Dental Options 2019 BALTIMORE CITY PUBLIC SCHOOLS
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Dental Options 2019
BALTIMORE CITY PUBLIC SCHOOLSContents Important Information for 2019 . . . . . . . . . . . . . . . . 1 Dental HMO (DHMO) Dental Plan . . . . . . . . . . . . . . 2 Preferred Dental PPO (DPPO) Dental Plan . . . . . . . 3 Summary of Dental PPO Benefits . . . . . . . . . . . . . . 4 Comparison of Benefits . . . . . . . . . . . . . . . . . . . . . . . 5 Notice of Nondiscrimination and Availability of Language Assistance Services . . . . . . . . . . . . . . . . . 6
Important Information for 2019
Phone numbers
■■ DHMO Customer Service
844-495-0653
■■ PPO Dental Customer Service
866-891-2802
Dental mailing address
CareFirst BlueCross BlueShield
Dental Claims, Appeals and Correspondence
P.O. Box 14114
Lexington, KY 40512-4114
Dental plan options
Baltimore City Public Schools offers its employees
and their dependents the choice of two dental
plans. Your first option is a Dental HMO (DHMO)
plan, which is available at no cost to you and no
annual maximum.
Your second option is a dental buy-up, PPO plan
(DPPO). This means that, for an additional premium,
which is shared between you and your employer,
you can “buy-up” to the CareFirst BlueCross
BlueShield Preferred dental plan.
Baltimore City Public Schools—Dental Plan Options 2019 ■ 1Dental HMO (DHMO) Dental Plan
Advantages of the DHMO plan Frequently asked questions
When you receive in-network care, you enjoy Do I need to select a dentist?
the following: Yes. Before you can receive benefits under this
■■ No claim forms. plan, you must first select a dentist within the
provider directory.
■■ No deductibles.
■■ Unlimited maximum benefit amount. Must family members go to the
same dentist?
■■ Braces covered for children and adults.
No. Each family member may select a different
Things to remember participating general dental office.
■■ ou can change your dentist at any time (if no
Y
What about orthodontia for adults
balance exists).
and children?
■■ ou can choose a different dentist for each
Y
Orthodontia is covered for both adults
family member.
and children.
■■ You must get a referral to see a specialist.
Do I have to fill out claim forms after each
routine visit?
There are no claim forms to complete.
Over 100 general dentists and Are there any benefit maximums?
specialists in over 50 locations There are no benefit maximums.
in Baltimore City.
What happens in a dental emergency away
from home?
The dental program will cover the cost of
diagnostic and therapeutic procedures delivered
by any general dentist up to a maximum of $50
per emergency occurrence greater than 50 miles
from home.
How do I find a participating
DHMO dentist?
To find a DHMO dentist, visit carefirst.com
and select Find a Provider; select Dental from
the options; select your search (by name or
specialty); for network select Dental HMO; then
your plan DHMO–5000S.
2 ■ Baltimore City Public Schools—Dental Plan Options 2019Preferred Dental PPO (DPPO) Dental Plan
Baltimore City Public Schools is giving you the option to purchase an enhanced dental plan,
called the CareFirst Preferred Dental PPO (DPPO), which provides a larger network of dentists.
Advantages of the DPPO plan Frequently asked questions
■■ reedom of choice, freedom to save—With
F Who is eligible to enroll?
Preferred Dental coverage, you have the All Baltimore City Public Schools Employees
freedom to see any dentist. This plan also and their dependents. Eligible dependents are
gives you the option to reduce your out-of- covered until the end of the month in which they
pocket expenses by visiting a dentist who turn age 26 regardless of student status.
participates in our network of Preferred
providers. It’s your choice! How do I find a preferred dentist?
■■ reventive care and more—Benefits for you
P You can access an online directory of dentists
and your family include regular preventive 24 hours a day at carefirst.com.
care, X-rays, dental surgery and more. A ■■ Under the Solution Center click on Find
summary of your benefits is available on page a Doctor.
5 of this guide.
■■ hen choose Dental under provider type
T
■■ Large network—Over 2,300 general and and select Preferred Dental (PPO).
pediatric dentists in Maryland participate in
CareFirst’s Preferred Dental Network. There Once you are on this page, you can find all the
are over 500 network dentists in Baltimore dentists in your area by putting in a zip code, city
City and 95% of participating dentists are and state, or you can check to see if your dentist
accepting new patients. You may already is in our network by typing their last name under
be seeing a dentist who is part of our option 3.
network. There are 77,000 dentists in the How much will I have to pay for dental
national network. services?
■■ Out-of-network care—For a higher out-of- The chart on page 4 gives you an overview
pocket cost, the Preferred plan allows you of many of the covered services along with
to go outside the network for care and still the percentage you will pay for each class of
receive valuable dental coverage. services, both in and out-of-network.
■■ asy to use—If you see a Preferred dentist,
E
Is there a lot of paperwork?
you will incur lower out-of-pocket costs for
all dental services and you will have no claim There is no paperwork when you use a dentist
forms to file. Preferred dentists have agreed in our Preferred Dental Network. If you see a
to accept CareFirst’s Allowed Benefit as non-participating dentist, you may be required
payment in full for covered services. Once you to pay all costs at the time of care, and then
meet your deductible and coinsurance, you submit a claim form in order to be reimbursed
won’t be faced with additional expenses. for covered services.
■■ ationwide emergency coverage—
N Who can I call with questions about my
Emergency dental coverage is there when you dental plan?
need it, no matter where you are using your Call CareFirst BlueCross BlueShield toll free at
out-of-network coverage. 866-891‑2802.
Baltimore City Public Schools—Dental Plan Options 2019 ■ 3Summary of Dental PPO Benefits
You Pay You Pay
Benefits
In-Network Out-of-Network
PREVENTIVE & DIAGNOSTIC SERVICES (CLASS I)
■■ Oral Exams (two per benefit period)
■■ Cleanings (two per benefit period)
■■ Bitewing X-rays (two procedures per benefit period)
■■ Full mouth X-ray or panoramic and bitewing X-ray combination and one
Difference between
cephalometric X-ray (once per 36 months)
■■ Fluoride treatments (two per benefit period per member, up to age 19)
CareFirst’s payment and
No charge
■■ Sealants on permanent molars (once per tooth per 36 months per
the Non-Participating
Dentist’s charges2
member, up to age 19)
■■ Space maintainers for prematurely lost posterior baby teeth (once per
60 months)
■■ Emergency oral exam and palliative treatment
BASIC SERVICES (CLASS II)
■■ Fillings using approved materials (one filling per surface per 12 months) 20% of Allowed Benefit 20% of Allowed Benefit
■■ Oral surgery (treatment for cysts, tumor and abscesses) after deductible1 after deductible2
■■ General anesthesia rendered for a covered dental service
■■ Tooth extractions
MAJOR SERVICES (CLASS III)
■■ Tooth scaling and root planing (once per 24 months, one full mouth 40% of Allowed Benefit 40% of Allowed Benefit
treatment) after deductible after deductible
■■ Gum surgery including bone surgery, tissue surgery and bite
adjustments (once per 60 months)
■■ Root canal treatment
■■ Full and/or partial dentures (once per 60 months)
■■ Fixed bridges, crowns, implants, inlays and onlays (once per 60 months)
■■ Denture adjustments and relining (limits apply for regular and
immediate dentures)
■■ Recementation of crowns, inlays and/or bridges (once per 12 months)
■■ Repair of prosthetic appliances as required (once in any 12 month
period per specific area of appliance)
ORTHODONTIC SERVICES (CLASS IV)
■■ Benefits for orthodontic services (braces) are available for covered 50% of 50% of
members who meet treatment criteria. Covered services are limited to Allowed Benefit1 Allowed Benefit2
36 consecutive months of covered services.
ANNUAL DEDUCTIBLE AND MAXIMUM $50 Individual / $150 Family Deductible
(IN- AND OUT-OF-NETWORK) (applies to classes II and III)
$1,500 Orthodontic Lifetime Maximum
$1,500 Annual Maximum
1
For in-network providers, plan payment is based on dental plan’s negotiated fee schedule. After the deductible is met, Preferred dentists
accept 100% of the Allowed Benefit as payment in full for covered dental services.
2
If you use an out-of-network provider, you will need to pay the provider and will be reimbursed by the plan using an out-of-network plan
allowance schedule. Your out-of-pocket costs will most likely be higher. Non-Participating Dentists may bill the Member for the difference (if
any) between the Allowed Benefit and the Non-Participating Dentist’s actual charge for Covered Dental Services.
Summary of Exclusions
Not all services and procedures are covered by your benefits contract. This plan summary is for comparison purposes only and does not create
rights not given through the benefit plan.
4 ■ Baltimore City Public Schools—Dental Plan Options 2019Comparison of Benefits
This chart shows key differences between the DHMO 5000S Plan and the DPPO Plan Estimated Out-of-
Pocket expenses for the most commonly used services. For a complete listing of the DHMO 5000S Plan:
Procedures, copayments and limitations, visit the Schools’ benefits website at www.baltimorecityschools.org.
ADA DHMO1 5000s DPPO
procedure Description
In-Network 2
Out-Network3
code You Pay
You Pay You Pay
120 Periodic Oral Evaluations $0.00 $0.00 $0.00
(once per 6 months)
272 Bitewings—Two Films $0.00 $0.00 $0.00
330 Panoramic Film $0.00 $0.00 $0.00
1110 Prophylaxis (cleaning)—Adult $0.00 $0.00 $0.00
(once per 6 months)
1120 Prophylaxis (cleaning)—Child $0.00 $0.00 $0.00
(once per 6 months)
2140 Amalgam—One Surface, Permanent $0.00 $9.90 $20.40
2160 Amalgam—Three Surface, Permanent $0.00 $15.12 $32.40
2330 Resin—Based Composite, One Surface, Anterior $0.00 $14.40 $24.80
2332 Resin—Based Composite, Three Surface, Anterior $0.00 $20.80 $37.60
2750 Crown—Porcelain/High Noble Metal $245.00 $248.00 $354.80
2751 Crown—Porcelain/Noble Metal $235.00 $238.00 $325.60
3330 Molar Root Canal $185.00/$490.005 $238.00 $332.00
4260 Osseous Surgery $196.00/$495.005 $239.00 $340.00
4341 Periodontal Scaling and Root Planing—Quad $40.00/$86.005 $48.00 $81.60
5110 Complete Denture—Upper $249.00 $267.48 $522.00
7140 Extraction, Erupted Tooth or Exposed Root $40.00/$73.005 $15.40 $25.20
7210 Surgical Extraction of Erupted Tooth $40.00/$80.00 5
$26.80 $43.40
7240 Removal of Impacted Tooth—Completely Bony $85.00/$155.005 $45.18 $78.40
8080 Comprehensive Orthodontic Treatment—Adolescent $1,850.00 $1,480.50 $3,198.004
9110 Palliative Treatment $15.00 $0.00 $0.00
1
Benefits are available in-network only.
2
ember estimated out-of-pocket expense when services are rendered by a CareFirst Preferred Participating Dentist without consideration of
M
deductible or annual benefit maximum.
3
ember estimated out-of-pocket expense based upon dentist fee at 50th percentile of 2007 NDAS schedule without consideration of
M
deductible or annual benefit maximum. Member subject to balance billing over and above this amount.
4
Allowed Benefit ($4,698) minus the $1,500 Ortho Lifetime Maximum.
5
Member copayment when service rendered by Participating Specialist.
This document is for comparison purposes only and does not create rights not given through the benefit plan.
Baltimore City Public Schools—Dental Plan Options 2019 ■ 5Notice of Nondiscrimination and
Availability of Language Assistance Services
(UPDATED 7/12/18)
CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc., CareFirst Diversified Benefits and all of their
corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the
basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them
differently because of race, color, national origin, age, disability or sex.
CareFirst:
■■ Provides free aid and services to people with disabilities to communicate effectively with us, such as:
Qualified sign language interpreters
Written information in other formats (large print, audio, accessible electronic formats, other formats)
■■ Provides free language services to people whose primary language is not English, such as:
Qualified interpreters
Information written in other languages
If you need these services, please call 855-258-6518.
If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis
of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights
Coordinator by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is
available to help you.
To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinator
as indicated below. Please do not send payments, claims issues, or other documentation to this office.
Civil Rights Coordinator, Corporate Office of Civil Rights
Mailing Address P.O. Box 8894
Baltimore, Maryland 21224
Email Address civilrightscoordinator@carefirst.com
Telephone Number 410-528-7820
Fax Number 410-505-2011
You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization
and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia
and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. In Virginia, CareFirst MedPlus and CareFirst Diversified Benefits are the business
names of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
6 ■ Baltimore City Public Schools—Dental Plan Options 2019Notice of Nondiscrimination and Availability of Language Assistance Services
Foreign Language Assistance
Baltimore City Public Schools—Dental Plan Options 2019 ■ 7Notice of Nondiscrimination and Availability of Language Assistance Services 8 ■ Baltimore City Public Schools—Dental Plan Options 2019
Notice of Nondiscrimination and Availability of Language Assistance Services
Baltimore City Public Schools—Dental Plan Options 2019 ■ 9CareFirst BlueCross BlueShield CareFirst BlueChoice, Inc. 10455 Mill Run Circle Owings Mills, MD 21117-5559 carefirst.com Health benefits administered by: C O NNE C T W I T H US : CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. which are independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. BOK5182-1S (10/18)
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