Chappaqua Central School District Employee Benefit Fund
Example: Out of network vs MAC plan
Services In-Network Out-of-Network (R&C)
Preventive Services* 100% 80%
Emergency Palliative Treatment
Oral Examination 3 per policy year
X-rays bitewings full mouth series every 3 years
Bitewings – no more than 8 films per policy year
Teeth Cleaning – 3 per policy year
Fluoride Treatments for Children
(2 per policy year to age 19)
Topical Sealants for unrestored molar teeth covered
Basic Services 80% 80%
Fillings: Amalgam, Silicate & Acrylic
Crowns: Stainless Steel
Repairs of dentures, bridgework, crowns, etc.
Endodontic Services/Root Canal Therapy
Oral Services – Uncomplicated extractions
General Anesthesia – surgical procedures only
Injectable Antibiotics – for treatment of a dental
Major Services 80% 80%
Bridges Installation-fixed and removable
Dentures-Full and Partial
Crowns: Acrylic Metal, Porcelain
Orthodontic Services 80% 80%
$3,000 Lifetime Maximum for child(ren) under age 19 (amount paid for orthodontics is included in your plan year maximum)
There is a $3,000 annual maximum for Preventive, Basic and Major services combined, subject to the maximum rollover.
A maximum of $5,000 per family per plan year.
Children are covered up to age 19 or 25 if a full time student.
Employee/Dependents enrolling outside of the plan eligibility period may be subject to Late Entrant penalties with a $500 family maximum for the first year.
All out of network services are based on usual, reasonable, and customary rates for given area.
Dental Claims – P.O. Box 9182, Farmingdale, NY 11735 Ph – (800) 321-1336 or (516) 777-4800
Fitzharris has contracted with dental providers to provide discounts off services and procedures to Fitzharris’ dental plan members. To locate a provider, please reference our on-line Provider Directory at www.fitzharrisinsurance.com. We have also contracted with Aetna Dental Administrator Network.
Predetermination Review – Fitzharris will gladly assist you and your dentist by determining what benefits are payable for services and procedures of $300 and more. Have your dentist send your treatment plan to Fitzharris. Note that it is a predetermination review and we will let your dentist know what benefits would be payable. (This includes orthodontic treatment if your plan includes it)
Special Limitation: Teeth lost or missing before a covered person becomes insured by this plan. A covered person may have one or more congenitally missing teeth or have lost one or more teeth before he became insured by this plan. We won’t pay for a prosthetic device which replaces such teeth unless the device also replaces one or more natural teeth lost or extracted after the covered person became insured by this plan.
General Limitations and Exclusions: This policy provides dental insurance only. Coverage is limited to those charges that are necessary to prevent, diagnose or treat dental disease, defect, or injury. Deductibles apply. The plan does not pay for: cosmetic or experimental treatments, any treatments to the extent benefits are payable by any other payor or for which no charge is made.
VISION CARE EXPENSE BENEFIT
Effective June 1, 2012, the Fund is establishing the vision coverage through Solstice Benefits, Inc. Under this program, members and eligible dependents have the option of utilizing an in-network provider (Davis Vision is the Solstice Benefit’s vision network). If an in-network provider is utilized, the plan will provide enhanced benefit. See the fund booklet for further details. If a member chooses not to use a network provider, he/she is able to use any vision provider.
Vision Care Cash Deductible – None
(Each Covered Person – per Plan Year)
Payment Percentage – The plan pays 100% of the Schedule shown below:
Eye Examination, Non Medical Diagnosis $75
A. Single $90
B. Bi-focal $155
C. Tri-focal $200
D. Lenticular $200
E. Contacts $290*
A Routine Eye Examination is covered once every 12-months.
Benefits Eyeglasses / Contact Lenses are paid once every 12-months.
The plan will only pay amounts up to the actual charge and is not responsible for charges in excess of the schedule. Glasses are covered if a visual deficiency exists.
For more details, consult our Claim Administrator, Fitzharris Benefits Administrators.
ADA Dentist Nomination Process
• If the dentist does not participate in any Aetna product currently, the Dentist should:
1. Access Aetna's Website, click here → Aetna Dental Access.
2. Click on “Contact Us” on the left hand side of the page.
3. This link will walk the provider through a brief series of questions
It is as simple as 1-2-3!
If the dentist currently participates in any Aetna dental product, they should call 1-800-451-7715 and request to opt-in to the Aetna Dental Access network.