The Fund offers Dental Benefits coverage to all eligible participants and their eligible dependents.
Covered Dental Benefits
Necessary dental care is a service or supply that is required to identify or treat a dental condition, disease or injury. The fact that a dental provider prescribes or approves a service or supply to be rendered does not make it necessary dental care. The service or supply must be all of the following:
- Provided by a dental provider, or solely in the case of cleaning or scaling of teeth, performed by a licensed, registered dental hygienist under the supervision and direction of a licensed dentist;
- Consistent with the symptoms, diagnosis or treatment of the condition, disease or injury;
- Consistent with standards of good dental practice;
- Not solely for the patient’s or the dental provider’s convenience; and
- The most appropriate supply or level of service that can safely be provided to the patient.
Annual Dental Maximum
Dental and orthodontia benefits are not subject to any annual deductible. For dental benefits, however, there will be an annual dental maximum per covered individual per each calendar year. The dental maximum is an annual maximum of $2,500 per covered individual per calendar year. The Plan’s annual dental maximum will not apply to pediatric dental care to the extent that such benefits are determined to be essential health benefits. Notwithstanding the foregoing, all applicable visit or frequency limitations will remain in effect.
A Note About Orthodontia Benefits
Orthodontia benefits are available for Eligible Dependent children under the age of 19 only.
All dental service over $500, all dental implants, and all orthodontia services must be pre-approved by Sele-Dent. Prior approval is necessary even if your dental provider is a participating dental provider in Local 94’s Network or Sele-Dent’s Network.
An approved treatment plan submitted by a dental provider can be used by that provider for one year from the date of the approval, provided that the approved services for the treatment plan shall be limited to the remaining balance of your applicable annual maximum for the calendar year at issue at the time the services are rendered. In addition, your approved treatment plan is subject to your eligibility at the time the services are rendered.
Dental Benefit Administrator
Sele-Dent administers all dental and orthodontia claims for the Plan. As such, all dental and orthodontia claim submissions (PDF) should be sent directly to:
One Huntington Quadrangle
Melville, NY 11747
All customer service questions may be directed to Sele-Dent at (800) 520-3368, Monday through Friday, 8:00 AM to 4:00 PM. In addition, you may also visit Sele-Dent online.
Local 94 Network
The Fund has an arrangement with certain dental providers (“Local 94 Network”) who have agreed to accept the Plan’s Fee Schedule (PDF) as payment in full except for dental implants where copayments apply. Prior to service being rendered, please verify that your dental provider is currently in the Local 94 Network.
To be certain of the applicable fees, if any, for your procedure, you or your dental provider’s office may contact the Fund Office at (212) 541-9880. In addition, you or your dental provider’s office may call Sele-Dent at (800) 520-3368 or visit its website.
Sele-Dent PPO Network
If you don’t visit a dental provider in the Local 94 Network, you can visit a dental provider in the Sele-Dent PPO. However, there will be applicable copayments (PDF) for services rendered by dental providers in the Sele-Dent PPO.
If you reside outside the New York Metro area, please call Sele-Dent for a dental provider near you. Please note co-payments may apply and may differ based on your location.
If a dental provider is a participating dental provider in both the Local 94 Network and the Sele-Dent PPO Network then the participating dental provider will be reimbursed the applicable allowances in accordance with the Plan’s Fee Schedule as payment in full with no out-of-pocket cost to the Member.
Non-Participating Dental Provider
If you visit a non-participating dental provider, you may still receive dental services and be reimbursed at the existing Plan's Fee Schedule. To be reimbursed, you must complete and return a Sele-Dent Claim Form (PDF).
A non-participating dental provider (e.g., a dentist that is not in either the Local 94 Network or Sele-Dent’s PPO Network) may not accept the Plan’s coverage as payment in full. If you choose a non-participating dental provider you will be reimbursed according to the Plan’s Fee Schedule.
You will be fully responsible for any excess charges over the applicable fees set forth under the Plan’s Fee Schedule. To this end, a non-participating provider will bill you directly for all charges over the Plan’s Fee Schedule (PDF).
Dental Implants and Orthodontia
Dental implants are covered procedures when they are approved by Sele-Dent and services are rendered by a Local 94-panel dental provider. If you visit a Sele-Dent or an Out-of-Network dental provider for implants, you will be responsible for fees in excess of the Local 94 Fee Schedule (PDF).
Orthodontia benefits are available for all Eligible Dependent children under the age of 19 only. The orthodontic lifetime maximum is $2154.00. Orthodontics are covered procedures when services are rendered by an orthodontist within the Local 94 Network. If you visit a Sele-Dent or Out-of-Network orthodontist you will be responsible for fees in excess of the Local 94 Fee Schedule (PDF).
NOTE: All dental implants regardless of the cost must be pre-approved by Sele-Dent.
|Surgical placement of implant body: endosteal implant
Procedure code D6010
Procedure code D6056 or D6057
|Abutment supported porcelain fused to metal crown (predominantly based metal or noble metal)
Procedure code D6059 or D6060
Local 94’s Fee Schedule and the Member’s Co-payment will be considered payment in full when using a Local 94 dental provider.
Dental Benefits Limitations And Exclusions
- Dental work that starts after the termination of coverage is not covered. However, you will continue to be covered, for 90 days after termination of coverage, for dental work that was started before termination of coverage.
- Surgical implants except where Medically Necessary and in cases where alternative procedures are not recommended. Whether these conditions are satisfied will be determined by the Trustees in their sole and absolute discretion.
Dental and/or Orthodontia Services Not Covered by the Fund:
- Dental conditions that existed prior to your eligibility for these benefits under the Plan may be covered, but dental work done prior to eligibility is not payable.
- Treatment of and appliances for temporomandibular joint (TMJ) syndrome are not covered by the Fund.
- Dental benefits are not payable for replacing lost appliances.
- Dental benefits are not payable for prosthetic appliances made in connection with periodontal care, unless it replaces a missing tooth.
- Cosmetic Dentistry including, without limitation, laminate, veneers and tooth bleaching.
- Orthodontia is not covered for anyone other than dependent children under age 19.
- Reimbursement for any services in excess of the applicable frequency limitations specified in the Plan’s Fee Schedule (PDF) with regard to either the Local 94 Network or Sele-Dent’s PPO Network.
- Charges in excess of your annual Maximum Allowance.
- Expenses incurred for broken appointments.
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What if I get injured on the job?
Benefits are not payable for occupational accidents, injuries or sickness covered by any Workers’ Compensation statute or similar legislation. All claims in relation to an injury or a condition that is directly or indirectly job-related are not covered by the Fund. For more information, please visit the Health and Safety section.