UFCW Midwest - Midwest Health and Pension Funds

United Food & Commercial Workers

Unions and Employers

Midwest Health and Pension Funds

Dental Benefit

Your eligible dependents are covered only if you elected Family Coverage and are working enough hours to qualify for full-time coverage.

Your dental coverage pays a significant portion of the cost of covered dental services for you and your eligible dependents. The Plan pays only for services that are provided by a licensed dentist or dental hygienist, including any required supplies. Payment for covered dental expenses is limited to a scheduled amount. The most common procedures are listed in the Schedule of Dental Procedures.

How the Plan Pays Benefits

You pay a $50 deductible per person each calendar year. The deductible does not apply to diagnostic and preventive services, which are described below.

The Plan pays the balance of the remaining expense for covered dental expenses, up to the maximum amount shown in the Schedule of Dental Procedures.

For any patient who is under age 19, the Plan pays 100% of the Usual and Customary Fee for oral exams, cleanings, sealants, x-rays and, after the $50 deductible, fillings.

Dental Fee Discounts

The Health Fund participates in a Labor Dental PPO Network through Dental Network of America (DNoA). If you use a dentist who participates in DNoA’s Labor Dental PPO Network, you can save on dental fees. Your out-of-pocket costs will be reduced due to the discounted fees.

To find out if your dentist is already in the network or to find a new dentist and maximize your savings, do any of the following:

  • Visit the DNoA website at www.dnoa.com
  • Call DNoA at 866-522-6758 between 8:00 a.m.–6:00 p.m. (Central Standard Time)

Your Health ID Card allows you to access Labor Dental PPO Network dentists and obtain discounts. The next time you visit the dentist, be sure to present your ID Card.

Covered Dental Expenses

The following services and supplies are covered under the Dental Benefit.

Diagnostic and Preventive Services:

  • Oral examination, if performed by a dentist
  • Prophylaxis (teeth cleaning), if performed by a dentist or dental hygienist; limited to twice a calendar year
  • Necessary x-rays—complete series, including bitewings, limited to once per calendar year; panoramic limited to once per calendar year
  • Fluoride treatments
  • Sealants

Other Services:

  • Tooth extractions
  • Amalgam and resin-based composite filling restorations for decaying or broken teeth
  • Onlays and crowns
  • Space maintainers
  • Oral surgery, including extractions and surgical procedures
  • Periodontal treatment (treatment of the gums and bones), including, but not limited to, periodontal scaling and periodontal maintenance procedures
  • Endodontic treatment, including root canal therapy
  • Initial fitting and replacement of complete and partial dentures and bridges. Replacements will be payable only once every five years

Orthodontic Benefit

Covered orthodontic expenses are payable at 50% up to the lifetime maximum benefit of $1,000.

Temporomandibular Joint Disorders (TMJ): The following services and supplies for treatment of TMJ are covered expenses payable under the Orthodontic Benefit:

  • Arthrocentesis
  • Cephalometric x-rays
  • CT scans
  • Diagnostic casts
  • Facebow transfer
  • Hinge axis mounting
  • Hydrostatic appliance
  • Injection of Xylocaine, alcohol, Benadryl, saline solutions or Cortisone
  • Magnetic Resonance Imaging
  • Occlusal equilibration
  • Occlusal guards
  • Occlusal splints
  • Orthopedic repositioners
  • Panoramic radiographs
  • Temporomandibular joint x-rays
  • Tomogram x-rays

Alternate Procedures

In some cases, there is more than one way to treat a dental problem. Your Plan will pay benefits based on the procedure that will provide a professionally acceptable result as determined by national standards of dental care, in a cost-effective manner.

Pre-Treatment Estimate

Whenever you expect that your dental expenses for a course of treatment will be more than $500, you may use the pre-treatment estimate procedure. You and your dentist should complete the regular dental claim form, indicating the type of work to be performed with the estimated cost. Once it is received, the form will be reviewed and you and your dentist will be sent a statement showing what the Plan will pay. This procedure lets you know how much you will have to pay before you begin treatment.

What’s Not Covered

Expenses not covered under the Dental Benefit include the following:

  • services or supplies provided or paid for by any other employer’s medical or dental coverage, mutual benefits association, labor union or similar organization under provisions governing the coordination of benefits
  • cosmetic treatment
  • replacement of a lost or stolen appliance
  • customization of a dental prosthesis, including personalized, elaborate, or precision attachment dentures or bridges or specialized techniques, unless the prosthesis cannot be made to function without the specialized technique
  • periodontal scaling procedures on patients not manifesting Case Type II, III or IV periodontal disease
  • complete series (including bitewings) of x-rays more often than once each calendar year
  • panoramic x-rays more often than once each calendar year
  • prophylaxis treatments are limited to a maximum of four per calendar year, as follows: up to two can be dental prophylaxis (ADA codes 1110/1120); up to four can be periodontal prophylaxis (ADA code 4910) provided that they are performed as adjunctive periodontal treatment rendered with respect to active periodontal treatment
  • temporary bridgework and temporary crowns except when a temporary crown is needed due to a fractured tooth
  • anything excluded under the Plan’s General Exclusions and Limitations

 

(Updated 11/20/15)