed to
covered dental condition; or that do not have
the prognosis for success is not reasonably the rights of payment or reimbursement of the
uniform professional endorsement.
favorable as determined by BCI at least three (3) compensated Provider, the Insured, and the
B. Charges for services that were started prior years. Insured’s heirs and personal representative against
to the Insured’s Effective Date. The following all insurers, underwriters, self insurers or other
Q. Myofunctional therapy and biofeedback
guidelines will be used to determine the date when such obligors contractually liable or obliged to
procedures.
a service is deemed to have been started: the Insured or his or her estate for such services,
R. For hospital Inpatient or Outpatient care for supplies, drugs or other charges so provided by
1. For full dentures or partial dentures: on the
extraction of teeth or other dental procedures. Blue Cross of Idaho in connection with such Illness,
date the final impression is taken.
S. Diagnostic casts. Disease, Accidental Injury or other condition.
2. For fixed bridges, crowns, inlays or onlays: on
the date the teeth are first prepared and a T. Occlusal adjustments. AG. For which an Insured would have no legal
final impression taken. obligation to pay in the absence of coverage under
U. Not prescribed by or upon the direction of a this Policy or any similar coverage; or for which
3. For root canal therapy: on the date the pulp Provider. no charge or a different charge is usually made
chamber is opened and the canals are V. Investigational in nature. in the absence of insurance coverage; or charges
explored to the apex. in connection with work for compensation or
W. Provided for any condition, Disease, Illness charges; or for which reimbursement or payment
4. For periodontal Surgery: on the date the or Accidental Injury to the extent that the Insured is
Surgery is actually performed. is contemplated under an agreement with a third
entitled to benefits under occupational coverage, party.
5. For all other services: on the date the service obtained or provided by or through the employer
is performed. under state or federal Workers’ Compensation AH. Provided to persons who were enrolled as
Acts or under Employer Liability Acts or other laws Eligible Dependents after they cease to qualify as
6. For orthodontic services, if benefits are Eligible Dependents due to a change in Eligibility
providing compensation for work related injuries or
available under this Policy: on the date any status which occurs during the Policy term.
conditions. This exclusion applies whether or not
bands or other appliances are first inserted.
the Insured claims such benefits or compensation AI. Provided outside the United States, which if
C. Cast restorations (crowns, inlays or onlays) or recovers losses from a third party. had been provided in the United States, would not
for teeth that are restorable by other means (i.e., by be Covered Services under this Policy.
X. Provided or paid for by any federal
amalgamor composite fillings).
governmental entity or unit except when payment AJ. Not directly related to the care and treatment
D. Replacement of an existing crown, inlay or under this Policy is expressly required by federal of an actual condition, Illness, Disease or Accidental
onlay that was installed within the preceding seven law, or provided or paid for by any state or local Injury.
(7) years or replacement of an existing crown, inlay governmental entity or unit where its charges
or onlay that can be repaired. therefor would vary, or are or would be affected by AK. For acupuncture or hypnosis.
E. Appliances, restorations or other services the existence of coverage under this Policy. AL. Repair, removal, cleansing or reinsertion of
provided or performed solely to change, maintain Y. Provided for any condition, Accidental Injury, Implants, unless otherwise specifically listed in the
or restore vertical dimension or occlusion. Disease or Illness suffered as a result of any act of Closed List of Dental Covered Services.
F. A service for cosmetic purposes. war or any war, declared or undeclared. AM. Precision or semi-precision attachments.
G. In excess of the Maximum Allowance. Z. Furnished by a Provider who is related to the AN. Denture duplication.
Insured by blood or marriage and who ordinarily
H. A replacement of a partial or full removable AO. Oral hygiene instruction.
dwells in the Insured’s household.
denture for fixed bridgework, or the addition AP. Treatment of jaw fractures.
of teeth thereto, if involving a replacement or AA. Received from a dental or medical
modification of a denture or bridgework that was department maintained by or on behalf of an AQ. Charges for acid etching.
installed during the preceding seven (7) years. employer, a mutual benefit association, labor union, AR. Charges for oral cancer screening which are
trust or similar person or group. included in a regular oral examination.
I. Orthodontic services and supplies unless
otherwise specifically listed in the Closed List of AB. For personal hygiene, comfort, beautification AS. No benefits are available for replacement
Dental Covered Services. or convenience items even if prescribed by and/or repair of orthodontic appliances. This
a Dentist, including but not limited to, air includes removable and/or fixed retainers.
J. Replacement of lost or stolen appliances. conditioners, air purifiers, humidifiers, physical
K. Ridge augmentation procedures unless fitness equipment or programs. AT. Support service(s) provided for a non-
otherwise specifically listed in the Closed List of Covered Service.
AC. For telephone consultations; for failure
Dental Covered Services. to keep a scheduled visit or appointment; for II. CONDITIONS
L. Any procedure, service or supply other than completion of a claim form; for interpretation A. Right to Review Dental Work
alveoloplasty or alveolectomy required to prepare services; or for personal mileage, transportation, Before providing benefits for Covered Services,
the alveolus, maxilla or mandible for a prosthetic food or lodging expenses or for mileage, Blue Cross of Idaho has the right to refer the
appliance. Excluded services include, but are transportation, food or lodging expenses billed by Insured to a Dentist of its choice and at its expense
not limited to, vestibuloplasty, stomatoplasty and a Dentist or other Provider. to verify the need, quantity and quality of dental
bone grafts (either synthetic or autogenous) to the AD. For Congenital Anomalies, or for work claimed as a benefit under this section.
alveolars, maxilla or mandible, unless otherwise developmental malformations, unless the patient is B. Care Rendered by More Than One Dentist
specifically listed in the Closed List of Dental an Eligible Dependent child. If an Insured transfers from the care of one Dentist
Covered Services.
AE. For the treatment of injuries sustained while to another Dentist during a Dental Treatment Plan,
M. Any procedure, service or supply required committing a felony, voluntarily taking part in a riot, or if more than one Dentist renders services for one
directly or indirectly to treat or diagnose a or while engaging in an illegal act or occupation, dental procedure, Blue Cross of Idaho will pay no
muscular, neural, orthopedic or skeletal disorder, unless such injuries are a result of a medical more than the amount that it would have paid had
dysfunction or Disease of the temporomandibular condition or domestic violence. but one Dentist rendered the service.
joint (jaw hinge) and its associated structures
AF. For treatment or other health care of any C. Alternate Treatment Plan
including, but not limited to, myofascial pain
Insured in connection with an Illness, Disease, If a Dentist and an Insured select a Dental
dysfunction syndrome.
Accidental Injury or other condition which would Treatment Plan other than that which is customarily
N. Orthognathic Surgery, including, but not otherwise entitle the Insured to Covered Services provided by the dental profession, payments of
limited to, osteotomy, ostectomy and other services under this Policy, if and to the extent those benefits benefits available under this section shall be limited
or supplies to augment or reduce the upper or are payable to or due the Insured under any to the Dental Treatment Plan that is the standard
lower jaw. medical payments provision, no fault provision, and most economical, according to generally
uninsured motorist provision, underinsured accepted dental practices.
6Blue Cross of Idaho | Dental Plans for Groups
DISCRIMINATION IS AGAINST THE LAW
Blue Cross of Idaho and Blue Cross of Idaho Care Plus, discriminated in another way on the basis
Inc., (collectively referred to as Blue Cross of Idaho) of race, color, national origin, age, disability or sex,
complies with applicable Federal civil rights laws and you can file a grievance with Blue Cross of Idaho’s
does not discriminate on the basis of race, color, national Grievances and Appeals Department at:
origin, age, disability or sex. Blue Cross of Idaho does Manager, Grievances and Appeals
not exclude people or treat them differently because of 3000 E. Pine Ave., Meridian, ID 83642
race, color, national origin, age, disability or sex. Telephone: 1-800-274-4018
Blue Cross of Idaho: Fax: 208-331-7493
• Provides free aids and services to people with Email: grievances&appeals@bcidaho.com
disabilities to communicate effectively with us, such as: TTY: 711
o Qualified sign language interpreters You can file a grievance in person or by mail, fax,
o Written information in other formats (large or email. If you need help filing a grievance, our
print, audio, accessible electronic formats, other Grievances and Appeals team is available to help you.
formats) You can also file a civil rights complaint with the U.S.
• Provides free language services to people whose Department of Health and Human Services, Office for
primary language is not English, such as: Civil Rights electronically through the Office for Civil
o Qualified interpreters Rights Complaint Portal, available at https://ocrportal.
hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
o Information written in other languages
U.S. Department of Health and Human Services, 200
If you need these services, contact Blue Cross of Idaho Independence Avenue SW., Room 509F, HHH Building,
Customer Service Department. Call 1-800-627-1188 Washington, DC 20201, 1-800-368-1019, 800-537-7697
(TTY: 711), or call the customer service phone number (TTY). Complaint forms are available at
on the back of your card. If you believe that Blue http://www.hhs.gov/ocr/office/file/index.html.
Cross of Idaho has failed to provide these services or
ATTENTION: If you speak Arabic, Bantu, Chinese, Farsi, French, German, Japanese, Korean, Nepali, Romanian,
Russian, Serbo-Croatian, Spanish, Tagalog, or Vietnamese, language assistance services, free of charge, are
available to you. Call 1-800-627-1188 (TTY: 711).
Form No. 3-1187 (09-20)
bcidaho.com
7There when you need us,
never when you don’t.
Sales 888-462-7677 | Customer Service 855-230-6862
3000 East Pine Avenue | Meridian, Idaho | 83642-5995
PO Box 7408 | Boise, Idaho | 83707-1408
1-800-365-2345 | TTY 1-800-377-1363
bcidaho.com
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