CUPE Local 3261 – 89 Chestnut: Dental Benefit Plan

The benefits shown below will be eligible, if based on the licensed dental practitioner’s reasonable and customary charge in accordance with the Fee Guide and the maximum shown in the Schedule of Dental Benefits.

Basic Services

1. Basic Diagnostic and Preventive Services:

  • complete oral examinations once every 3 years
  • emergency and specific oral examinations
  • consultations, 2 units every 12 months
  • full series x-rays and panoramic x-rays once every 3 years
  • bitewing x-rays once every 9 months (once every 6 months for children age 18 and under)
  • recall examinations once every 9 months (once every 6 months for children age 18 and under)
  • cleaning of teeth (up to 1 unit of polishing plus up to 1 unit of scaling) once per recall period
  • topical application of fluoride
  • oral hygiene instruction once per recall period
  • denture cleaning once per recall period
  • pit and fissure sealants once per lifetime per tooth for children 15 years of age and under
  • space maintainers

2. Basic Restorative Services:

  • amalgam, tooth coloured filling restorations, and temporary sedative fillings
  • inlay restorations – these are considered basic restorations and will be paid to the equivalent non-bonded amalgam

3. Basic oral surgery:

  • extractions of teeth and/or residual roots

4. Anaesthesia and intravenous sedation in conjunction with eligible oral surgery only

5. Standard denture services:

  • denture repairs and/or tooth/teeth additions
  • standard relining and rebasing of dentures, once every 2 years
  • denture adjustments and remount and equilibration procedures, only after 3 months have elapsed from the installation of an initial or replacement denture
  • soft tissue conditioning linings for the gums to promote healing
  • remake of a partial denture using existing framework, once every 5 years

6. Comprehensive oral surgery:

  • surgical exposure, repositioning, transplantation or enucleation of teeth
  • remodeling and recontouring – shaping or restructuring of bone or gum
  • excision – removal of cysts and tumors
  • incision – drainage and/or exploration of soft or hard tissue
  • fractures including the treatment of the dislocation and/or fracture of the lower or upper jaw and repair of soft tissue lacerations
  • maxilofacial deformities – frenectomy – surgery on the fold of the tissue connecting the lip to the gum or the tongue to the floor of the mouth

Comprehensive Basic Services

1. Endodontic treatment including:

  • root canal therapy, excluding extra charges for difficult, calcified, exceptional or retreatments
  • pulpotomy (removal of the pulp from the crown portion of the tooth)
  • pulpectomy (removal of the pulp from the crown and root portion of the tooth)
  • apexification (assistance of root tip closure)
  • apical curettage, root resections and retrograde fillings (cleaning and removing diseased tissue of the root tip)
  • root amputation and hemisection
  • bleaching of non-vital tooth/teeth
  • emergency procedures including opening or draining of the gum/tooth

2. Periodontal treatment of diseased bone and gums including:

  • periodontal scaling and/or root planing
  • occlusal equilibration – selective grinding of tooth surfaces to adjust a bite 8 time units every 12 months

The fees for periodontal treatment are based on units of time (15 minutes per unit) and/or number of teeth in a surgical site in accordance with the General Practitioners Fee Guide.

  • bruxism appliance

Major Services

1. Standard onlays or crown restorations (paid to full metal on molar) to restore diseased or accidentally injured natural teeth, once every 5 years

2. Standard bridges, including pontics, abutment retainers/crowns (paid to full metal on molar) on natural teeth, once every 5 years

3. Standard dentures including complete, immediate, transitional, and partial dentures, once every 5 years

4. Standard repair or recementing of crowns, onlays and bridge work on natural teeth

Orthodontic Services

Reimbursement for orthodontic treatment to straighten teeth and correct the bite.

When a lump sum fee has been paid toward orthodontic treatment, the total amount of the claim will be split into equal portions to include the initial fee and a monthly fee and will be reimbursed over the duration of the treatment.

If orthodontic treatment is terminated for any reason before completion, the obligation to pay benefits will cease with payment to the date of termination. If such services are resumed, benefit for the remaining services, will be resumed. The benefit payment for orthodontic services will be only for the months that coverage is in force.

Alternate Benefit Clause

This benefit plan will reimburse the amount shown in the Fee Guide for the least expensive service or supply where two or more professionally accepted courses of treatment are a benefit under the plan. The covered person can choose to have a more expensive treatment performed, however reimbursement will be limited to the cost of the least expensive alternative.

Predetermination

Before your treatment begins:

  • for all proposed treatment for crowns, onlays and bridges, an estimate completed by your dental practitioner, must be submitted for assessment. Our assessment of the proposed treatment, may result in a lesser benefit being payable or may result in benefits being denied. Failure to submit an estimate prior to beginning your treatment will result in the delay of the assessment.
  • if the total cost of any other proposed treatment is expected to exceed $300, it is recommended that you submit an estimate completed by your dental practitioner.

Limitations

1. Laboratory services must be completed in conjunction with other services and will be limited to the co-pay of such services. Laboratory services that are in excess of 40% of the dentist’s fee in the current General Practitioners Fee Guide will be reduced accordingly; co-pay is then applied;

2. Reimbursement will be made according to standard and/or basic services, supplies or treatment. Related expenses beyond the standard and/or basic services, supplies or treatment will remain your responsibility;

3. When more than one surgical procedure is performed during the same appointment in the same area of the mouth, only the most comprehensive procedure will be eligible for reimbursement;

4. Reimbursement will be pro-rated and reduced accordingly, when time spent by the dentist is less than the average time assigned to a dental service procedure code in the General Practitioners Fee Guide;

5. Reimbursement for root canal therapy will be limited to payment once only per tooth. The total fee for root canal includes all pulpotomies and pulpectomies performed on the same tooth;

6. Common surfaces on the same tooth/same day will be assessed as one surface. If individual surfaces are restored on the same tooth/same day, payment will be assessed according to the procedure code representing the combined surface. Payment will be limited to a maximum of 5 surfaces in any 36 month period;

7. Where multiple services are performed at one appointment and the full fee guide price is charged for each service, the first service will be paid in full and all remaining services will be reduced by 20%;

8. Core build-ups are eligible only for the purpose of retention and preservation of a tooth when performed with crown treatment. Necessity must be evident on mounted pre-treatment X-rays. Core build-ups to facilitate impression taking and/or block out undercuts are considered included in the cost of a crown;

9. Root planing is not eligible if done at the same time as gingival curettage;

10. In the event of a dental accident, claims should be submitted under the health benefits plan before submitting them under the dental plan.

Dental Exclusions

Eligible benefits do not include and reimbursement will not be made for:

1. Services or supplies received as a result of disease, illness or injury due to:

  • a) intentionally self-inflicted injury while sane or insane;
  • b) an act of war, declared or undeclared;
  • c) participation in a riot or civil commotion; or
  • d) committing a criminal offence;

2. Services or supplies provided while serving in the armed forces of any country;

3. Failure to keep a scheduled appointment with a legally qualified dental practitioner;

4. The completion of any claim forms and/or insurance reports;

5. Any dental service that is not contained in the procedure codes developed and maintained by the Canadian Dental Association, adopted by the provincial or territorial dental association of the province or territory in which the service is provided (or your province of residence if any dental service is provided outside Canada) and in effect at the time the service is provided;

6. Restorations necessary for wear, acid erosion, vertical dimension and/or restoring occlusion;

7. Appliances related to treatment of myofacial pain syndrome including all diagnostic models, gnathological determinants, maintenance, adjustments, repairs and relines;

8. Posterior cantilever pontics/teeth and extra pontics/teeth to fill in diastemas/spaces;

9. Service and charges for sleep dentistry;

10. Diagnostic and/or intraoral repositioning appliances including maintenance, adjustments, repairs and relines related to treatment of temporomandibular joint dysfunction;

11. Any specific treatment or drug which:

  • a) does not meet accepted standards of medical, dental or ophthalmic practice, including charges for services or supplies which are experimental in nature,
  • b) is not considered to be effective (either medically or from a cost perspective) as determined by GSC’s drug review process regardless if Health Canada’s approved the drug;
  • c) is an adjunctive drug prescribed in connection with any treatment or drug that is not an eligible service;
  • d) is administered in a hospital or is required to be administered in a hospital in accordance with Health Canada’s approved indication for use;
  • e) is not dispensed by the pharmacist in accordance with the payment method shown under the Health Benefit Plan Prescription Drugs benefit;
  • f) is not being used and/or administered in accordance with Health Canada’s approved indication for use (i.e. off-label use), even though such drug or procedure may customarily be used in the treatment of other illnesses or injuries;

12. Services or supplies that:

  • a) are not recommended, provided by or approved by the attending legally qualified (in the opinion of Green Shield) medical practitioner or dental practitioner as permitted by law;
  • b) are legally prohibited by the government from coverage;
  • c) you are not obligated to pay for or for which no charge would be made in the absence of benefit coverage; or for which payment is made on your behalf by a not-for-profit prepayment association, insurance carrier, third party administrator, like agency or a party other than Green Shield, your plan sponsor or you;
  • d) are provided by a health practitioner whose license by the relevant provincial regulatory and/or professional association has been suspended or revoked;
  • e) are not provided by a designated provider of service in response to a prescription issued by a legally qualified health practitioner;
  • f) are used solely for recreational or sporting activities and which are not medically necessary for regular activities;
  • g) are primarily for cosmetic or aesthetic purposes, or are to correct congenital malformations;
  • h) are provided by an immediate family member related to you by birth, adoption, or by marriage and/or a practitioner who normally resides in your home. An immediate family member includes a parent, spouse, child or sibling;
  • i) are provided by your plan sponsor and/or a practitioner employed by your plan sponsor, other than as part of an employee assistance plan;
  • j) are a replacement of lost, missing or stolen items, or items that are damaged due to negligence. Replacements are eligible when required due to natural wear, growth or relevant change in your medical condition but only when the equipment/prostheses cannot be adjusted or repaired at a lesser cost and the item is still medically required;
  • k) are video instructional kits, informational manuals or pamphlets;
  • l) are delivery and transportation charges;
  • m) are a duplicate prosthetic device or appliance;
  • n) are from any governmental agency which are obtained without cost by compliance with laws or regulations enacted by a federal, provincial, municipal or other governmental body;
  • o) would normally be paid through any provincial health insurance plan, Workplace Safety and Insurance Board or tribunal, or any other government agency, or which would have been payable under such a plan had proper application for coverage been made, or had proper and timely claims submission been made;
  • p) relates to treatment of injuries arising from a motor vehicle accident;Note: Payment of benefits for claims relating to automobile accidents for which coverage is available under a motor vehicle liability policy providing no-fault benefits will be considered only if–
    • i) the service or supplies being claimed is not eligible; or
    • ii) the financial commitment is complete;

    A letter from your automobile insurance carrier will be required;

  • q) are cognitive or administrative services or other fees charged by a provider of service for services other than those directly relating to the delivery of the service or supply.