2016 Healthfirst Medicare Dental Benefits Handbook. A guide to coverage administered by - PDF

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2016 Healthfirst Medicare Dental Benefits Handbook A guide to coverage administered by H3359_MKT16_20 CMS Approved About this Guide You deserve access to high-quality healthcare. With more than
2016 Healthfirst Medicare Dental Benefits Handbook A guide to coverage administered by H3359_MKT16_20 CMS Approved About this Guide You deserve access to high-quality healthcare. With more than 120,000 Medicare Plan members, Healthfirst has you (and your teeth) covered. We work hard to understand your needs, and we even provide extra services to help life get a little easier. This Dental Benefits Handbook will explain why good oral health is so important. Inside, you ll find advice on how to take advantage of the dental benefits included with Healthfirst Medicare Plans, as well as tips on how to make future visits with your dentist go more smoothly. If you have any questions, we re always here to help. You can call Healthfirst at (TTY: ), 7 days a week, 8am to 8pm, or stop by a Healthfirst Community Office near you. Locations and hours are listed at the back of this guide. At Healthfirst, we want you to get the most out of your dental benefits! 2 3 Healthy Mouth, Healthy Body Did you know that having a healthy mouth is one of the best ways to have a healthy body? Poor oral health can lead to gum disease, cavities, and other infections. No matter what kind of dental work is done, healthy teeth and gums can improve a lot more than just your smile. Poor oral health can lead to gum disease, cavities, and other infections that can have larger effects on your overall health. The American Dental Association (ADA) also says that an unhealthy mouth can worsen serious medical conditions such as: Heart disease Stroke Diabetes Osteoporosis Alzheimer s disease 4 This is why it s so important to keep your mouth clean. By brushing and flossing regularly, going to routine cleanings and checkups with your dentist, and practicing overall healthy habits, you can take control over your oral health. Tips to Get Good Oral Health Brush at least twice a day (use a fluoride toothpaste) Floss at least once a day Visit a dentist for regular cleanings and oral exams Great Dental Care that Keeps You Smiling Original Medicare can be very limited when it comes to dental coverage. Healthfirst wants our Medicare Plan members to have more. That s why comprehensive dental coverage is included with many of our plans. As a Healthfirst Medicare Plan member, you get access to high-quality dental care through our partner, DentaQuest. As one of the nation s leading oral health companies, DentaQuest offers and administers dental benefits programs for more than 20 million people across the country. Best of all, you won t need a referral from your Primary Care Provider (PCP) to see a dentist. Whenever you go in, just show your Healthfirst ID card. 5 More Ways to Save More Want to cut your copayments for covered services in half? Just use a participating dental clinic. For a list of participating dental clinics, see the Provider Directory or call Healthfirst. Questions to Expect During a Dental Exam About how long ago did you last see a dentist? Any reason for that visit? Any recent changes in your mouth? Any loose or sensitive teeth? Any difficulty tasting, chewing, or swallowing? Any pain, discomfort, sores, or bleeding in your mouth? Any lumps, bumps, or swelling in your mouth? We ve Got You Covered As a Healthfirst member, you ll get extra dental benefits that Original Medicare doesn t cover, like: Diagnostic and preventive services Restorative services Oral and root canal surgeries Periodontics (prosthetics/crowns) Denture adjustments and repairs 6 Certain individual services are subject to copays and may require prior authorization from DentaQuest, the Healthfirst Medicare Plan-contracted dental benefits administrator. All procedures are subject to review and will be evaluated for long-term prognosis as well as necessity. Included in this evaluation, but not limited to it, are bone support, furcation involvement, periodontal condition, and sub-crestal decay. Dental Benefits Limitations* Once every 6 months Oral exams Bitewing X-rays Prophylaxes (cleanings) Scaling Fluoride Once every 12 months Once every 24 months Once every 36 months Once every 5 years Once per tooth, per lifetime Fillings (same tooth/tooth surface) (retrograde fillings aren t covered) Periodontic scaling Root planning (only two quadrants will be reimbursed on the same date of service) Full mouth and panoramic X-rays Dentures (one set) Crowns, bridges, and other periodontal work (per tooth) Endodontics (root canals) Extractions *Some dental services can have limits when it comes to coverage. This isn t a complete list of those services, but you can find out if a different dental service is covered under your Healthfirst Medicare Plan by calling Healthfirst. Certain procedures may also have age limitations just ask us for that list, too! 7 8 Dental Benefits Exclusions The following is not a complete list of exclusions, please contact Healthfirst to find out if a dental service is covered. Generally, plans do NOT cover: Retrograde fillings Dental implants Occlusal guards/night guards Services not provided by a dentist (unless the service is performed by a licensed dental hygienist under the supervision of a dentist or is for an X-ray ordered by a dentist) General anesthesia, analgesia, and any service provided in a hospital environment. (While general anesthesia is not a covered benefit, local anesthesia is considered part of the reimbursement for services such as, but not limited to, fillings, extractions, and root canals) Certain diagnostic radiology services are not covered Any dental procedures done primarily for cosmetic reasons or to treat congenital or developmental malformations are not covered Partial dentures with a resin base (including any conventional clasps, rests, and teeth), restorations, crowns, or fixed prosthetics when acceptable results can be achieved with other methods or materials. Porcelain and pontic crowns are only covered in certain quadsor arches. In cases where the selection of a more expensive treatment plan is decided upon, your Healthfirst Medicare Plan will pay for the least costly option. You will be responsible for all additional fees charged by the dentist Stop Smoking, Start Smiling Smoking increases problems with gum disease, tooth decay, and tooth loss. It also affects healing after dental procedures, as well as keeping dental implants in place. For tips on how to quit smoking, or to learn more about the programs we offer, just give us a call! 9 10 Dental Benefits Copay Chart Questions? Contact us! We re here to help. Healthfirst (TTY: ) 7 days a week, 8am to 8pm DentaQuest (for dental care questions) Monday to Friday, 8am to 8pm 11 Stop in for help at a Healthfirst Community Office near you! BRONX 412 East Fordham Road Bronx, NY (office entrance is on Webster Avenue, near the intersection of East Fordham Road and Webster Avenue) Monday Saturday, 8:30am 5:30pm BROOKLYN 635 Fulton Street Brooklyn, NY (between Hudson Avenue and Rockwell Place) Monday Saturday, 8:30am 5:30pm th Avenue Brooklyn, NY (corner of 54 th Street and 7 th Avenue) 7 days a week, 9:00am 5:30pm MANHATTAN 128 Mott Street, Room 407 New York, NY (between Grand and Hester Streets) 7 days a week, 9:00am 5:30pm 28 East Broadway, 5 th Floor New York, NY (between Catherine and Market Streets) 7 days a week, 9:00am 5:30pm 1467 Saint Nicholas Avenue New York, NY (between 183 rd and 184 th Streets) Monday Saturday, 8:30am 5:30pm 12 QUEENS Roosevelt Avenue Jackson Heights, NY (between 94 th Street and Whitney Avenue) Monday Friday, 8:30am 5:30pm Saturday, 8:30am 5:00pm st Street, 1 st Floor Elmhurst, NY (between Roosevelt and 41 st Avenues) Monday Friday, 9:00am 6:00pm Saturday and Sunday, 9:00am 5:30pm Main Street, Rooms 201 and 311 Flushing, NY (between Sanford and Maple Avenues) 7 days a week, 9:00am 5:30pm LONG ISLAND 50 Clinton Street, 1 st Floor Hempstead, NY (corner of Fulton and Clinton Streets, in the Hempstead Executive Plaza next to the Clinton Plaza) Monday Friday, 8:30am 5:00pm Saturday, 8:30am 1:00pm (Note: We do not offer Medicare services at the Long Island office.) Dental Benefits Copay Chart Diagnostic (1 every 6 months) Coordinated Benefits Plan (HMO) 65 Plus Plan (HMO) Mount Sinai Select (HMO) Increased Benefits Plan (HMO) Life Improvement Plan (HMO SNP) CompleteCare (HMO SNP) Initial/Periodic oral exam Radiographic (1 every 6 months) Complete intraoral series, periapical, and bitewing films Intraoral periapical Each additional single film (periapical or bitewing) Occlusal view/lateral jaw X-ray One to four bitewing X-ray films Antero-posterior X-ray of head and jaw Panoramic, including bitewings (1 every 3 years) Preventive Oral prophylaxis (1 cleaning every 6 months) Emergency dental treatment (palliative treatment) 13 Dental Benefits Copay Chart Coordinated Benefits Plan (HMO) 65 Plus Plan (HMO) Mount Sinai Select (HMO) Increased Benefits Plan (HMO) Life Improvement Plan (HMO SNP) CompleteCare (HMO SNP) Operative (Restorative) Services (1 every year for the same tooth) Permanent silver amalgam Composite filling Pin retention (per tooth) Periodontia (1 every 2 years) Scaling of teeth (full mouth) Occlusal adjustment Gingivectomy (per quad) Osseous surgery (per quad) $40 $0 $0 $150 $100 $0 Endodontics (including radiographs) Single root canal filling Double root canal filling Apicoectomy (per root) $40 $0 $0 Triple or more root canal filling $150 $100 $0 Simple Extractions (including local anesthesia) Single tooth Each additional tooth 14 Dental Benefits Copay Chart Coordinated Benefits Plan (HMO) 65 Plus Plan (HMO) Mount Sinai Select (HMO) Increased Benefits Plan (HMO) Life Improvement Plan (HMO SNP) CompleteCare (HMO SNP) Oral Surgery Extractions (including local anesthesia) Alveolectomy (per quad) Surgical extraction Tooth extraction (soft tissue impaction) Tooth extraction (partial/ complete bony impaction) $60 $20 $0 Prosthetics (1 every 5 years) Dentures (incl. adjustments and relines for 6 months after installation) Broken denture repair Full upper/lower denture $150 $100 $0 Partial upper/lower denture (cast chrome base) $150 $100 $0 Crowns Stainless steel crown Recementation (per crown) Post $60 $10 $0 Acrylic, Porcelain, Porcelain with metal, $125 $75 $0 full cast crown Fixed Bridges Recementation (bridges) Acrylic/Porcelain with metal bridge (crown or pontic) $150 $100 $0 Full cast, Acrylic/metal, Porcelain abutment $150 $100 $0 15 16 Notes All covered dental services must be medically necessary. You must access all dental treatment from providers through the Healthfirst Medicare Plan-contracted dental network. The copays are the amounts that you will pay directly to the participating dental provider for services rendered. Copays for covered services may be reduced by 50% when services are received at a participating Healthfirst owner-hospital s dental clinic. Managed Health, Inc., dba Healthfirst Medicare Plan, offers HMO plans that contract with the Federal Government. Healthfirst Medicare Plan has a contract with the New York Medicaid program for Healthfirst CompleteCare (HMO SNP) and a Coordination of Benefits Agreement for the Healthfirst Life Improvement Plan (HMO SNP). Enrollment in Healthfirst Medicare Plan depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, and/or copayments/ coinsurance may change on January 1 of each year. This information is available for free in other languages. Please call our Member Services number at , TTY number , 7 days a week, from 8am to 8pm. Esta información está disponible en forma gratuita en otros idiomas. Por favor, comuníquese con nuestro número de Servicios a los Miembros al , o al para los usuarios de TTY, los 7 días de la semana, de 8:00 a.m. a 8:00 p.m. 17 For more information about Healthfirst s dental benefits, please call: (TTY: ) 7 days a week, 8am 8pm HF Management Services, LLC. NYMED00679
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