Arizona dental insurance limitations and exclusions

Eligibility, covered charges, and related limitations, exclusions, and reductions

 

Eligibility

Active, full-time employees living in the United States (except part-time, seasonal, temporary or contract employees) who work a minimum number of hours per week as defined by the employer. If you are not actively at work on the day your benefits would otherwise become effective, your insurance will not be in force until the day you return to active work. If dependent coverage is offered, the employee must be enrolled before their dependents are eligible.

You must request insurance for you or your dependent within 31 days of becoming eligible or within 31 days of terminating your insurance. Otherwise, you must request insurance during the annual enrollment period, special enrollment period, or in compliance with a legal mandate.

Maximum benefit

The employer elects calendar year and lifetime maximum benefits for the group.

Maximum accumulation

If offered, allows a portion of unused maximum benefit to roll over to the next year. The entire accumulation amount is forfeited if no dental service is submitted within a calendar year. Individuals with fourth quarter effective dates will not qualify for rollover until the next calendar year. Qualifications, annual rollover limits, and total accumulation limits are elected by the employer for the group.

Payment limits

Benefits payable for all covered treatments and services cannot exceed the maximum payment limits per unit, per calendar year, per member and dependent. The employer elects the maximum payment limit.

Coordination of benefits

As allowed by state law, we coordinate benefits with coverage provided by any other employer, trust, union, association, or educational institution – other than student accident policies, governmental program, or state law.  Total benefits from all sources cannot exceed 100% of covered charges.

Covered charges

Covered charges are limited to the listed procedures shown in the Schedule of Dental Procedures section of your policy. All covered charges are subject to frequency limits, age restrictions and clinical criteria. A treatment or service is considered a covered charge if prescribed by a dentist and determined by Principal Life to be necessary, appropriate, and generally accepted. If there is more than one way to correct a dental condition, covered charges will be limited to the prevailing charge for the least expensive procedure that would provide professionally acceptable results. Covered charges will only include charges for treatment or service that begin and are completed while you and your dependents are insured under the policy.

Limitations and exclusions

Covered charges will not include and no benefits will be paid for any treatment or service: that is not a covered charge; performed by any person who is not a dentist or dental hygienist; that exceeds prevailing charges; for implants; that does not meet professionally recognized standards of quality; for veneers, anterior 3/4 cast crowns, personalization of dentures or crowns, or any other treatment or service that is primarily cosmetic; for drugs, medicines, or therapeutic drug injections; for instructions for plaque control, oral hygiene, or diet; for bite registration or occlusal analysis; to alter or maintain vertical dimension or restore or maintain occlusion; for the purpose of duplicating or replacing a lost or stolen prosthetic device or appliance; orthodontic treatment or service if the appliance or bands were placed prior to being insured under the group policy, unless you or your dependent are currently in a treatment plan which was covered under prior group orthodontic coverage, and there has been no lapse in coverage; for orthodontia, unless specifically covered; for provisional or permanent splinting; for which you or your dependent have no financial liability or that would be provided at no charge or at a different charge in the absence of insurance; that is temporary; that is paid for or furnished by the United States Government or one of its agencies (except as required under Medicaid provisions or Federal law); resulting from a sickness that is covered by a Workers' Compensation Act or other similar law; resulting from an injury arising from or in the course of any employment for wage or profit, except for partners, proprietors, or corporate officers of the employer who are not covered by a Workers' Compensation Act or other similar law; resulting from war or act of war; resulting from participation in criminal activities; provided outside the United States, unless you or your dependent are outside of the United States for: a) travel (for a reason other than securing dental care),  or b) temporary business assignments, or c) full-time students in certain academic arrangements, or d); Mormon missionary work of a dependent child; to replace tooth structure lost from abrasion, attrition, erosion, or abfraction; which may not reasonably be expected to successfully correct the patient’s dental condition for a period of at least three years; that is an experimental or investigational measure; paid for by a Medicare Supplement Insurance Plan; for temporomandibular joint disorders; charged by an anesthesiologist for services that were performed in facilities other than a dental office; for emergency room charges or outpatient facility charges (including but not limited to hospital outpatient facility charges); for patient management (including but not limited to nitrous oxide and analgesia), local anesthetic and general anesthesia and IV sedation, except as otherwise provided in the group policy; for occlusal guards; for charges that are billed incorrectly or separately for treatment or services that are an integral part of another billed treatment or service, as determined by Principal Life.