Fact Sheet #37
Printable Format

SHBP EMPLOYEE DENTAL PLANS

State Health Benefits Program

ELIGIBILITY

The SHBP Employee Dental Plans are available to full-time State employees, full-time employees of a local employer (county, municipality, school board, etc.) that elects by resolution to provide the Employee Dental Plans to its employees, and the eligible dependents of these employees. New eligible employees may enroll by completing the dental portion of a NJ SHBP Dental Benefits Application during the first 60 days of employment. The application is available from your Human Resources Representative or Benefits Administrator. If you do not enroll when first eligible, you have the option to enroll during an annual SHBP Open Enrollment Period. Open Enrollment is normally held in the fall, with coverage effective the following January. If you do not enroll because of other dental coverage and you lose that coverage, you can be enrolled within 60 days of the loss of coverage.

Once enrolled, you and your eligible dependents must remain in the dental plan you elect for a minimum of 12 months before you can switch plans or drop coverage. In the event that you wish to switch dental plans, you will not be permitted to do so until the next open enrollment period following the 12-month period. In addition, no employee or dependent can be covered under more than one SHBP dental plan.

Note: Duplicate coverage within the Employee Dental Plans is not permitted; an individual may be covered as an employee or as a dependent but not as both an employee and a dependent. Dependent children may only be covered by one parent.

WHAT ARE MY DENTAL PLAN CHOICES?

You have a choice between two types of dental plans:

• The Dental Expense Plan; or
• A Dental Plan Organization (DPO).

Dental Expense Plan

The Dental Expense Plan is a traditional indemni-ty-type plan administered by Aetna Dental. The plan allows you to choose any licensed dentist for your dental care. There is a deductible to satisfy for some services and some services are eligible only up to a limited amount. The annual plan deductible is $50 per person; $150 per family. The deductible does not apply to diagnostic, preventive, and orthodontic services. After you satisfy the annual deductible, you are reimbursed a percentage of the reasonable and customary charges for services that are covered under the plan.

The Dental Expense Plan provides for the following benefits:

• Diagnostic and Preventive services are paid at 100% of reasonable and customary allowances with no deductible.
  Basic Services such as fillings and extractions, are paid at 80% of reasonable and customary allowances after deductible.
  
  
• Major Restorative services, such as crowns, are paid at 65% of reasonable and customary allowances after deductible.
  
  
• Prosthodontic services for new or replacement dentures are covered at 50% of reasonable and customary allowances after deductible. Repairs to existing dentures are covered at 80% of reasonable and customary allowances after deductible.
  
  
• Periodontics (treatment of gum disease) is covered at 50% of reasonable and customary allowances after deductible.
  
  
• Orthodontics are available after you have been employed for 10 months (with no deductible), but only for your children under the age of 19. Orthodontic services are reimbursed at 50% of reasonable and customary allowances and have a separate $1,000 individual lifetime reimbursement benefit maximum.
  
  
• Benefit Maximum per covered individual is $3,000 annually. This maximum applies to all eligible services except orthodontic, which has a separate $1,000 individual lifetime benefit maximum.

With the exception of emergency care, if your Dental Expense Plan treatment includes charges that are expected to cost more than $300, it is strongly recommended tht your dentist file for predetermination of benefits with Aetna. With advance approval you will know what services are covered and what payments will be made. Dental Expense Plan members can take advantage of a special Aetna network of participating dental providers. In this network, participating dental providers contract with Aetna for a discounted fee schedule. When you use a participating dental provider, you only pay the provider any applicable deductible and the appropriate coinsurance based on the discounted fee, thereby reducing your out-of-pocket cost. In many cases the participating dental provider will submit the claims directly to Aetna, eliminating the necessity of your filing claim forms. To find out if your provider participates in the discounted network, call Aetna at
1-877-238-6200

Dental Plan Organizations

The Dental Plan Organizations (DPOs) are companies that contract with a network of providers for dental services. There are several DPOs participating in the SHBP Employee Dental Plans from which you may choose. The SHBP Employee Dental Plans Member Handbookcontains a list of the participating DPOs. To obtain a handbook, see "For More Information".

You must use providers participating with the DPO you select to receive coverage. Be sure you confirm that the dentist or dental facility you select is taking new patients and participates with the SHBP Employee Dental Plans, since DPOs also service other organizations.

When you use a DPO dentist, diagnostic and preventive services are covered in full. Most other eligible expenses require a copayment (see chart below). In addition, orthodontic treatment is covered for both children and adults, subject to a copayment. If your dentist drops out of the DPO, you must select another dentist from the DPO. If there are none available within 30 miles of your home, or if you move and your DPO cannot provide a dentist within 30 miles of your home, you may switch plans immediately.

HOW MUCH OF THE PREMIUM COST DO I PAY?

For employees of the State, the premium cost for dental plan coverage is shared between the State and the employee. The amount of your payroll deduction is available from your Human Resources Representative or Benefits Administrator.

State employee premiums can be paid on a pretax basis through participation in the Premium Option Plan (POP) of Tax$ave — the State's IRC Section 125 program. Participation in the POP is automatic unless you file a form declining participation. The Internal Revenue Service strictly regulates enrollment in the POP and prohibits any benefit changes outside of an open enrollment period or unless a qualifying life event occurs (e.g., loss of other coverage, marriage, divorce, etc.). Fact Sheet #44, Tax$ave, explains the POP in more detail. To order this fact sheet, see "For More Information".

For employees of a participating local employer, the premium cost for dental plan coverage will vary based upon the policies of that employer in regard to health benefit costs and any labor agreements between the employer and the unions representing the employee. Employees of a participating local employer should see their Human Resources Representative or Benefits Administrator for more information.

WHICH PLAN IS BEST FOR ME?

Your choice of a dental plan is a personal decision. In deciding whether to enroll and which plan to choose, you should consider:

• The nature and amount of your anticipated dental expenses for the next year;
• The covered services provided by the Dental Expense Plan or a DPO;
• The differences in out-of-pocket costs for each type of plan; and
• The degree of flexibility that you may want in selecting a dentist.

You can use the summary chart on this fact sheet to compare benefit levels under each type of dental plan.

If you choose a DPO, you must select a dentist who participates with that particular DPO and who can accept you and your dependents as patients.

FOR MORE INFORMATION

For more information on the SHBP Employee Dental Plans or the names and phone numbers for the individual dental plans, see the SHBP Employee Dental Plans Member Handbook, available from your Human Resources Representative or Benefits Administrator, by contacting the Division of Pensions and Benefits at (609) 292-7524, or over the Internet at:
www.state.nj.us/treasury/pensions/shbp.htm

Fact Sheet #44, Tax$ave, is available over the internet at: www.state.nj.us./treasury/pensions/fact44.htm

Print this fact sheet in Adobe Acrobat PDF format.
To print this fact sheet in PDF, you must have Acrobat Reader which is available free from Adobe.

PLAN COMPARISON

The following chart provides a summary description of a variety of dental services under the two types of dental plans offered by the SHBP Employee Dental Plans. The chart is not complete and does not describe all the benefits, limitations, or conditions associated with coverage under either type of plan. Please refer to the SHBP Employee Dental Plans Member Handbook for additional details.

¹You are responsible for the amount the dentist charges above the reasonable and customary allowances.

²See pages 21-30 of the SHBP Employee Dental Plans Member Handbook.