2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 89
ELIGIBLE DENTAL EXPENSES
If a Covered Person incurs expenses for a service on the list of "Eligible Dental Expenses," such charges are
covered to the extent that they meet all of the following conditions:
(1)
Constitute necessary treatment.
(2)
Are Incurred while covered under this Dental/Vision Plan.
(3)
Are Usual and Customary Charges.
The Dental/Vision Plan will pay for such eligible expenses as shown in the Dental Schedule of Benefits.
Reimbursement for eligible expenses will be made directly to the provider of the service, unless a receipt showing
payment is submitted.
Deductible
A Deductible is the total amount of eligible expenses as shown in the Dental Schedule of Benefits, which must
be Incurred by a Covered Person during any Calendar Year before Covered Dental Expenses are payable under
the Dental/Vision Plan.
Date Expenses are Incurred
An expense is Incurred when the service is performed, except that it is deemed to be Incurred:
(1)
When the impression is taken in the case of dentures or fixed bridgework;
(2)
When preparation of the tooth is begun in the case of crown work;
(3)
When the pulp chamber is opened in the case of root canal therapy.
Alternative Treatment
The Dental/Vision Plan has an "alternative treatment" clause that limits the Dental/Vision Plan's payment to the
most cost effective treatment of a dental condition that provides a professionally acceptable result as determined
by national standards of dental practice. If a Covered Person chooses a more expensive treatment according to
accepted standards of dental practice to correct a dental condition, the Dental/Vision Plan's payment will be based
on the treatment that provides professionally satisfactory results at the most cost-effective level.
Eligible Dental Expenses
Class A-Preventive
Services:
(1) Routine oral examinations, including the cleaning and scaling of teeth, are limited to 2 exams per Covered
Person each Calendar Year.
(2)
X-rays as follows:
(a)
Bitewing x-rays are limited to a set of 4 every 12 months.
(b)
Full mouth and panoramic x-rays are limited to every 36 months, unless special need is shown.
(3)
2 fluoride treatments for Dependent Children under age 19 each Calendar Year.
(4)
Sealants on the occlusal surface of a permanent posterior tooth for a Covered Person under age 16, once
per tooth in any 36 months.
(5)
Space maintainers for a Dependent Children under age 16 to replace primary teeth.
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