Chappaqua Congress of Teachers benefit fund

 

Dental Summary

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Services                                                                                   In-Network                                    Out-of-Network

 

Preventive Services*                                                                      100%                                                       MAC* 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%                                                       MAC* 80%    

Laboratory Test

Fillings: Amalgam, Silicate & Acrylic

Crowns: Stainless Steel

Repairs of dentures, bridgework, crowns, etc.

Endodontic Services/Root Canal Therapy

Periodontal Services

Oral Services – Uncomplicated extractions

General Anesthesia – surgical procedures only

Injectable Antibiotics – for treatment of a dental

condition only.

 

Major Services                                                                                   80%                                                       MAC* 80%    

Bridges Installation-fixed and removable

Dentures-Full and Partial Crowns: Acrylic, Metal, Porcelain

Inlays

Onlays

Posts

Implants

 

*MAC: Maximum Allowable Charge is equivalent to the amount paid to in-network providers.

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Beginning July 1, 2023 individuals no longer have an annual deductible of $50 and families no longer have an annual deductible of $150.

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Orthodontic Services                                                                      80%                                                       MAC* 80%    

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$3,000 Individual Lifetime Maximum and $5,000 Combined Family Lifetime Maximum. 

(As of July 1, 2017, the amount paid for pediatric orthodontia is NOT included in your plan year maximum.) 

• New member per person maximum is $500 during the first year of eligibility.  

• The plan year runs from July 1 to June 30.

• Employee/Dependents enrolling outside of the plan eligibility period may be subject to the first year $500 per person maximum.

• Children are covered up to age 19, or up until age 25 if an eligible full time student with proof of full time college enrollment.

• All out of network services are based on Maximum Allowable Charge (MAC) which is equivalent to the amount paid to in-network providers.

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Predetermination Review – The Preferred Group 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 The Preferred Group.  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. 

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HOW TO FIND A DENTAL PROVIDER:

 

The Preferred Group (CCTBF Administrator) has contracted with dental professionals to provide discounts on services and procedures to dental plan members.

 

To locate a provider, please reference our on-line Provider Directory at:

● https://www.cctbf.com/dental-plan (or go to www.cctbf.com and select Dental from top navigation bar)

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● Click on “Aetna Dental” or “Anthem Network” (Here are explicit instructions to search the Anthem network)

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● Answer prompt for type of provider (dentist, periodontist, etc..) See types of providers listed.

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● Type in zip code

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● When prompted to select your plan, select: “AccessSM/AetnaDental Administrators”

 

DENTAL CLAIMS WHEN SHOULD YOU SUBMIT A CLAIM?

 

When you have a claim, you should promptly submit the completed claim form and any bills or receipts.

Claim forms must be fully completed by all parties (provider and member) and filed within 90 days from the close of the plan year.

The plan year is July 1 – June 30.

 

Please note: Benefit checks may have an expiration date. Please cash promptly.

 

HOW TO FILE YOUR DENTAL CLAIM FORMS:

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Complete the entire Employee portion of the Claim Form.

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If the Claim is for yourself, your coverage is the primary plan.

 

If the claim is for your spouse and he/she has other coverage, be sure to attach the 19 CHAPPAQUA CONGRESS OF TEACHERS BENEFIT FUND Explanation of Benefits (EOB) or declination from his/her plan.

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If the claim is for your dependent children and your birthday (month and day) is earlier in the calendar year than your spouse's, you should file first. If your spouse's birthday is earlier, you must file with your spouse's plan first, and attach copies of his/her EOB to the claim you are filing through our plan.

 

Attach provider’s itemized bill(s) or have the provider complete his or her portion of the form.

 

American Dental Association Dental Claim Form

 

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WHERE TO FIND YOUR DENTAL CLAIM FORMS: 

 

Dental Claims Forms can be found at:   https://www.cctbf.com/forms or by visiting the CCTBF website at www.cctbf.com. 

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Please submit Dental Claim Form to ANTHEM (address listed on form).

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For details/questions, contact: 

Chappaqua Congress of Teachers Benefit Fund 

℅  The Preferred Group

P.O. Box 15136

Albany, NY 12212-5136

(518) 591-4965 phone / (518) 641-0325 fax

(866) 989-8997  /  Web: www.mytpgplan.com 

General E-mail questions: benefits@tpgplans.com

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