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General Information
The Fund has contracted with Delta Dental of Illinois (Delta Dental) for access to the Delta Dental PPO and Premier networks. The name of your plan is the Chicago Regional Council of Carpenters Welfare Fund. Your Delta Dental Group # is 20203. Refer to Group #20203 when calling Delta Dental or filing claims with them. Delta Dental’s extensive network of dental providers gives you many choices and typically lower costs. The Plan’s benefit schedule is as follows:
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Delta Dental PPO
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Delta Dental Premier
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Out of Network
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Annual Maximum
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$1,500
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$1,500
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$1,500
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Annual Deductible (only applies to Basic and Major Care)
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$50/Person
$100/Family
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$50/Person
$100/Family
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$50/Person
$100/Family
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Balance Billing (The difference between the dentist’s actual charge and the amount allowed by Delta Dental.)
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Does not apply
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Does not apply
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Applies. You are responsible for charges exceeding Delta Dental’s maximum plan allowance
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Preventive/Diagnostic Care (1):
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· Dependent Children through Age 18
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Paid at 100% of Delta Dental’s PPO reduced schedule, not subject to the Annual Deductible or Annual Maximum
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Paid at 100% of Delta Dental’s Maximum Plan Allowance, not subject to the Annual Deductible or Annual Maximum
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Paid at 100% of Delta Dental’s maximum plan allowance, not subject to the Annual Deductible, but subject to the Annual Maximum
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· Adults - Ages 19 and older
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Paid at 100% of Delta Dental’s PPO reduced schedule, not subject to the Annual Deductible, but subject to the Annual Maximum
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Paid at 100% of Delta Dental’s maximum plan allowance, not subject to the Annual Deductible, but subject to the Annual Maximum
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Paid at 100% of Delta Dental’s maximum plan allowance, not subject to the Annual Deductible, but subject to the Annual Maximum
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Basic Care (2):
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· All Ages
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Paid at 80% of Delta Dental’s PPO reduced schedule, subject to the Annual Deductible and the Annual Maximum
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Paid at 80% of Delta Dental’s maximum plan allowance, subject to the Annual Deductible and the Annual Maximum
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Paid at 80% of Delta Dental’s maximum plan allowance, subject to the Annual Deductible and the Annual Maximum
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Major Care (3):
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· All Ages
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Paid at 80% of Delta Dental’s PPO reduced schedule, subject to the Annual Deductible and the Annual Maximum
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Paid at 80% of Delta Dental’s maximum plan allowance, subject to the Annual Deductible and the Annual Maximum
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Paid at 80% of Delta Dental’s maximum plan allowance, subject to the Annual Deductible and the Annual Maximum
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Orthodontia:
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· Dependent Children through Age 18
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The first $4,000 in orthodontia charges are paid at 50% with additional charges paid at 25% when services are rendered by a Delta Dental provider. Benefit payments will be reflective of any orthodontia payments made by the Fund or Delta Dental prior 07-01-2011. If you met the $2000 lifetime maximum benefit in that was in effect prior to 07-01-2011, all future orthodontia payments will be paid at 25%. |
Paid at 80% of the dentist’s usual fee subject to a Lifetime Maximum of $2,000
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· Adults - Ages 19 and older
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Paid at 80% of Delta Dental’s PPO reduced fee schedule, subject to a Lifetime Maximum of $2,000
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Paid at 80% of the dentist’s usual fee subject to a Lifetime Maximum of $2,000
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Paid at 80% of the dentist’s usual fee subject to a Lifetime Maximum of $2,000
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(1) Preventive/Diagnostic Care includes:
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ü Oral Evaluations (two in 12 month period)
ü Prophylaxis/Cleaning (two in a 12 month period)
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ü X-rays (bitewings two in a 12 month period; full mouth or panoramic once in 36 month period; cephalometric once in a 24 month period)
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ü Fluoride Treatment (once in a 12 month period for dependent children through age 18)
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ü Palliative Treatment
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(2) Basic Care includes:
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ü Fillings
ü Oral Surgery
ü General Anesthesia
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ü Periodontics
ü Endodontics
ü Consultations
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ü Sealants (1st & 2nd Molars only, for dependent children through age 14)
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ü Space Maintainers
ü Removal of cysts & tumors
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(3) Major Care (services are covered once in a 5 year period, to the day) include:
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ü Crowns, Jackets & Case Restoration
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ü Fixed & Removable Bridges
ü Partial & Full Dentures
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ü Veneers (Permanent Teeth Only)
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ü Implants and related services
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Note: All frequency limitations listed above are to the day.
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Is Your Dentist A Network Provider?
Visit the Delta Dental of Illinois’ website at www.deltadentalil.com to find out. To obtain a list of providers in your area, click on “Find a Network Dentist” and select a network. Remember, your Plan gives you access to both the PPO and Premier networks. Add your city and state or zip code and pick your mileage limitation (i.e. less than 5 miles). You may also add additional criteria, such as a provider’s specialty, or a specific name. You can also call 1-800-323-1743 between 7:00 am and 7:00 pm CST to speak to a Delta Dental representative. The name of your plan is the Chicago Regional Council of Carpenters Welfare Fund. Your Delta Dental Group # is 20203.
Filing a Claim for Benefits
All claims for dental services must be filed directly with Delta Dental of Illinois. Many network providers file electronically. Mail paper claims to: Delta Dental of Illinois, P.O. Box 5402, Lisle, IL 60532. Refer to Group #20203.
Appliances made for TMJ and Bruxism (Occlusal), including their Adjustments, and Snore Guards
The Plan covers appliances for TMJ and Bruxism, including their adjustments, and snore guards under the Comprehensive Medical Benefit as follows:
| Appliances for TMJ and Bruxism, including Adjustments
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80% of the Reasonable and Customary Allowance, subject to the $600 Individual Calendar Year Deductible and the Lifetime Maximum TMJ Benefit of $2,000 per Covered Individual
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| Snore Guards
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80% of the Reasonable and Customary Allowance, subject to the $600 Individual Calendar Year Deductible
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After a Covered Individual has exhausted his/her $1,500 calendar year maximum dental benefit, the Plan covers repair of teeth due to an accidental injury (not work related) under the comprehensive medical portion of the Plan. The patient must provide proof of accidental injury and must have been eligible for benefits at the time of injury.
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