Dental Insurance Benefits

This dental plan provides benefits for most types of dental services. Your level of dental benefits is known as the GHI Preferred Dental Plan. This document is your Certificate of Insurance.

This dental insurance plan provides coverage for you and your family. Like most dental plans, it will not pay all the bills you may incur for dental care for yourself or your dependents.

Dental Insurance Coverage

Your dental plan does not have a deductible. Your dental insurance coverage will provide payments based upon the GHI Preferred Dental Schedule for covered services. Dental services rendered by participating and non-participating providers are covered to the extent that they are a covered service, are necessary for dental health and are performed by a licensed dentist or physician.

When covered services are rendered by non-participating providers, you are reimbursed based on the Reimbursement Schedule. When rendered by participating providers, these dental services are covered on a paid-in-full basis.

GHI may cover unlisted dental procedures that are of the type listed in the Reimbursement Schedule. GHI will cover such procedures at its sole discretion. GHI will determine payment in a manner consistent with the Reimbursement Schedule.

Selecting a Dentist—Freedom Of Choice

Enrollees are free to go to any licensed dentist for covered services. This includes participating and non-participating dentists. When you use a participating dentist, however, your out-of-pocket costs, if any, are minimal, and a higher level of benefits is provided. The freedom to make that choice is always yours.

Your GHI Dental Insurance I.D. Card

Your GHI Dental Insurance I.D. Card indicates your Certificate and Category numbers. You should show this card to the dentist or receptionist before services are performed.

Participating Dentists And Participating Specialists

If you use a Participating Dentist:

Many dentists have agreed to be participating dentists in GHI's Preferred Dental Plan. A participating dentist is either a dentist in General Practice or a Specialist who has agreed to accept GHI's Preferred Dental Schedule of Allowances as payment-in-full for covered services, up to the annual maximum of $3,000, effective 1/1/19. (Note: Specific services which are not covered are shown under Dental Exclusions. Those services that have limitations are noted as such in the Covered Services and Limitations section of this certificate.)

You must advise the dentist of your GHI coverage and confirm that he or she is currently a participating dentist in the GHI Preferred Dental Plan before services are rendered. GHI reimburses participating dentists/specialists directly for covered services which means you do not have to submit any claim forms. For information regarding the GHI Preferred Dental Plan and to obtain the names of participating dentists in your area, refer to the Directory of Participating Dentists, call GHI Customer Service at 1-800-947-0101, or Link to GHI/Emblem website.

Non-Participating Dentists

If you use a non-participating dentist:

A non-participating dentist has no agreement with GHI to limit fees. You must pay the non-participating dentist directly and then file a dental claim form with GHI. GHI will then reimburse you for covered services based on the Reimbursement Schedule. This schedule shows GHI's maximum reimbursement to you for covered services. You are responsible for any difference between the GHI payment for services rendered by the non-participating dentist and the non-participating dentist's charge. (Note: Specific services which are not covered are shown under Dental Exclusions. Those services that have limitations are noted as such in the Covered Services and Limitations section of this certificate.)

Covered Services and Limitations

Preventive and diagnostic services

Examinations: You are covered for the routine examination of the oral cavity and the charting of teeth. GHI will cover two (2) examinations for each Member per calendar year. You are eligible for one (1) initial examination per provider per lifetime. All subsequent non-emergency examinations done by the same provider are paid as periodic examinations.

Prophylaxes: You are covered for Prophylaxis which is the scaling, cleaning and polishing of teeth. You are covered for two (2) prophylaxes per calendar year. Prophylaxis is not payable if periodontic treatment is rendered on the same day.

X-Rays: You are covered for the taking of x-ray films of the teeth, mouth or jaw. You are covered for four (4) bitewing x-rays in each calendar year. GHI will cover fourteen (14) standard periapical x-ray films or one (1) panoramic film once every three (3) years. GHI will also cover two (2) occlusal intra-oral x-ray films within a three (3) year period. Individual periapical x-rays performed on the same day as a full mouth series are not covered. Duplication of x-rays is not covered.

Fluoride treatment: Each covered dependent child is eligible for one fluoride treatment per calendar year.

Sealants: Each covered dependent child is eligible for sealants to the end of the month in which the child reaches age 14. Sealants are covered only when applied to the occlusal (biting) surface of the first and second permanent molars and bicuspids if these teeth have not previously been filled. Coverage is provided once per covered tooth every three (3) years.

Space maintainers: Each covered dependent child is eligible for space maintainers. Coverage includes the treatment and the appliance. If the insertion of a space maintainer is performed in conjunction with the recementation of a space maintainer, GHI will only pay for insertion of the space maintainer. A separate allowance will not be provided for the recementation.

Tests and lab examinations: You are covered for biopsy and examination of oral tissue. However, you are not covered for sialography, TMJ arthrogram including injection, tomographic survey, bacteriological studies, caries susceptibility, pulp vitality test, diagnostic casts and photographs, nutritional counseling or oral hygiene instructions.

Palliative services: You are covered for one emergency palliative visit per year. A palliative visit is for the relief of pain. This includes an adjustment of a prosthetic appliance which must have been inserted for over one (1) year.

Mouth guards: Each dependent child is covered for one (1) mouth guard per lifetime. It must be prescribed by a dentist and used for athletic purposes.

Basic Restorative Services

Extractions: You are covered for the routine removal of a tooth or teeth. The allowance for the extraction includes payment for pre- and post-operative x-rays, post operative care and local anesthesia.

Restorations: You are covered for restorations which are fillings, inlays and crowns. This amount applies even if you have a crown or an inlay. Temporary fillings, acid etch, sedative fillings or tissue conditioning are not covered.

Amalgam restorations are denied when reported with a fixed prosthetic or crown procedure on the same tooth.

There is a maximum benefit for fillings done on the same tooth by the same Dentist or Provider within a six (6) month period. GHI will not pay more than this maximum benefit for fillings for each Member in any six (6) month period.
If two (2) fillings are done on the same posterior tooth on the same day, GHI's allowance will be up to the Scheduled Amount for a three (3) surface amalgam.
If two (2) fillings are done on the same anterior tooth on the same day, GHI's allowance will be up to the Scheduled Amount for three (3) composite fillings.
If a three (3) surface inlay, crown or abutment is done on a tooth that has been filled within the last six (6) month period, GHI will deduct the Scheduled Amount for the filling from its payment for the inlay, crown or abutment.
The allowance for a one (1) surface inlay will be the Scheduled Amount for a one (1) surface amalgam.
The allowance for an onlay will be the Scheduled Amount for a three (3) surface inlay. If an onlay and three (3) surface inlay are done on the same tooth on the same day, GHI's allowance will be the Scheduled Amount for the three (3) surface inlay. A separate allowance for the onlay will not be provided.
The allowance for composite resin inlays will be the Scheduled Amount for amalgam restorations.
The charge for cementation of a crown/inlay is included in the allowance for the crown/inlay.
Posts are covered only if there is evidence of root canal therapy on the tooth.
Pins are covered once every six (6) months. However, pins are not covered if they are inserted in conjunction with a prosthetic service.
Core buildups including pins are not covered.
The allowance for chairside laminates for anterior teeth will be the comparable maximum composite Scheduled Amount.

Repair of appliances: You are covered for the repair of dentures, the replacement of broken or missing teeth or clasps in a denture and the replacement of broken facings. You are also covered for the repair of appliances including recementation of space maintainers, bridges, inlays and crowns. There is an annual maximum benefit for all repairs. GHI will not pay more than that maximum benefit for each member per calendar year.

Consultations: You are covered for consultation with a specialist in the field of oral surgery, orthodontics, periodontics or endodontics. The consultation is covered only if there is no other service rendered by the specialist on that date or during the next three (3) months. If treatment is performed by the consulting dentist within 90 days of the consultation, the consultation allowance will be reduced and processed as an exam. If you are referred by a dentist who practices in the same office or in association with the specialist, the consultation is not covered. The report of the specialist must be submitted with the claim form.

Endodontics: You are covered for endodontics commonly known as root canal therapy. This is treatment for the removal of pulp and the filling of the canals of the teeth that have damaged pulp.

Pulpotomy is covered once per tooth, per lifetime. However, pulpotomy is not covered if root canal therapy was done on the tooth by the same Dentist or Provider within the prior three (3) month period.
If any combination of apicoectomy, root end amalgam and apical curettage is done on the same tooth by the same Dentist or Provider within a three (3) month period of root canal therapy, GHI will not apply the Scheduled Amounts for these services. GHI will apply a combined allowance for these services.
Occlusal adjustments done on the same tooth and in conjunction with fillings, prosthetic services, root canal therapy or repairs, inlays and crowns are not covered.
The allowance for incision and drainage done within two (2) weeks of root canal therapy or periodontal surgery on the same tooth by the same Dentist or Provider will be deducted from the allowance for the root canal therapy or periodontal surgery.
Pulp capping is not covered.
Surgical replacement of rubber dam, recalcification of perforation, preparation of canal for post or dowels, and bleaching of discolored teeth are not covered.

Periodontics: You are covered for periodontics which is the treatment of diseases of the gums and the long structure of the jaw, including subgingival scaling, medication, curettage and minor bite correction (occlusal adjustment). You are covered for five (5) periodontal treatments per calendar year. You are covered for one (1) type of periodontal surgery and/or one (1) graft per quadrant. Five (5) single tooth periodontal surgeries or grafts are considered to be a quadrant. Periodontal appliances are not covered.

Repeated periodontal surgeries or grafts will not be covered for a period of three (3) years from the date of the original surgery or graft.
Occlusal adjustments done on the same tooth and in conjunction with fillings, prosthetic services, root canal therapy or repairs, inlays and crowns are not covered.
Splints are not covered except when a missing tooth is being replaced. Only the portion replacing the missing tooth is covered. Splints using enamelite or similar material are not covered.
Achatite synthetic fiber and unscheduled dressing changes are not covered.
Periodontal prophylaxis are counted toward the five treatments.

Oral surgery: You are covered for the removal of a tooth. You are covered for other surgical procedures in or about the oral cavity.

X-rays taken solely for the surgery, local anesthesia and post operative care are not covered separately. They are included in the fee for oral surgery.
There is an annual maximum benefit per arch for alveolectomy and alveoplasty. GHI will not pay more than that maximum benefit per arch for each Member in each calendar year for these services.
An alveolectomy done in conjunction with a surgical extraction is not covered.
Surgery on fractured jaws, impactions, lesions in and around the mouth are covered. Orthognathic surgery, and surgery relating to accidental injury are not covered.
Implants and transplantations are not covered. Reimplantations are covered. (Reimplantations are the return of a tooth to the bone to which a tooth is attached.)

Bedside calls: You are covered for bedside calls made during an emergency.

Anesthesia: You are covered for general anesthesia under the following conditions: The anesthesia must be rendered in connection with a covered service. It must be given by a practitioner licensed in New York State to administer anesthesia. The anesthesia may be rendered in or out of a hospital. Local anesthesia is included in the allowance for the procedure being performed. Intravenous sedation and nitrous oxide are not covered.

Temporary services and appliances: There is not a separate allowance for a temporary service or appliance. The allowance for a temporary service or appliance is included in the allowance for the completed, permanent service or appliance.

Major Restorative Services

(These services are subject to a five year frequency limitation.)

You are covered for:

Dentures which are constructed prior to the removal of teeth and inserted on the same day the teeth are removed. These are known as immediate dentures.
Full or partial permanent dentures.
Fixed bridgework and removable partial dentures.
Crowns and inlays inserted on teeth. They are covered only if a tooth cannot be restored by filling. If it can be restored, the Scheduled Amount for a filling will be paid.
Crowns over implants.

There are specific limits on your coverage for Major Restorative services. These limits are set forth below.

If the repair of a partial denture is done in conjunction with the insertion of a new denture in the same area of the mouth, GHI's allowance will be the Scheduled Amount for the insertion of the new denture.
If a denture adjustment is performed in conjunction with palliative treatment, GHI's allowance will be the Scheduled Amount for the palliative treatment.
If the repair of a broken denture is performed in the same arch as the insertion of a full denture, GHI's allowance will be the Scheduled Amount for the insertion of the new denture.
The allowance for an upper or lower overdenture will be the Scheduled Amount for full upper and lower dentures. There will be no benefits for any treatment of the abutment tooth or attachment tooth.
You are not covered for the replacement or the substitution of appliances unless five (5) years have passed since the appliance was inserted.
If a fixed bridge and partial denture are inserted in the same arch, only the partial denture is covered during the prosthetic replacement limitation period of five (5) years.
You are not covered for implants.
You are not covered for double or multiple abutments.
Crowns or pontics for attachment or clasp purposes are not covered unless the tooth is so broken down that it cannot be restored by fillings. A cantilever pontic used for attachment purposes is not covered.
Splints are not covered except when a missing tooth is being replaced. Only the portion replacing the missing tooth is covered.
Crowns used in splints for periodontal conditions are not covered.
Crown buildups done in connection with individual crowns and abutments are not covered.
Crowns and inlays used as abutments are not covered unless they are used as primary support for fixed appliances.
Precious metal material used in crowns is reimbursed at a base metal rate.
The allowance for a ceramic inlay/onlay is the maximum Scheduled Amount for an amalgam filling.
Duplication, rebase or chairside reline to a denture is limited to one (1) per denture in a five year period. This applies to both full and partial dentures.
Acrylic crowns are only covered on the six (6) anterior teeth. They must be laboratory processed and permanent. The allowance for acrylic crowns will be the Scheduled Amount for single crowns, not the Scheduled Amount for a bridge abutment or splint.
Rebase or repair of new dentures are not covered until six (6) months after insertion.
Adjustment of appliances is not covered within one (1) year of insertion.
GHI does not cover services or appliances used solely as an adjunct to periodontal care.
Precision attachment, metal coping, tissue conditioning and stress breakers are not covered.
Cosmetic surgery and/or treatment is not covered unless medically necessary.
There is not a separate allowance for a temporary service or appliance. The allowance for a temporary service or appliance is included in the allowance for the completed, permanent service or appliance.

Orthodontic Services

The following limitations apply to coverage for Orthodontic treatment:

Orthodontic Services are available only to your enrolled dependent children under 19 years of age. There is no coverage for completing a course of treatment for orthodontic service after age 18.
GHI will not pay Orthodontic benefits unless the teeth are seriously abnormal. The teeth must also be correctable.
It is recommended that you have your dentist request a pre-determination of benefits from GHI before Orthodontic treatment is started.
MultiPhasal Orthodontia services are included in your benefit under the administration of insertion of appliances. Benefits for multi-phasal orthodontia and insertion of appliances will be provided up to a lifetime maximum of $550.
Each eligible enrollee is covered up to twenty (20) months of active treatment plus eighteen (18) months of passive treatment.
The maximum lifetime orthodontic benefit per covered dependent is $3,000, effective 1/1/19.
X-rays reported with an orthodontic appliance will be included in the appliance fee.
Orthodontics to correct temporomandibular joint problems are not covered.
Occlusal guards are not covered.
There is not a separate allowance for a temporary service or appliance. The allowance for a temporary service or appliance is included in the allowance for the completed, permanent service or appliance.

Annual Maximum Amount

GHI will pay a maximum of $3,000, effective 1/1/19, in benefits including orthodontia (for dependent children under age 19), per person, per calendar year for covered dental services rendered by participating and non-participating providers.

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