Dental Options 2020 BALTIMORE CITY PUBLIC SCHOOLS

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Dental Options 2020

       BALTIMORE CITY PUBLIC SCHOOLS
Contents
Important Information for 2020 .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 1

Dental HMO (DHMO) Dental Plan  .  .  .  .  .  .  .  .  .  .  .  .  .  . 2

Preferred Dental PPO (DPPO) Dental Plan .  .  .  .  .  .  . 3

Summary of Dental PPO Benefits  .  .  .  .  .  .  .  .  .  .  .  .  .  . 4

Comparison of Benefits .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 5

Notice of Nondiscrimination and Availability of
Language Assistance Services  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 6
Important Information for 2020
Phone numbers
■■   DHMO Customer Service
     844-495-0653
■■   PPO Dental Customer Service
     866-891-2802

Dental mailing address
CareFirst BlueCross BlueShield
Dental Claims, Appeals and Correspondence
P.O. Box 14114
Lexington, KY 40512-4114

Dental plan options
Baltimore City Public Schools offers its employees
and their dependents the choice of two dental
plans. Your first option is a Dental HMO (DHMO)
plan, which is available at no cost to you and no
annual maximum.

Your second option is a dental buy-up, PPO plan
(DPPO). This means that, for an additional premium,
which is shared between you and your employer,
you can “buy-up” to the CareFirst BlueCross
BlueShield Preferred dental plan.

                                                      Baltimore City Public Schools—Dental Plan Options 2020   ■   1
Dental HMO (DHMO) Dental Plan
Advantages of the DHMO plan                                        Frequently asked questions
When you receive in-network care, you enjoy                        Do I need to select a dentist?
the following:                                                     Yes. Before you can receive benefits under this
■■   No claim forms.                                              plan, you must first select a dentist within the
                                                                   provider directory.
■■   No deductibles.
■■   Unlimited maximum benefit amount.                            Must family members go to the
                                                                   same dentist?
■■   Braces covered for children and adults.
                                                                   No. Each family member may select a different
Things to remember                                                 participating general dental office.
■■    ou can change your dentist at any time (if no
     Y
                                                                   What about orthodontia for adults
     balance exists).
                                                                   and children?
■■    ou can choose a different dentist for each
     Y
                                                                   Orthodontia is covered for both adults
     family member.
                                                                   and children.
■■   You must get a referral to see a specialist.
                                                                   Do I have to fill out claim forms after each
                                                                   routine visit?
                                                                   There are no claim forms to complete.

                   Over 100 general dentists and                   Are there any benefit maximums?
                   specialists in over 50 locations                There are no benefit maximums.
                   in Baltimore City.
                                                                   What happens in a dental emergency away
                                                                   from home?
                                                                   The dental program will cover the cost of
                                                                   diagnostic and therapeutic procedures delivered
                                                                   by any general dentist up to a maximum of $50
                                                                   per emergency occurrence greater than 50 miles
                                                                   from home.

                                                                   How do I find a participating
                                                                   DHMO dentist?
                                                                   To find a DHMO dentist, visit carefirst.com
                                                                   and select Find a Provider; select Dental from
                                                                   the options; select your search (by name or
                                                                   specialty); for network select Dental HMO; then
                                                                   your plan DHMO–5000S.

2     ■   Baltimore City Public Schools—Dental Plan Options 2020
Preferred Dental PPO (DPPO) Dental Plan
Baltimore City Public Schools is giving you the option to purchase an enhanced dental plan,
called the CareFirst Preferred Dental PPO (DPPO), which provides a larger network of dentists.

Advantages of the DPPO plan                           Frequently asked questions
■■    reedom of choice, freedom to save—With
     F                                                Who is eligible to enroll?
     Preferred Dental coverage, you have the          All Baltimore City Public Schools Employees
     freedom to see any dentist. This plan also       and their dependents. Eligible dependents are
     gives you the option to reduce your out-of-      covered until the end of the month in which they
     pocket expenses by visiting a dentist who        turn age 26 regardless of student status.
     participates in our network of Preferred
     providers. It’s your choice!                     How do I find a preferred dentist?

■■    reventive care and more—Benefits for you
     P                                                You can access an online directory of dentists
     and your family include regular preventive       24 hours a day at carefirst.com.
     care, X-rays, dental surgery and more. A         ■■   Under the Solution Center click on Find
     summary of your benefits is available on page         a Doctor.
     5 of this guide.
                                                      ■■    hen choose Dental under provider type
                                                           T
■■   Large network—Over 2,300 general and                 and select Preferred Dental (PPO).
      pediatric dentists in Maryland participate in
      CareFirst’s Preferred Dental Network. There     Once you are on this page, you can find all the
      are over 500 network dentists in Baltimore      dentists in your area by putting in a zip code, city
      City and 95% of participating dentists are      and state, or you can check to see if your dentist
      accepting new patients. You may already         is in our network by typing their last name under
      be seeing a dentist who is part of our          option 3.
      network. There are 77,000 dentists in the       How much will I have to pay for dental
      national network.                               services?
■■   Out-of-network care—For a higher out-of-        The chart on page 4 gives you an overview
      pocket cost, the Preferred plan allows you      of many of the covered services along with
      to go outside the network for care and still    the percentage you will pay for each class of
      receive valuable dental coverage.               services, both in and out-of-network.
■■    asy to use—If you see a Preferred dentist,
     E
                                                      Is there a lot of paperwork?
     you will incur lower out-of-pocket costs for
     all dental services and you will have no claim   There is no paperwork when you use a dentist
     forms to file. Preferred dentists have agreed    in our Preferred Dental Network. If you see a
     to accept CareFirst’s Allowed Benefit as         non-participating dentist, you may be required
     payment in full for covered services. Once you   to pay all costs at the time of care, and then
     meet your deductible and coinsurance, you        submit a claim form in order to be reimbursed
     won’t be faced with additional expenses.         for covered services.

■■    ationwide emergency coverage—
     N                                                Who can I call with questions about my
     Emergency dental coverage is there when you      dental plan?
     need it, no matter where you are using your      Call CareFirst BlueCross BlueShield toll free at
     out-of-network coverage.                         866-891‑2802.

                                                           Baltimore City Public Schools—Dental Plan Options 2020   ■   3
Summary of Dental PPO Benefits
                                                                                               You Pay                      You Pay
    Benefits
                                                                                             In-Network                  Out-of-Network
    PREVENTIVE & DIAGNOSTIC SERVICES (CLASS I)
    ■■ Oral Exams (two per benefit period)
    ■■ Cleanings (two per benefit period)
    ■■ Bitewing X-rays (two procedures per benefit period)

    ■■ Full mouth X-ray or panoramic and bitewing X-ray combination and one
                                                                                                                        Difference between
       cephalometric X-ray (once per 36 months)
    ■■ Fluoride treatments (two per benefit period per member, up to age 19)
                                                                                                                      CareFirst’s payment and
                                                                                               No charge
    ■■ Sealants on permanent molars (once per tooth per 36 months per
                                                                                                                       the Non-Participating
                                                                                                                         Dentist’s charges2
       member, up to age 19)
    ■■ Space maintainers for prematurely lost posterior baby teeth (once per

       60 months)
    ■■ Emergency oral exam and palliative treatment

    BASIC SERVICES (CLASS II)
    ■■ Fillings using approved materials (one filling per surface per 12 months)        20% of Allowed Benefit         20% of Allowed Benefit
    ■■ Oral surgery (treatment for cysts, tumor and abscesses)                            after deductible1              after deductible2
    ■■ General anesthesia rendered for a covered dental service

    ■■ Tooth extractions

    MAJOR SERVICES (CLASS III)
    ■■  Tooth scaling and root planing (once per 24 months, one full mouth              40% of Allowed Benefit         40% of Allowed Benefit
        treatment)                                                                         after deductible               after deductible
    ■■ Gum surgery including bone surgery, tissue surgery and bite

        adjustments (once per 60 months)
    ■■ Root canal treatment

    ■■ Full and/or partial dentures (once per 60 months)

    ■■ Fixed bridges, crowns, implants, inlays and onlays (once per 60 months)

    ■■ Denture adjustments and relining (limits apply for regular and

        immediate dentures)
    ■■ Recementation of crowns, inlays and/or bridges (once per 12 months)

    ■■ Repair of prosthetic appliances as required (once in any 12 month

        period per specific area of appliance)
    ORTHODONTIC SERVICES (CLASS IV)
    ■■   Benefits for orthodontic services (braces) are available for covered                   50% of                          50% of
         members who meet treatment criteria. Covered services are limited to              Allowed Benefit1                Allowed Benefit2
         36 consecutive months of covered services.
    ANNUAL DEDUCTIBLE AND MAXIMUM                                                              $50 Individual / $150 Family Deductible
    (IN- AND OUT-OF-NETWORK)                                                                         (applies to classes II and III)
                                                                                               $1,500 Orthodontic Lifetime Maximum
                                                                                                      $1,500 Annual Maximum

1
    For in-network providers, plan payment is based on dental plan’s negotiated fee schedule. After the deductible is met, Preferred dentists
    accept 100% of the Allowed Benefit as payment in full for covered dental services.
2
    If you use an out-of-network provider, you will need to pay the provider and will be reimbursed by the plan using an out-of-network plan
    allowance schedule. Your out-of-pocket costs will most likely be higher. Non-Participating Dentists may bill the Member for the difference (if
    any) between the Allowed Benefit and the Non-Participating Dentist’s actual charge for Covered Dental Services.
Summary of Exclusions
Not all services and procedures are covered by your benefits contract. This plan summary is for comparison purposes only and does not create
rights not given through the benefit plan.

4          ■   Baltimore City Public Schools—Dental Plan Options 2020
Comparison of Benefits
This chart shows key differences between the DHMO 5000S Plan and the DPPO Plan Estimated Out-of-
Pocket expenses for the most commonly used services. For a complete listing of the DHMO 5000S Plan:
Procedures, copayments and limitations, visit the Schools’ benefits website at www.baltimorecityschools.org.

       ADA                                                                   DHMO1 5000s                            DPPO
    procedure       Description
                                                                                                      In-Network    2
                                                                                                                          Out-Network3
      code                                                                        You Pay
                                                                                                        You Pay             You Pay
        120         Periodic Oral Evaluations                                       $0.00                 $0.00                 $0.00
                    (once per 6 months)
        272         Bitewings—Two Films                                             $0.00                 $0.00                 $0.00
        330         Panoramic Film                                                  $0.00                 $0.00                 $0.00
       1110         Prophylaxis (cleaning)—Adult                                    $0.00                 $0.00                 $0.00
                    (once per 6 months)
       1120         Prophylaxis (cleaning)—Child                                    $0.00                 $0.00                 $0.00
                    (once per 6 months)
       2140         Amalgam—One Surface, Permanent                                  $0.00                 $9.90                 $20.40
       2160         Amalgam—Three Surface, Permanent                                $0.00                 $15.12                $32.40
       2330         Resin—Based Composite, One Surface, Anterior                    $0.00                 $14.40                $24.80
       2332         Resin—Based Composite, Three Surface, Anterior                  $0.00                 $20.80                $37.60
       2750         Crown—Porcelain/High Noble Metal                               $245.00               $248.00               $354.80
       2751         Crown—Porcelain/Noble Metal                                    $235.00               $238.00               $325.60
       3330         Molar Root Canal                                          $185.00/$490.005           $238.00               $332.00
       4260         Osseous Surgery                                           $196.00/$495.00     5
                                                                                                         $239.00               $340.00
       4341         Periodontal Scaling and Root Planing—Quad                  $40.00/$86.005             $48.00                $81.60
       5110         Complete Denture—Upper                                         $249.00               $267.48               $522.00
       7140         Extraction, Erupted Tooth or Exposed Root                  $40.00/$73.005             $15.40                $25.20
       7210         Surgical Extraction of Erupted Tooth                       $40.00/$80.00  5
                                                                                                          $26.80                $43.40
       7240         Removal of Impacted Tooth—Completely Bony                 $85.00/$155.005             $45.18                $78.40
       8080         Comprehensive Orthodontic Treatment—Adolescent                $1,850.00             $1,480.50             $3,198.004
       9110         Palliative Treatment                                           $15.00                 $0.00                 $0.00

1
    Benefits are available in-network only.
2
     ember estimated out-of-pocket expense when services are rendered by a CareFirst Preferred Participating Dentist without consideration of
    M
    deductible or annual benefit maximum.
3
     ember estimated out-of-pocket expense based upon dentist fee at 50th percentile of 2007 NDAS schedule without consideration of
    M
    deductible or annual benefit maximum. Member subject to balance billing over and above this amount.
4
    Allowed Benefit ($4,698) minus the $1,500 Ortho Lifetime Maximum.
5
    Member copayment when service rendered by Participating Specialist.

This document is for comparison purposes only and does not create rights not given through the benefit plan.

                                                                               Baltimore City Public Schools—Dental Plan Options 2020      ■   5
Notice of Nondiscrimination and
Availability of Language Assistance Services
(UPDATED 8/5/19)

CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc., CareFirst Diversified Benefits and all of their
corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the
basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them
differently because of race, color, national origin, age, disability or sex.

CareFirst:

■■   Provides free aid and services to people with disabilities to communicate effectively with us, such as:
       Qualified sign language interpreters
       Written information in other formats (large print, audio, accessible electronic formats, other formats)
■■   Provides free language services to people whose primary language is not English, such as:
       Qualified interpreters
       Information written in other languages

If you need these services, please call 855-258-6518.

If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis
of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights
Coordinator by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is
available to help you.

To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinator
as indicated below. Please do not send payments, claims issues, or other documentation to this office.

Civil Rights Coordinator, Corporate Office of Civil Rights
Mailing Address                         P.O. Box 8894
		                                      Baltimore, Maryland 21224

Email Address                           civilrightscoordinator@carefirst.com

Telephone Number                        410-528-7820
Fax Number                              410-505-2011

You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc.,
Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and
Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business
name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). The Blue Cross® and Blue Shield® and the Cross and Shield Symbols are registered service marks of the
Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

6     ■    Baltimore City Public Schools—Dental Plan Options 2020
Notice of Nondiscrimination and Availability of Language Assistance Services

Foreign Language Assistance

                                                       Baltimore City Public Schools—Dental Plan Options 2020   ■   7
Notice of Nondiscrimination and Availability of Language Assistance Services

8    ■   Baltimore City Public Schools—Dental Plan Options 2020
Notice of Nondiscrimination and Availability of Language Assistance Services

                                                      Baltimore City Public Schools—Dental Plan Options 2020   ■   9
CareFirst BlueCross BlueShield
CareFirst BlueChoice, Inc.
10455 Mill Run Circle
Owings Mills, MD 21117-5559
carefirst.com

Health benefits administered by:

C O NNE C T W I T H US :

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services,
Inc. which are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross® and Blue Shield® and the Cross and
Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and
Blue Shield Plans.

BOK5182-1S (9/19)
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