Adult & Dependent
Orthodontic
Benefit Rider
TYPE
LIFETIME MAXIMUM BENEFIT
BENEFIT
$1000
$41.70 Monthly benefit received
during treatment/enrollment
A-Ortho Adult & Dep.
All orthodontic procedures as listed herein are payable at 50% by Health Resources, Inc.
(HRI) up to the maximum benefit payment per month and the LIFETIME MAXIMUM BENEFIT.
Limited Orthodontic Treatment
D8010 Primary Dentition
D8020 Transitional Dentition
D8030 Adolescent Dentition
D8040 Adult Dentition
Interceptive Orthodontic Treatment
D8050 Primary Dentition
D8060 Transitional Dentition
Comprehensive Orthodontic Treatment
D8070 Transitional Dentition
D8080 Adolescent Dentition
D8090 Adult Dentition
Treatment to Control Harmful Habits
D8210 Removable Appliance Therapy
D8220 Fixed Appliance Therapy
BENEFIT PAYMENTS LIMITED TO A LIFETIME MAXIMUM
1. Claims for orthodontic procedures are payable only until the covered dependent reaches the employer group’s maximum dependent age & whether or not treatment has been completed or maximum lifetime orthodontics benefits have been paid.
2. Initial orthodontic claims must be submitted by the dentist. Quarterly updates must
then be verified by the dentist after treatment is initiated; payments at a rate of 50%
of covered charges billed will be made monthly.
3. Benefit payments for orthodontic services are IN ADDITION to the maximum annual benefit payments for non-orthodontic services.
4. Benefit payments stop when plan coverage ends, even if total payments have not reached the lifetime maximum & whether or not treatment has been completed.
5. To receive maximum benefit, patient must be in active orthodontic treatment a
minimum of two years.
6. A lifetime maximum benefit is the maximum amount HRI will pay in orthodontic
benefits to a covered person during that individual’s lifetime. Once an individual has exhausted his or her lifetime maximum benefit under any HRI plan, additional charges will be excluded.
PRE-EXISTING CONDITIONS
1.The dentist providing orthodontic services must identify to HRI when orthodontic
services began, the estimated total time for treatment, and the total cost for treatment.
2.Benefits may be paid even if orthodontic services began before dental coverage.
The total cost for treatment will be divided between two periods:
a. Period #1: the date treatment started to the date dental coverage began
(this cost will NOT be covered);
b. Period #2: the date dental coverage began to the date when treatment should
be completed (this cost will be covered for the time REMAINING in the
treatment program).
Payments are subject to the limitations previously described.
Published: 2009-01
LIMITATIONS
Dental Health Options (DHOs) offer coverage for many services, but some restrictions apply. Coverage for some procedures is limited by age, frequency, or specific teeth. Change of coverage or
reinstatement of coverage does not eliminate frequency limitations. The following are some of the
limitations associated with this plan. For a complete list, refer to your member Plan Book.
• Charges for more than two examinations, of any procedure code combinations, are not
allowable within any consecutive 12 month period. The 12 month period is NOT based on
contract year or calendar year.
• Routine teeth cleaning and applying fluoride are covered every 6 months.
• X-rays of your whole mouth will be paid once every 4 years. Cavity-checking x-rays (bitewings) are covered once per 12 months. Obviously, x-rays should be taken as often as your particular need indicates.
• Fillings will not be covered if they are replacements within 3 years of the original or placed
within 3 years of a crown.
For work in progress, HRI recognizes the American Dental Association’s definition for the date of
service/payment.
Provider dentists are independent contractors and are not HRI employees.
GENERAL EXCLUSIONS
All DHOs are issued subject to the following general exclusions.
1. Within the HRI service area, claims will not be paid for services rendered by dentists who are not contractual providers for HRI.
2. To be considered for payment, a claim must be submitted within 1 year from the date of service.
3. HRI will not pay claims for the following:
• Procedures which are not listed in the employer’s Master Group Contract.
• Dental services rendered before the effective date of coverage or after the last day in which
coverage terminated.
• Dental services covered under non-dental insurance.
• Charges made by hospitals.
• Services performed primarily to rebuild occlusion or for full mouth reconstruction.
• Claims for enrollees until HRI receives the appropriate premium payment.
• Claims for services which are not completed.
• Claims for duplicates, lost, or stolen prostheses or appliances.
4. Dependent coverage: Unless the laws of the state in which your principle place of business
resides mandates otherwise for dependent coverage:
• Indiana: HRI will pay claims until age 24, unless the employer group defines differently.
• Kentucky: HRI will pay claims for an unmarried dependent child based on 2 options. (1)
Persons age 19-25 who are enrolled as fulltime(12 hours or more) students at an
accredited educational institution and primarily dependent on the policyholder for
maintenance and support. (2)Coverage until age 25 which may have tax implications.
5. Dependents who suffer a permanent physical or mental disability that precludes their gainful
employment may qualify for coverage beyond the applicable age limit. However, HRI accepts each
individual employer’s definition of “dependent”. Such definition has precedent over HRI’s criteria.
Although reasonable effort has been made to represent the intent of contract language, your
employers Master Group Contract and your Member Plan Book control the relationship of the
parties at all times.
E N R O L L M E N T I N F O R M AT I O N
OPTION 4
CONGRATULATIONS! You and your family have the opportunity
to enroll in Dental Health Options by Health Resources Inc. (HRI).
Members using participating providers enjoy:
• No deductibles
• No claim forms
• No waiting periods
• No pre-existing condition clauses
• No balance billing
• A large dentist network, including specialists
• High annual maximum benefits
• Exams, x-rays, routine cleanings, and fluoride covered
at 100% with few limitations
Complete and submit a Subscriber Enrollment Application to begin coverage. No
one may add, drop or change coverage during each contract period unless a change
of family status or employment termination occurs.
As a subscriber, you will receive ID cards and every time you use Dental Health
Options, you will receive an Explanation of Benefits. Visit a dentist in our exclusive
network to receive coverage and realize the benefits from our negotiated discounts! If you live or work in a county where there are no participating dentists, HRI will
provide coverage from a non-network dentist in either county. Utilize our website
www.hri-dho.com at any time of day to access a detailed Plan Book of all covered
procedures and limitations associated with your option, verify coverage, check on
claims for you and your covered dependents, and review a current provider dentist
directory.
Insuring Smiles for the Whole Family!
Health Resources Inc.
Dental Health Option 4
D E N TA L S E R V I C E S C O V E R E D AT 1 0 0 %
DIAGNOSTIC SERVICES
Examinations
Periodic, limited, comprehensive,
periodontal
Radiographs (x-rays)
Complete series (full mouth x-rays)
Panoramic films
Single x-ray(s)
Cavity checking
Surgical films of jaws
TMJ films
Cephalometric film
Other procedures
Pulp vitality tests
Diagnostic casts
Oral/facial images
PREVENTIVE SERVICES
Routine teeth cleaning
Fluoride applications (adult or children)
Sealants (under 15 years of age,
permanent molar teeth only)
Space maintainers (under 13 years of
age, not orthodontic retainers)
Fixed, unilateral, and bilateral
Removable, bilateral
Recementation
D E N TA L S E R V I C E S C O V E R E D AT 8 0 %
RESTORATIVE
Silver fillings
Primary teeth
Permanent teeth
White fillings
Anterior teeth
Posterior teeth
Inlay/Onlay (gold & porcelain)
Crowns (single tooth)
Porcelain/ceramic
Full cast
¾ cast
Prefabricated stainless steel
Recementation
Other restorative services
Temporary filling
Crown buildup including pins
Pin retention
Post & core
Labial veneers (anterior teeth)
ENDODONTICS
Vital pulpotomy (primary teeth only)
Pulp therapy (primary teeth only)
Root canal therapy
Anteriors
Premolars
Molars
Retreatment
Apexification
Apicoectomy
Retrograde filling
Root amputation
Hemisection
Preparation for post
PERIODONTICS
Gingivectomy, per quadrant
Crown lengthening
Osseous surgery
Soft tissue grafts
Distal or proximal wedge
Scaling and root planing
IMPLANT SUPPORTED PROSTHETICS
(RESTORATIONS)
Crowns, abutment supported (single tooth)
Porcelain/ceramic
Cast metal
ORAL SURGERY
Extractions
Routine removals or exposed roots
Surgical removals
Impactions
Natural tooth reimplantation
Surgical exposure or unerupted tooth
Biopsy, soft tissue
Incision and drainage of abscess (intraoral)
Frenectomy
Excise hyperplastic tissue (removal
of excess gum tissue)
ADJUNCTIVE SERVICE
Bleaching (anterior teeth, supervised
in office)
D E N TA L S E R V I C E S C O V E R E D AT 5 0 %
PERIODONTICS
Guided tissue regeneration
Full mouth debridement
Periodontal maintenance
PROSTHODONTICS
Removable
Complete/Immediate dentures
Partial dentures
All acrylic
Metal framework, acrylic saddles
Repairs
Rebase
Reline
Tissue conditioning
Overdentures
Fixed bridgework
Bridge pontics & retainers
Resin bonded (Maryland) bridge
Recementation
Post & core
Cast coping
IMPLANT SUPPORTED PROSTHETICS
(RESTORATIONS)
Removable dentures, abutment supported
Fixed bridgework, abutment supported
Porcelain/ceramic
Cast metal
ORAL SURGERY
Alveoloplasty (smoothing of bone)
Removal of benign lesions and cysts
Removal of exostosis
TMJ manipulation under anesthesia
Sialolithotomy
ADJUNCTIVE SERVICES
Palliative emergency treatment
Anesthesia
General anesthesia
Intravenous sedation
Analgesia (nitrous oxide)
Occlusal splints for bruxism
Athletic mouth guards
$1500 annual maximum benefit per plan year of July through June (fiscal year).
Health Resources, Inc. • www.hri-dho.com • PO Box 15660 • Evansville IN 47716-0660 • Tel: (800) 727-1444 • Fax: (812) 424-2096