Please read the following information carefully for your procedure frequencies and provisions.
All dental benefits are paid according to the terms of the Master Contract between the Health Plan, Dental Plan and Group Insurance Board. The Uniform Dental Benefits are wholly incorporated in the Master Contract.
This is a list of Uniform Dental Benefits and is based upon the Current Dental Terminology © American Dental Association. Codes are provided as a reference and may be subject to change; plans may substitute alternative codes to provide essentially equivalent coverage.
Dental Plan Administrator: The third party administrator responsible for providing the Uniform Dental Benefit plan under the Group Insurance Board’s program. Delta Dental of Wisconsin is the current Dental Plan Administrator for the Uniform Dental Benefit plan.
Dental Plan: Means all benefits, limitations, and exclusions included in the Uniform Dental Benefit Certificate.
Dental Provider: A dentist or any other person or entity licensed by the State of Wisconsin, or other applicable jurisdiction, to provide one or more dental plan benefits.
In-Network Dental Provider: A dental provider who has agreed in writing by executing a participation agreement to provide or direct dental care services, supplies, or other items covered under the policy to participants. The dental provider’s written participation agreement must be in force at the time of such services, supplies or other items covered under the policy are provided to the participant.
Note that there are no out-of-network benefits available under this dental plan.
No payment will be made for a benefit that is not listed.
- Your benefits are based on a calendar year. A calendar year runs from January 1 through December 31.
- During the first year a person is insured, benefits begin on the effective date and continue through December 31 of that year.
- Covered procedures are subject to all plan provisions, procedure and frequency limitations, and/or consultant review.
- X-ray films, periodontal charting and supporting diagnostic data may be requested for health plan review.
- We recommend that a pre-treatment estimate be submitted for all anticipated work that is considered to be expensive.
- A pre-treatment estimate is not a pre-authorization or guarantee of payment or eligibility; rather it is an indication of the estimated benefits available if the described procedures are performed.
- Note that your medical insurance may provide coverage for some oral surgery. Refer to your medical benefits certificate for additional oral surgery coverage.
The following services are limited under this dental plan:
- Oral Exams limited to two per year.
- Full Mouth or Panoramic x-rays limited to once every 60 months.
- Bitewing x-rays limited to one set per year.
- Cleaning of teeth limited to two times per year.
- Fluoride treatment allowed only for a child under age 19, limited to two times per year.
- Sealants allowed only for a child under age 19, and must be applied to non-restored, non-decayed first and second permanent molars, limited to once per tooth per lifetime.
- Routine pediatric dental services as required under federal law.
**Special Note on Fillings: On anterior (front) teeth, you will have 100% coverage subject to your benefit maximum for both amalgam (silver) and composite/resin (tooth colored) fillings. On posterior (back) teeth, you have 100% coverage subject to your benefit maximum for amalgam (silver) fillings only. If you have a composite/resin (tooth colored) filling on a posterior tooth, you will be responsible for the difference between the amount your provider charges for an amalgam and a composite/resin filling.
The following are not covered services under this dental plan:
- Services for injuries or conditions that can be compensated under workers’ compensation or employer liability laws.
- Services or appliances started prior to the date the patient became eligible for coverage under the State of Wisconsin’s Group Health Insurance Program’s Uniform Dental Benefit.
- Prescription drugs, pre-medications or relative analgesia charges for anesthesia in connection with covered oral surgery procedures.
- Preventive control programs; charges for failure to keep a scheduled visit with a dentist; charges for completion of forms; charges for consultation.
- Charges by any hospital or other surgical or treatment facility, or any additional fees charged by a dentist for treatment in any such facility.
- Charges for treatment of, or services related to, temporomandibular joint dysfunction.
- Services that are determined to be partially or wholly cosmetic in nature.
- Appliances, restorations or procedures for increasing vertical dimension; for restoring occlusion; for correcting harmful habits; for replacing tooth structure lost by attrition; for correcting congenital or developmental malformations, including replacement of congenitally missing teeth, unless restoration is needed to restore normal bodily function; for temporary dental procedures; for implantology techniques or for splints, unless necessary as a result of accidental injury.
- Replacement of lost or broken retainer.
- Treatment by other than a dental provider, his or her employees, or his or her agents.
- Dental care injuries or diseases caused by war or act of war, riots or any form of civil disobedience; injuries sustained while committing a felony; injuries intentionally inflicted; injuries or diseases caused by atomic or thermonuclear explosion or by the resulting radiation.
- Claims not submitted to Dental Plan Administrator within 12 months, or if later, as soon as reasonably possible, from the date the procedure was provided.
- Dental procedures in cases where, in the professional judgment of the attending dentist, a satisfactory result cannot be obtained.
- Procedures and services not specifically provided under this Certificate of Coverage and procedures and services excluded by dental plan.
- Any oral surgical procedures not specifically listed as a covered benefit or for which coverage exists under Uniform Benefits.
Key Contract Provisions
Covered Services (Examples)
Annual Benefit Max:
$1,000 per participant
Diagnostic / Preventive:
X-rays (bitewing and panoramic)
Emergency Pain Relief:
|Non-surgical extractions (above gumline):
50% (Under age 19)
Ortho Lifetime Max*:
$1,500 per participant
*Lifetime max does not reset when you change health plans
Routine Oral Evaluation - exams are limited to two per year.
Note that comprehensive exams are not done multiple times in a year.
Limited Oral Evaluation
Complete Series or Panoramic Film: limited to one (either D0210 or D0330) once every 60 months.
Bitewing Films - limited to one set per year.
Prophylaxis (Cleaning) and Fluoride:
Fluoride - limited to twice per year up to age 19.
Space Maintainers - limited to primary teeth lost prematurely.
Evidence-Based Integrated Care Plan ("EBICP"):
The following Evidence-Based Integrated Care Plan (“EBICP”) Benefits are provided under your policy. To participate in EBICP, eligible dental policy enrollees or their providers are required to set the appropriate health condition indicator online at deltadentalwi.com/state-of-wi or a Delta Dental of Wisconsin representative will assist in setting the EBICP indicator by telephone. The EBICP periodontal disease health condition indicator will be automatically updated when non- surgical or surgical periodontal procedures are processed by Delta Dental of Wisconsin. This amendment supersedes any previous amendment provided to you regarding EBICP.
The EBICP Benefits are as follows:
- With an indicator of surgical or non-surgical treatment of periodontal disease, a participant is eligible for up to two additional dental visits in a benefit year for periodontal maintenance or adult prophylaxis.
- With an indicator of surgical or non-surgical treatment of periodontal disease, a participant is eligible for topical fluoride application beyond the age limitation of the Master Group Contract.
- With an indicator of a diabetes diagnosis, a participant is eligible for up to two additional dental visits in a benefit year for periodontal maintenance or adult prophylaxis.
- With an indicator of pregnancy, a participant is eligible for one additional dental visit for adult prophylaxis or periodontal maintenance during the pregnancy.
High Risk Cardiac Conditions
- With an indicator for high risk cardiac conditions, a participant is eligible for up to two additional dental visits in a benefit year for periodontal maintenance or adult prophylaxis. High risk cardiac condition indicators are:
- History of infective endocarditis
- Certain congenital heart defects (such as having one ventricle instead of the normal two)
- Individuals with artificial heart valves
- Heart valve defects caused by acquired conditions like rheumatic heart disease
- Hyper tropic cardiomyopathy which causes abnormal thickening of the heart muscle
- Individuals with pulmonary shunts or conduits
- Mitral valve prolapse with regurgitation (blood leakage)
Suppressed Immune System Conditions
- With an indicator for suppressed immune system conditions, a participant is eligible for up to two additional dental visits in a benefit year for periodontal maintenance or adult prophylaxis.
- With an indicator of suppressed immune system conditions, a participant is eligible for topical fluoride application beyond the age limitation of the Master Group Contract.
Kidney Failure or Dialysis Conditions
- With an indicator for kidney failure or dialysis conditions, a participant is eligible for up to two additional dental visits in a benefit year for periodontal maintenance or adult prophylaxis.
Cancer Related Chemotherapy and/or Radiation
- With an indicator for cancer related chemotherapy and/or radiation, a participant is eligible for up to two additional dental visits in a Benefit year for periodontal maintenance or adult prophylaxis.
- With an indicator of cancer related chemotherapy and/or radiation, a participant is eligible for topical fluoride application beyond the age limitation of the Master Group Contract.
Please note that eligible oral surgical procedures are covered under Uniform Medical Benefits when furnished by a covered dental provider.
Limited to age 19, 50% coverage.
This page was last modified on: 9/20/2018 8:42:43 AM