Dental Benefits

 

              


 

Dental Plans Overview:

 


 

 

  • Milwaukee County Conventional Plan SPD:

    • Milwaukee County sponsors a prepaid fully insured dental maintenance organizations (DMO):

      • Care-Plus, in addition to the DMO plan,  a self-insured fee-for-service dental plan is also available.

    • The self-insured dental plan has a $2,500 per person per plan year maximum benefit.

    • Some oral surgeries may be covered under your medical plan.

    • The Dental Plans have similar regulations and procedures as the health plans regarding:

      •  Eligibility, Enrollment, Dependent Enrollments, Insurability, Open Enrollment, and Continuation of Coverage.

    • Milwaukee County does not provide a retiree dental plan.

      • Retirees can continue their coverage under the Federal COBRA law:

        •  For up to eighteen (18) months by paying the full Premium of the plan.

 

  • Dental Comparison and Plan Features:

    • For details concerning each Milwaukee County dental plan:

      • Review the comparison of Dental plans shown below to see the plan-by-plan comparison of the different benefit levels available through each plan. 

    • Before enrolling, think through your dental care needs when considering your dental plan options.

      • Once enrolled, you cannot change your plan until the next open enrollment period.

 

 

Benefit Comparison At-a-Glance:

Benefit

Milwaukee County

Conventional Plan

(Delta Dental)

Care-Plus (DMO)

Network of providers

Services may be performed by the dentist of your choice

Services must be performed at

a Dental Associates, Ltd. Dental Center

Annual Maximum Benefit

$2,500 per person

$3,000 per person

Annual Deductible
Diagnostic and Preventive:

$25 per person
(Maximum of 3 deductibles per family per year)

$25 per person
(Maximum of 3 deductibles per family per year)

 

- Dental exams and cleanings

100% of approved charges

100% of approved charges

- Bitewing x-rays

100% of approved charges

100% of approved charges

- Full mouth x-rays

100% of approved charges

100% of approved charges

Minor Restorations
(regular fillings: acrylics, amalgams, & composites)

80% of approved charges

100% of approved charges

Major Restorations

(crowns, inlays, on lays)

50% of approved charges

80% of approved charges

Prosthetics
(dentures, bridges)

50% of approved charges

80% of approved charges

Simple Extractions

80% of approved charges

100% of approved charges

Endodontics
(root canal treatment)

80% of approved charges

100% of approved charges

Periodontics

80% of approved charges

100% of approved charges

Orthodontics

50% of approved charges

with a:  $2500 life time maximum benefit

75% of approved charges

(includes coverage for adults

if approved by the plan).

Emergency Treatment

80% of approved charges

100% of approved charges at network provider.

(All other providers limited to a

$50.00 benefit maximum)

Ancillary Services

80% of approved charges

100% of approved charges

Oral Surgery

80% of approved charges

100% of approved charges
(surgeon fee only)

 

 

Note: This at-a-glance guide is intended as a summary only.

 

Note: Dental plans are only for active employees and their dependents.

 

  • For specific terms, provisions, conditions, limitations, or exclusions, please refer to your Summary Plan  Description.
  1. Limited to one service per 6 months
  2. Limited to 1 service per 36 months
  3. Precious metal (Noble/High Noble) costs are extra and are the responsibility of the patient/insured
     

 

  • Dental Enrollment Cards:

    • ID cards are proof of your enrollment, and are sent to you about three to four weeks after the effective date of your coverage, if you are newly enrolled.
    • Cards are mailed directly from the dental carrier you selected. 
      • If you need additional cards, request them directly from the dental care plan you have selected.
        • Please present this card whenever you request services from a dentist as it will speed up claim processing.

 

 

  • Dental Claims:

    • If you enrolled in a DMO:

      • You should not have to complete claim forms.

        • If you enrolled in the self-insured dental plan, you can obtain claim forms from the claims payer's office by calling: 1-800-236-3712.

    • Generally speaking:

      • Your dentist will submit claims directly to the claims administrator if you show the office your dental enrollment card with billing information on it.

    • If you must submit a claim:

      • Please provide all the information requested on the claim form as it will speed up claim processing;

        • NOTE: All claims should be submitted as soon as possible after services have been rendered.

          •  *All covered charges will be subject to your individual deductibles.**

    • Once you have met the deductible:

      • The claims administrator will make the appropriate payment directly to the provider

      • You will receive a letter with an Explanation of Benefits (EOB) from the claims administrator in the mail.

        • It is always a good practice to compare this EOB with any statements you have received.

        • This helps you to determine what portion of the bill remains to be paid by you directly to the dentist. EOBs also provide proof of dental expenses for tax purposes.

 

 

  • Benefit Levels:

    • Oral surgery benefits are payable for oral surgical procedures and surgical extractions of impacted teeth not covered under your medical plan.

    • If you are enrolled in a DMO and your dentist recommends oral surgery:

    • You will have to use specific providers for oral surgery.

 

 

  • Coordination of Benefits:

    • When a claim arises, and your family has more than one plan:

      •  Submit the claim to the primary dental carrier.

    • If you have a question about who is the primary dental carrier, see the points below.

    • If the County claims administrator determines that another carrier is the primary carrier for your claim:

      • The claim will be rejected and you may submit it to a different dental carrier.

    • At least once a year the County claims administrator will contact you by mail to determine if any other family members have dental insurance in order to properly minimize the County's dental costs.

      • You will also be contacted annually regarding the eligibility of dependents aged 19-25.

      • To help you determine who are the primary and secondary payers when both husband and wife are employed outside the home and both have dental coverage, the following rules apply:

        • The employer's coverage is always primary on its employee.

        •  Dependent Children. Payment order is based on birthdays rather than the gender of parents. This means that the plan of a parent with a birthday (month and day, not year) which occurs first in the calendar year will be the primary plan, i.e., pay its benefits first. **Exceptions to the birthday rule determination will occur if:

        • Another plan covering the children: ( For example a contract issued in another state; and does Does not contain the birthday rule );

          • In this situation, the plan of the male covering the children will pay its benefits before the plan of the female.

        • Parents are divorced or separated:

          • In this situation; the plan of a mother or stepfather with custody, or the plan of a parent with court ordered financial responsibility, will pay its benefits before the plan of the other parent.

 

 

  • Subrogation:

    • If you sustain a claim due to an illness or injury caused by another party, or as a result of a work related illness or injury:

      •  Your dental plan will attempt to collect their paid claim expenses from the insurance carrier of the other party.

    • You must inform the County carrier of such instances.

      •  It is required that you cooperate with the claims administrator or DMO in providing the necessary information in order for the plan to complete its investigation.

        • This is handled the same way as a homeowner's or renter's liability policy would be handled.

 

 

  • Pre-Certification:
    • Prior to getting extensive dental work, it is a good idea to obtain pre-certification of the treatment plan by the insurance company. 

 

 

 

 

 

 


Milwaukee County is an equal opportunity/affirmative action employer that is actively seeking qualified applicants for various positions throughout County government. Milwaukee County does not discriminate based on age, ancestry/national origin, arrest/conviction record, color, creed, disability, marital status, military membership, race, sex or sexual orientation.

 

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