NPD Freedom DPOS Plan Brochure


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NPD Freedom DPOS Plan Brochure

  1. 1. NPD � Enrollment & Benefit Coverage 1432 S. Jones Blvd., Las Vegas, NV 89146 • 1-800-926-0925 • 702-737-8900 • Fax 702-259-8381 WELCOME TO MEMBER ELIGIBILITY NEVADA PACIFIC The Freedom Plan is designed for the employee and, if eligible, his/ DENTAL her family. Unless stated otherwise by your Administrator, coverage is extended to the spouse and unmarried dependent children. A Dental Plan of Choice Nevada Pacific Dental (NPD) Dependent children include: 1. all natural, 2. adopted, 3. step-children. is Nevada’s largest dental An unmarried dependent child will be eligible to age 19, or age 23 if a benefit organization that full-time student, defined as taking at least 12 credit hours. Automaticoffers you and your family a variety of comprehensive and affordable coverage is provided for mentally and/or physically challengeddental benefit choices. With NPD’s Freedom Plan dental benefit, you dependent children. You are eligible to enroll in the Plan after youwill enjoy immediate benefits because the Freedom Plan has no have met your organization’s waiting period for benefits or during yourwaiting period and no pre-existing exclusions or limitations–except organization’s annual open enrollment.for treatment in progress prior to eligibility. Once you are eligible andenrolled in the Plan, you will have immediate access to a dentist andyour benefit! CHOOSE YOUR DENTIST AND OFFICE When you enroll in the Freedom Plan you and your family choose a dentist from a network of private practice dental offices. A list of NPDNPD’s Freedom Plan Exclusive Provider Network offices is available so you can select theoffers you a choice of where to receive your care: most convenient office. You may transfer to a different Provider Office atYou will find the best benefit and the most affordable care is available any time. Changes made before the 20th of the month are effective thethrough NPD’s Exclusive Provider Network. When you choose to 1st of the following month. Simply call NPD and speak to a Customerreceive your care from any dentist in the Exclusive Provider Network, Service Representative. You must select an Exclusive Network Provideryou will have NO Deductible to meet, NO Annual Maximum (or a even if you plan to use an Out-of-Network dentist for your care. If you dohigh Annual Maximum Out-of-Network) that limits your care, and NO not select a provider office, one will be chosen for you.Claim Forms to submit. To receive In-Network specialty care benefits,you must be referred to an NPD contracted specialist by your NPD DENTAL FACILITIESExclusive Provider Network dentist and have your specialty referral The NPD Exclusive Provider Network list represents privately ownedpreauthorized by NPD. and operated dental offices that provide general dentistry services.If you choose to receive care from a dentist that is not in the NPD Please select a dental office from the list and indicate the ID# on theExclusive Provider Network, your benefit is still comprehensive and enrollment form or transfer card. If your treatment plan requires theno waiting periods still apply, however; your Out-of-Network benefit is services of a specialist, your NPD Exclusive Provider Network dentistmore limited and you will have an Annual Deductible and an Annual will refer you to a contracted NPD contracted specialist. In-NetworkMaximum. Specialty care that is not referred from the NPD Exclusive specialty care requires pre-authorization from NPD.Provider Network will be reimbursed using the Out-of-Network benefit If you choose to utilize the services of a non-contracted generalschedule. dentist or specialist (a dentist that is not an NPD Exclusive ProviderAt anytime, unless you are in mid-treatment, you may go to an In- Network dentist), then your dental benefit for that treatment shall beNetwork general dentist and access the better benefit. the allowance for that procedure listed, subject to your Plan’s Annual Deductible and Annual Maximum. You are responsible for all dental charges above the scheduled benefit. QUESTIONS? Customer Service Can Help: 1-800-026-0925 or 702-737-8900 APPOINTMENTS Spanish speaking representatives available. You can schedule your appointment with your chosen dental office after you are eligible and CUSTOMER SERVICE CAN: enrolled (your effective date) in the Plan. Your • Send you an Exclusive Provider Network list first appointment will be to meet the dentist • Change your current Exclusive Provider Network (changes and receive an evaluation of your oral health. received byt the 20th of the month will be effective the 1st of the Your dentist may then complete a treatment following month) plan (if additional work is necessary) that best • Explain your benefits and your costs meets your individual dental health needs. • Facilitate care for a dental emergency for In-Network services Office policies and practices vary by dental • Help you obtain a new ID card (for Member only) office. Not all dentists perform all procedures. • Explain the specialty referral process for In-Network services Your appointments are important. If you are • Give you information on an In- or Out-of-Network claim or In- network specialty referral unable to keep your scheduled appointment, • Explain the formal grievance process, and help you report a please notify the dental office at least 24 problme or concern hours in advance or the office can charge a • Provide additional benefit information missed appointment fee.
  2. 2. IN-NETWORK BENEFITS ADVANTAGES • No (or high) annual maximum • No deductibles • No claim forms VI • No or low fixed copayments for procedures DEN SIT YOUR T • No pre-existing exclusions or limitations (except for treatment in progress prior to eligibility) 2 TIM IST AT L ES P EAS • No waiting period for benefits ER Y T EAR • Lower “out-of-pocket” expenses for treatment • No “balance billing” from dentist ! DISADVANTAGES • In-Network benefit is available only when treatment is performed by an NPD Exclusive Provider Network dentist • A pre-authorized referral from an NPD Exclusive Provider Network dentist is required to access In-network specialty IN-NETWORK CHARGES care benefits When receiving treatment In-Network, you pay the copayment listed in the Member Copayment Schedule for each dental procedureOUT-OF-NETWORK BENEFITS completed as described. These fees are paid directly to your NPD Exclusive Provider Network dentist. Payments are due the day of ADVANTAGES service. • Out-of-Network benefit applies to services provided by any licensed U.S. dentist • Benefit allowance is fixed in advance OUT-OF-NETWORK CHARGES If you choose to receive your care from a dentist who is not a member DISADVANTAGES of the NPD Exclusive Provider Network, the Plan will pay the fixed • Annual calendar Deductible amount listed in the Out-of-Network Benefit schedule of allowance for • Annual calendar Maximum each specific procedure reported, subject to the Annual calendar-year Deductible and Annual calendar-year Maximum for your Freedom • Fixed schedule of allowances may result in you paying the Plan. In most cases you will have to pay the Out-of-Network dentist difference between the allowance and the dentist’s fee, the difference between this allowance and the dentist’s billed fee. This known as “balance billing” difference may be substantial and we recommend that you request • Reimbursement requires the use of a claim form that your Out-of-Network dentist submit your proposed treatment plan • Higher “out-of-pocket” expenses for treatment than In- to NPD prior to beginning your work so you may receive your benefit Network amount.ENROLLMENT PROCEDURETo enroll in the Freedom Plan, simply fill out and return the enrollment IN-NETWORK METHOD OF REIMBURSEMENTform to your Benefits Administrator at your place of employment or NPD contracts with private practice general and specialty careto your Trust Fund office. You will be eligible for benefits when NPD dentists to provide quality dental services for eligible group members.receives the enrollment card and eligibility verification from your NPD compensates its providers in a variety of ways, including directemployer or Trust Fund. You and your dependents must enroll in the reimbursement, discounted fee-for-service, fee-for-service andPlan within 31 days of becoming eligible for benefits. If you do not capitation. NPD does not use provider incentives or bonus plans toenroll at that time, you will not be able to enroll or add dependents until influence specific dental care decisions.your organization’s annual Open Enrollment period. Members mayadd dependents immediately if there is a “qualifying event”, i.e. birthof child, adoption of child, or marriage. All newly eligible dependents OUT-OF-NETWORK METHOD OFmust be added within 31 days of the “qualifying event”. REIMBURSEMENT The Plan will pay a fixed allowance for covered procedures reported to the plan by a non-Network dentist. These payments are listed in the Out-of-Network Schedule of Allowances. Payments are further reduced by the Annual calendar-year Deductible and limited by the Annual calendar-year Maximum. The member, and not NPD, is responsible for S LOS ND F the difference between the Out-of-Network dentist’s billed charges and the Out-of-Network Schedule of Allowance. HA BRUS A DAY & E TWIC MEALS EXCLUSIONS & LIMITATIONS FTER A Except for the Annual Maximum and Deductible amount on the Out- of-Network benefit, both In-Network and Out-of-Network benefits are subject to the same list of Plan Exclusions and Limitations. Benefit limitations, for example a prophy (cleaning), is limited as a covered benefit to only once every six months, applicable whether an In- Network or Out-of-Network dentist delivers the treatment.
  3. 3. PRINCIPAL EXCLUSIONS 3. Oral hygiene instruction is limited to one per twenty-four (24) months.The following dental procedures and services are not included in the Plan: 4. Fluoride treatment is limited to one per twelve (12) months.1. Dental services for aesthetics only. Cosmetic dental care. 5. Crowns, bridges and dentures (including immediate dentures) are2. General Anesthesia, intravenous and inhalation sedation, prescription not to be replaced within a five (5) year period from initial placement. drugs, and the services of a special anesthesiologist. 6. Partial dentures are not to be replaced within any five (5) year period3. Dental conditions arising out of and due to member’s employment or from initial placement, unless necessary due to natural tooth loss for which Workers’ Compensation is payable. where the addition or replacement of teeth to the existing partial is4. Treatment required by reason of war or any act of war, whether not feasible. declared or not; disaster or epidemic; a suicide attempt, while sane 7. Denture relines are limited to one per denture during any twelve (12) or insane; a intentional self inflicted injury; any accident of sickness consecutive months. resulting from participation in an insurrection or riot or participation 8. Replacement will be provided for an existing denture, partial denture in the commission of an assault or felony or as the aggressor in an or bridge only if it is unsatisfactory and cannot be made satisfactory altercation. by reline or repair.5. Hospital and medical charges of any kind, except for dental services 9. Covered charge for both a temporary and a permanent prosthesis otherwise covered. will be limited to the charges for a permanent one only. Charges6. Treatment of fractures or dislocations. for specialized techniques involving precision attachments,7. Loss or theft of dentures, partials, or other appliances (crowns, personalization or characterization, and additional charges for bridges, full or partial dentures). adjustments within six months of installation are not included as8. Preventive extraction (e.g. the removal of asymptomatic or covered benefits. nonpathologic teeth). Extractions resulting from fractures, neoplastic 10. Crowns will be covered only if there is not enough retentive quality surgery, or radiation treatment. left in tooth to hold a filling. (Example: buccal or lingual walls either9. Services which are normally reimbursed by a third party or liability fractured or decayed to the extent that they do not hold a filling). insurance and/or under the medical portion of an insurance/health Veneers, posterior to the second bicuspid, are considered purely and welfare plan. cosmetic dentistry. Allowance will be made for cast full crown. If10. Services which are provided to the member by state government or agency thereof, or are provided without cost to the member by an performed, patient must pay the additional fee. municipality, country or other subdivision. 11. Treatment for conditions is generally limited to conventional11. Dental procedures started when not eligible for Benefits and techniques and does not include splinting, hemisection, implants, Coverage. overdentures, grafting, precision attachments, duplicate dentures and bruxating appliances.12. Procedures, appliances, or restorations to correct congenital or 12. Periodontal treatments (root planing/subgingival curettage) are developmental malformations. limited to four quadrants during any twelve (12) consecutive months.13. Treatment/removal of malignancies. Cysts or benign tumors not 13. Full mouth debridement (gross scale) is limited to one treatment in within the scope of usual comprehensive dental care. Odontogenic cysts exceeding 1.25 cm in diameter. Procedures, appliances, or any twenty-four (24) consecutive month period. restorations to correct or replace soft or hard tissue defects resulting 14. Osseous surgery is limited to not more than one treatment in any from such treatment. five (5) year period.14. Dispensing of drugs not normally supplied in a dental office. 15. Bitewing x-rays are limited to not more than one series of four films15. Any treatment which, in the opinion of dentist, is not necessary for the in any six (6) month period. member’s dental health. 16. Full mouth x-rays and/or panographic type films are limited to one16. Replacement of an existing bridge, partial or denture which is set every twenty-four (24) consecutive months. A full mouth x-ray is satisfactory or which can be made satisfactory. defined as a minimum of 6 periapical films plus bite wing x-rays.17. Orthognathic surgery. 17. Sealant benefits include the application of sealants only to18. Implants or any prosthesis attached to or dependent upon an implant. permanent first and second molars with no decay, with no19. An experimental or exotic procedure not approved by the ADA restorations and with the occlusal surface intact, for first molars up Council on Dental Therapeutics. to age nine and second molars and bicuspids up to age fourteen. Sealant benefits do not include the repair or replacement of a20. Treatment to alter vertical dimension or to restore occlusion, unless sealant on any tooth within three (3) years of its application. full dentures are involved. 18. Single unit cast metal and/or ceramic restorations and crowns are21. Major therapy for Temporo-Mandibular Joint (TMJ) problems covered only when the tooth cannot be adequately restored with including, assessment beyond that customarily provided in general other restorative materials. Crown build ups including pins are only dental practice. Minor therapy such as night guard, bite planes and allowable as a separate procedure in the exceptional instance where minor equilibration (e.g. occlusal adjustment for one or two teeth) may extensive tooth structure is lost and the need for a substructure can be covered. be demonstrated by written report and x-rays.22. Expenses incurred for any procedure which commenced within ninety 19. With complete or partial dentures, or fixed bridges, using standard (90) days before the date the Member joined the plan. procedures, is covered. However, treatment involving the following23. Crown lengthening procedures. procedures is considered optional and, if performed, Member should24. Dental treatment or services rendered by an individual who is a be advised of his/her responsibility for the additional fee: relative by blood or marriage to the eligible member or dependent, or a. precious metal for removable appliances; who normally lives in the subscriber’s home. b. precision attachments;25. Expense or charge incurred by a subscriber confined to an institution c. overlays and implants; and that is primarily a place of rest, a place for the aged or a nursing d. personalization and characterization. home. 20. Cosmetic dental care is limited to composite restorations on posterior26. Cases that, in the reasonable professional judgment of the attending teeth “distal to canines” when an Nevada Pacific Dental dentist Dentist, a satisfactory result cannot be obtained. determines treatment to be appropriate dental care. Composite27. Replacement of long-standing missing tooth/teeth in an otherwise restorations will be covered on premolar facial surfaces. stable dentition. 21. PLAN does not pay for any expense or charge for failure to appear28. Orthodontic services. Care related to the bite, alignment of teeth, or for an appointment as scheduled, for the completion of claim forms, bite correction. Unless provided by an additional orthodontic benefit or OSHA related fees. (rider) attached to Plan. 22. Treatment may vary according to the DENTIST’S treatment plan andPRINCIPAL LIMITATIONS the Member’s individual needs. An individual’s treatment plan may1. Prophylaxis is limited to one treatment each six (6) month period require dental procedures that are not covered under the PLAN. (includes periodontal maintenance following active therapy). 23. If two or more covered procedures would appropriately correct a2. Oral evaluation is limited to one each six (6) month period. clinical situation, the COMPANY will select the most appropriate (excluding limited oral evaluation). procedure.
  4. 4. TERMINATION OF BENEFITS DO I NEED TO CHOOSE A PRIMARY DENTAL1. On Expiration Date of Dental Coverage. OFFICE?2. When dependent member gets married, attains the age or 19 Yes, all members must choose an In-Network Primary Dental Office or ceases to be a full-time student prior to age 23 (unless stated from the NPD Exclusive Provider Network. However, under the otherwise in your Plan Agreement.) Freedom Plan the member has the option of receiving care from a3. Members who violate the Plan’s rules may have their benefits dentist other than an NPD Exclusive Provider Network dentist. If the suspended or be transferred to a schedule of allowances plan. member decides to receive care from an Out-of-Network dentist,4. Permitting or committing fraud. benefits are paid in accordance with the Out-of-Network Schedule of Allowances. Additionally, the member is subject to an AnnualGRIEVANCE PROCEDURE Deductible, Annual Maximum, and balance billing for the difference between the plan payment and the dentist’s charge.The Nevada Division of Insurance is responsible forregulating health care service plans. The Divisionhas a toll-free telephone number (888) 872-3234 WHAT IF I NEED TO SEE A SPECIALIST?to receive complaints regarding health plans. If In order to be eligible for In-Network specialty care benefits, youryou have a grievance against the health plan, you selected Exclusive Provider Network dentist must refer you to an NPD Exclusive specialist via NPD’s request for specialty care referralshould contact the Plan and use the Plan’s grievance process. A member may utilize a non-participating specialist or aprocedure. The Plan has 30 days to make a decision participating specialist without NPD’s approval; however, claims will bewhen an emergency is not involved. You may also reimbursed in accordance with the Out-of-Network Benefit Schedule of Allowances (“Plan Pays”). If a procedure is not listed on the Schedulehave the right to take a dispute with a Plan to of Benefits, it is not covered. Please see the Exclusions and Limitationsarbitration with an independent arbitrator from the section of this brochure.American Arbitration Association. If you require theDivision’s help with a complaint involving a grievance IF I GO TO AN OUT-OF-NETWORK DENTISTthat has not been satisfactorily resolved by thePlan, you may call the Division’s toll-free telephone HOW DO I SUBMIT A CLAIM? Have your Out-of–Network dentist submit a claim on a standard ADAnumber. A member can submit a grievance in writing approved claim form to :to Nevada Pacific Dental or call during regular Nevada Pacific Dental, hours and request a Grievance form. 1432 South Jones Blvd. Las Vegas, NV 89146DO I HAVE AN ANNUAL DEDUCTIBLE?With an NPD Freedom Plan, there is no Deductible for In-Network WHAT ABOUT ORTHODONTIC CARE?services; however there is a per calendar year Deductible for Out- Your plan must include an Orthodontic Benefit Rider to receiveof-Network services or non-NPD approved specialty services paid Orthodontic care. Check with your employer, human resourcesunder the Schedule of Allowances. Please refer to your Freedom Plan department, Trust Fund, or NPD to determine if your Plan includesSchedule of Benefits for the specific Deductible amount. orthodontic benefits. NPD offers orthodontic benefits for children to age 19. NPD does not offer adult orthodontic coverage. BenefitsDO I HAVE AN ANNUAL MAXIMUM? are available only through an In-Network provider referral to an In-Network Orthodontist. There is no Out-of-Network coverage forWith the NPD Freedom Plan, there is usually no dollar limit regarding orthodontic treatment. NPD does not provide benefits for orthodonticIn-Network services. However, for Out-of-Network services, there is treatment in progress. Please refer to your Orthodontic Benefit Annual calendar-year Maximum per member. Please refer to yourFreedom Plan Schedule of Benefits for the specific Annual Maximumamount.DO I NEED TO SUBMIT A CLAIM? Toll Free:With the NPD Freedom Plan, there is no need to submit a claim form 1.800.926.0925for services provided by an NPD Exclusive Provider Network dentist.For Out-of-Network services, the member or dentist will need to submitclaim forms for reimbursement. NPD Nevada Pacific Dental, Inc. � 1432 South Jones Blvd. Las Vegas, NV 89146 Phone: 702.259.8320 Fax: 702.259.8381