Dental Benefits

The SBA Health & Welfare Fund provides a choice of two dental program options. You may select one of the following programs for you and your eligible dependents. These choices include a:
(1) Self-Insured, Fee-for-Service Reimbursement Schedule Plan, and a
(2) Self-Insured, Comprehensive Managed Care Option.

Eligibility
Members and their eligible dependents as defined in the section titled “Eligibility FAQs” are covered. However, only eligible dependent children up to their 19th birthday are covered for orthodontia benefits.

Fee-for-service dental reimbursement schedule
You may select any duly licensed dentist or specialist whom you and/or your eligible family members prefer. Upon completion of dental services and submission of a required claim form you will be reimbursed according to the schedule of payments for expenses you incur for preventive, basic and major non-orthodontia dental services. There are no deductibles to satisfy, however you are responsible to your dentist for any costs beyond the schedule of reimbursement.

Submitting a claim
Claim forms are available through our dental provider, Healthplex, or at the Fund office. The forms provide instructions concerning proper filing. Read these forms carefully. When you have a claim, you should promptly submit the completed claim form to Healthplex direct. Claims submitted 180 days after completion of dental services will be denied. It may become necessary to submit additional proof or information concerning a particular claim. Healthplex reserves the right to require such proof or information, including but not limited to any or all of the following:

(1) dental chart showing work to be performed before the treatment of submitted claim,
(2) X-rays, lab or hospital reports,
(3) cast molds or other evidence of the dental condition or treatment,
(4) post-treatment examination of the patient, at the Fund’s expense, by a dentist it selects.

Claims must be submitted direct to:

Healthplex
333 Earle Ovington Blvd.
Uniondale, New York 11553
(800) 468-0600

Download claim form
Click here to download a claim form.

How benefits are affected by the alternate benefit provision
When more than one dental service would provide suitable treatment, your benefits will be based on the treatment determined by Healthplex to be best suited to your condition by accepted standards of dental practice. If two services provide satisfactory results according to accepted standards of dental practice and one service is less expensive than the other, the Fund will reimburse up to the scheduled allowance for the less expensive service.

In addition to this description, each subscribing participant is provided with a Healthplex brochure expanding on the above provisions and containing the schedule of reimbursement for most frequently performed dental services. This booklet and the applicable Healthplex brochure contain a general description of your dental benefit plan for your use as a convenient reference. All benefits are governed by the provisions of the master group contract between Healthplex and the Health & Welfare Fund.

Pre-authorization
When a dentist’s charge for a proposed course of treatment is $250 or more, a dental service treatment plan must be submitted to Healthplex for approval before treatment is started. X-rays and a description of the procedure must be included with treatment plan being submitted for pre-authorization. The treatment plan, prepared by the dentist, must be submitted direct for review by Healthplex, no later than 30 days after the initial examination. Pre-authorization by Healthplex is limited to the approval of the course of the treatment proposed; it does not include approval of payment for services not covered under the dental plan, nor is it a determination of the patient’s eligibility.

A claim submitted to Healthplex for pre-authorization will be returned to the dentist indicating their decision. Your dentist should contact you upon receipt of the returned form. Approval will include the maximum amount of reimbursement you will receive upon completion of the approved dental services. The dentist may proceed to provide the approved services after you have been notified of the reimbursement amount and agree to have the approved work performed. Healthplex reserves the right to modify or deny payment of claims of $250 or more which have not been approved by Healthplex before treatment begins.

Orthodontia benefit eligibility
Orthodontia benefits are available only to eligible dependent children up to their19th birthday only.

Orthodontia benefits
Benefits shall be provided for eligible dependent children consisting of necessary diagnosis and treatment of Class 2 and 3 malocclusions which cause interference with normal functions. The treatment plan, with requires X-Rays and molds, must be approved by Healthplex before treatment is started. Orthodontia services are reimbursed according to a fee schedule up to a lifetime maximum of $1,905. A period of orthodontia treatment starts on the first day your eligible dependent incurs a covered expense for orthodontia and extends for a period of 20 consecutive months, or less if the treatment is completed in less time. The orthodontia benefit payments are not included in the yearly dental maximum.

Covered orthodontia expenses
(1) Initial work up, diagnosis and insertion of appliance are covered once in a lifetime up to $460.

(2) $70 per active monthly treatment with a maximum of 20 consecutive treatments. If your dependent misses a monthly treatment, Healthplex will not reimburse for that month but it will be counted toward the 20 consecutive treatments. Also covered are 3 passive treatments at $15 per treatment. Please note that the Fund does not cover replacement or repair of any lost or damaged orthodontic appliance.

Coverage exclusions
Charges incurred for the following services will not be paid:

• Treatment from anyone other than a licensed dentist or physician (except routine cleaning of teeth and fluoride application which can be performed by a licensed dental hygienist under the direct supervision of, and billed by, a dentist or physician),
• Facings, veneers, or similar material placed on molar crowns or pontics,
• Services performed by a member of your or your spouse’s immediate family, unless acceptable proof of payment is provided for those services,
• Services or supplies that are cosmetic in nature or directed toward a cosmetic end,
• Any service or supplies incurred, installed or delivered before you or your dependent(s) become eligible for benefits from this Fund,
• Replacement of a lost, missing or stolen prosthetic orthodontic appliance,
• A broken appointment,
• Any services received from a medical department, clinic or any facility provided or furnished by your spouse's/domestic partner's employer,
• Any service that is not medically necessary or is not normally performed for proper dental care of the condition or any:
service that is not approved by the attending dentist,
• services or supplies that do not meet accepted standards of dental practice including experimental or investigational services or supplies,
• services or supplies received as a result of dental disease, defect, or injury due to an act of war, declared or undeclared,
• any duplicate prosthetic appliance except as specifically provided,
• oral hygiene, or dietary instruction or plaque control programs,
• implants
• wiring or bonding teeth or crowns to act as a splint for any reason,
• injury arising from employment, covered by workers’ compensation,
• services or supplies for which you are not required to pay,
• appliances, restorations or any procedure to alter vertical dimension for cosmetic purposes, or
• services or supplies not specifically listed under covered expenses.