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STRS Ohio Optional Health Care

Optional Delta Dental Plan
All information displayed in the STRS Ohio Optional Health Care section applies only to benefit recipients in the Defined Benefit and Combined Plans.

Evaluating Your Option to Enroll
To help you decide if the dental plan is right for you, please consider the following:

  1. Eligibility and enrollment guidelines. Click here for more information.

  2. Length of the contract period. Once you are enrolled in the dental plan, you must remain enrolled through Dec. 31, 2008, regardless of the covered plan features you use.

  3. Monthly premium rates. Click here for more information.

  4. Plan features, exclusions and limitations. Click here for more information.

  5. Participating dental providers in your area. Call Delta Dental toll-free at 1-866-349-1286 or visit the Web site. When calling, the STRS Ohio dental network is Delta Dental PPO. If there are no PPO dentists, request a list for Delta Dental Premier. Please be sure to review the different levels of coverage when using PPO versus Premier providers. (Click here for further information about finding a participating dentist.)

Eligibility
Dental coverage is an optional plan available to benefit recipients, their spouse, dependent children and sponsored dependents. Enrollment in an STRS Ohio health care plan is not required to enroll in the dental plan; however, the benefit recipient must be enrolled in the dental plan for any eligible dependents to participate.

Premiums for dental coverage are deducted monthly from your STRS Ohio net benefit payment. If your monthly dental plan premium exceeds your STRS Ohio net benefit payment, STRS Ohio will send you a bill for your monthly premium. Once enrolled in the dental plan, you must remain in the plan through Dec. 31, 2008.

If you experience a life event, such as death, divorce, marriage, birth of a child, the addition of a dependent child or an enrolled dependent who no longer meets eligibility requirements, please contact STRS Ohio for an explanation of how the change will affect coverage for you and your dependents.

If you have questions about eligibility, contact STRS Ohio toll-free at 1-888-227-7877.

Enrollment Guidelines for Benefit Recipient, Spouse, Dependent Children and Sponsored Dependents
Review the following guidelines to determine if you are eligible to enroll. You may enroll yourself, a spouse, sponsored dependents or dependent children by calling STRS Ohio toll-free at 1-888-227-7877. To enroll sponsored dependents, completion of a sponsored dependent enrollment application is required.

No waiting period is required if you, your spouse, dependent children or sponsored dependents enroll within 31 days of terminating other group dental coverage. STRS Ohio coverage can be effective the first of the month following termination of other coverage if STRS Ohio receives and approves the request to enroll within the 31-day period.

A six-month waiting period is required if:

  1. You and/or your dependents are not currently covered under a dental plan when the request to enroll is made; or

  2. Your coverage under another plan is not terminating when the request to enroll is made; or

  3. You fail to request enrollment for your dependents within 31 days of marriage, birth, legal guardianship, adoption or placement for adoption.

New Spouse
You may enroll a spouse by calling STRS Ohio. A waiting period may apply depending on whether other coverage is terminating. Coverage for a new spouse may be effective on the first of the month following the marriage, if a request to enroll is received within 31 days of the marriage date. A waiting period may also apply if the request to enroll is made after 31 days of marriage.

Child
You may enroll a newborn, adopted child or child for whom you are the legal guardian by calling STRS Ohio. STRS Ohio must receive the request to enroll within 31 days of birth, adoption, placement for adoption or legal guardianship. If dependent child coverage is currently in effect and a request to enroll is received later than 31 days following birth, adoption, placement for adoption or legal guardianship, coverage for the new dependent child is effective the first of the month after STRS Ohio receives the request. If a request to enroll is received later than 31 days following the date of the event and no other dependent children are enrolled, there will be a six-month waiting period.

Definition of Eligible Dependent
Eligible dependents who may qualify for dental coverage include:

  • Benefit recipient’s spouse.
  • A dependent biological child(ren) or a nonbiological child(ren)1 that is legally adopted, placed for adoption, a stepchild or a child for whom you have been appointed guardian and resides in your home and meets the following eligibility requirements:
    1. Unmarried and under age 18; or
    2. Unmarried, under age 22 if the benefit recipient’s effective date of benefits was Jan. 1, 2003, or later, or under age 23 if the effective date of benefits was prior to Jan. 1, 2003, and the dependent is attending school2 on at least a two-thirds-of-full-time basis and the benefit recipient is providing at least 50% or more financial support3; or
    3. Unmarried and unable to earn a living because of a mentally or physically disabling condition that started before the date the child reaches the maximum age for dependent children as outlined above.

    1 If the child falls into this category, you must complete a Dependent Child’s Financial Status form, which shows you provide 50% or more financial support.

    2 If the child is attending school, you must complete a Student Status Verification form.

    3 If dependent children are survivors of a member who was receiving benefits at the time of death, the effective date of the member’s service retirement or disability benefit is used for determining the maximum age at which the children qualify for dental coverage.

Important Note: You must notify STRS Ohio in writing when a dependent child no longer meets eligibility requirements and indicate the day, month and year your dependent is no longer eligible. Premium deductions from your monthly STRS Ohio benefit payment do not guarantee coverage if your dependent no longer meets the eligibility requirements.

Definition of Sponsored Dependent
A child sponsored dependent and an adult sponsored dependent must meet the definition of a sponsored dependent as outlined below. In addition, a child sponsored dependent must be under age 18 and unable to qualify as a dependent child (outlined above). An adult sponsored dependent must be age 18 or older and unable to qualify as a dependent child or a spouse. Eligibility for sponsored dependent coverage is evaluated annually by STRS Ohio. To enroll a sponsored dependent, an application is required. The application is available from STRS Ohio upon request. Sponsored dependents who may qualify for dental coverage include:

  • A blood relative living in the home of a benefit recipient. “Home” includes a convalescent center or any other type of institution that retains the person only temporarily. To qualify as a blood relative, a person must have a direct genetic relationship to the benefit recipient, rather than a relationship through marriage.

  • A blood relative not living in the home of the benefit recipient, but receiving 50% or more support from the recipient in the last six months (as demonstrated by completion of a financial status form provided by STRS Ohio or your most recent individual or joint federal income tax return on which you claimed your sponsored dependent).

  • Any person (including the spouse of a survivor benefit recipient) living in the home of a benefit recipient and receiving 50% or more support from the survivor or benefit recipient in the last six months (as demonstrated by completion of a financial status form provided by STRS Ohio or your most recent federal income tax return on which you claimed your sponsored dependent).

  • Any person living in the home of an unmarried service retirement or disability benefit recipient who does not claim the sponsored dependent as a financial dependent on the IRS tax return.

Important Note: You must notify STRS Ohio in writing when a sponsored dependent no longer meets eligibility requirements and indicate the day, month and year your dependent is no longer eligible. Premium deductions from your monthly STRS Ohio benefit payment do not guarantee coverage if your sponsored dependent no longer meets the eligibility requirements.

Effective Date of Coverage
The effective date of coverage is the first of the month following the date your request to enroll is received by STRS Ohio, or on the effective date of monthly retirement benefits — whichever is later. Enrollees will be covered through Dec. 31, 2008.

Please note that there will be a six-month waiting period before coverage is effective if you are not currently covered under another plan or are enrolled in a plan that will not be terminating. Also, coverage is effective the first of the month following termination of other coverage only if STRS Ohio receives and approves your request to enroll within 31 days of the termination of your other coverage.

Premium Rates

$25.38/month Per benefit recipient
$31.01/month Per other adult (includes adult sponsored dependent)
$17.17/month Children (includes child sponsored dependent; flat rate regardless of the number of children covered)

Example: Dental coverage for a benefit recipient, his/her spouse and two children would be $73.56/month.

Benefit recipient $25.38
Spouse $31.01
Two children +$17.17
Total $73.56

Plan Features
This dental plan includes two network options: Delta Dental PPO and Delta Dental Premier. Although you can seek services from any licensed dentist, you will increase your coverage and lower your out-of-pocket costs by going to a PPO dentist. If you choose a Premier provider, you will receive a lower level of coverage; however, you may still save money. The chart below describes plan features and coverage levels.

  PPO Dentist (highest benefit level) Premier Dentist Nonparticipating Dentist
Plan Pays You Pay Plan Pays You Pay Plan Pays You Pay
Class I Preventive & Diagnostic Services
Diagnostic & Preventive Services — Used to diagnose and/or prevent dental abnormalities or disease. Includes exams and cleanings, twice per calendar year; fluoride treatments once per calendar year. 100% 0% 80% 20% 80% 20%
Space Maintainers (to age 19) — Used to prevent tooth movement. 100% 0% 80% 20% 80% 20%
Radiographs — X-rays. Bitewing X-rays limited to twice per calendar year; full-mouth X-rays once per 36 months. 100% 0% 80% 20% 80% 20%
Sealants — Used to prevent decay of pits and fissures of permanent back teeth. Once per molar every 36 months for dependent children to age 14. 100% 0% 80% 20% 80% 20%
Emergency Palliative Treatment — Used to temporarily relieve pain. 60% 40% 50% 50% 50% 50%
Class II Basic Services
Endodontic Services — Used to treat teeth with diseased or damaged nerves (for example, root canals). 60% 40% 50% 50% 50% 50%
Periodontic Services — Used to treat diseases of the gums and supporting structures of the teeth. 60% 40% 50% 50% 50% 50%
Oral Surgery Services — Extractions and dental surgery, including preoperative and postoperative care. 60% 40% 50% 50% 50% 50%
Minor Restorative Services — Used to repair teeth damaged by disease or injury (for example, fillings). 60% 40% 50% 50% 50% 50%
Relines and Repairs — Relines and repairs to bridges and dentures (once per 36 months). 60% 40% 50% 50% 50% 50%
Class III Major Services
Major Restorative Services — Used when teeth cannot be restored with another filling material (for example, crowns, inlays or onlays limited to once per tooth per five years). 35% 65% 25% 75% 25% 75%
Prosthodontic Services — Used to replace missing natural teeth (for example, bridges and dentures). Once per five years. 35% 65% 25% 75% 25% 75%
Maximum Payment — $1,500 total per person per calendar year for Class I, Class II and Class III services.
Deductible — $50 deductible total per person per calendar year limited to a maximum deductible of $100 per family per calendar year on emergency palliative treatment, Class II and Class III services.

Exclusions
Standard exclusions for the plan include but are not limited to:

  1. Services for injuries or conditions payable under Workers’ Compensation or Employer’s Liability laws. Benefits or services that are available from any government agency, political subdivision, community agency, foundation or similar entity.
    Note: This provision does not apply to any programs provided under Title XIX Social Security Act, that is, Medicaid.
  2. Services, as determined by Delta Dental, for correction of congenital or developmental malformations, cosmetic surgery or dentistry for aesthetic reasons.
  3. Services or appliances started before an individual became eligible under this plan.
  4. Prescription drugs, premedications and relative analgesia. General anesthesia and/or intravenous sedation for restorative dentistry or for surgical procedures, unless medically necessary. Charges for hospitalization, laboratory tests and examinations.
  5. Preventive control programs including home care items.
  6. Charges for failure to keep a scheduled visit with the dentist.
  7. Replacement, repair, relines or adjustments of occlusal guards.
  8. Charges for completion of forms. A participating dentist may not make these charges to an enrollee.
  9. Lost, missing or stolen appliances of any type and replacement or repair of orthodontic appliances.
  10. Services for which no valid dental need can be demonstrated, that are specialized techniques or that are experimental in nature as determined by the standards of generally accepted dental practice.
  11. Appliances, surgical procedures and restorations for increasing vertical dimension; for restoring occlusion (orthodontia); for replacing tooth structure loss resulting from attrition, abrasion or erosion; or for implantology techniques.
  12. Treatment by other than a dentist, except for services performed by a licensed dental hygienist under the scope of his or her license.
  13. Those plan features excluded by the policies and procedures of Delta Dental including the processing policies.
  14. Services or supplies for which no charge is made, for which the patient is not legally obligated to pay, or for which no charge would be made in the absence of Delta Dental coverage.
  15. Services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared.
  16. Services that are covered under a hospital, medical/surgical or prescription drug program.
  17. Appliances, restorations or services for the diagnosis or treatment of disturbances of the temporomandibular joint (TMJ).
  18. Services that are not within the classes of benefits that have been selected and are not in the contract.

Limitations

Standard limitations for the plan include but are not limited to:

  1. Prophylaxes and oral exams are payable twice per calendar year. Periodontal cleanings are payable twice per calendar year after periodontal surgery.
  2. Bitewing X-rays are payable twice per calendar year.
  3. Full mouth X-rays (which include bitewing X-rays) are payable once in a 36-month period. A panographic X-ray (including bitewings) is considered a full mouth X-ray.
  4. Amalgam and resin restorations (fillings) are payable once within a 24-month period, regardless of the number or combination of restorations placed on a surface.
  5. Cast restorations (including jackets, crowns, inlays and onlays) and associated procedures (such as cores and post substructures) on the same tooth are payable once in any five-year period.
  6. Porcelain, porcelain substrate and cast restorations are not payable for children less than 12 years of age.
  7. Optional treatment: If you select a more expensive service than is customarily provided or for which Delta Dental does not determine a valid dental need is shown, Delta Dental can make an allowance based on the fee for the customarily provided service.

    For example, if a tooth can be satisfactorily restored with amalgam (silver filling) and you choose to have the tooth restored with a more costly material, the plan will pay only the amount that it would have paid to restore the tooth with amalgam. You are responsible for the difference in cost.
  8. Prosthodontic (Class III) limitations:

    a. One complete upper and one complete lower denture can be covered once in any five-year period for any individual.

    b. A partial denture, fixed bridge or removable bridge for any individual can be covered once in any five-year period unless the loss of additional teeth requires the construction of a new appliance.

    c. Fixed bridges and removable cast partials are not payable for people less than 16 years of age.

    d. A reline or the complete replacement of denture base material is limited to once in any three-year period per appliance.
  9. Preventive fluoride treatments are payable for children until their 19th birthday, once per calendar year.
  10. When services in progress are interrupted and completed later by another dentist, Delta Dental will review the claim to determine the amount of payment, if any, to each dentist.
  11. Care terminated due to the death of an enrollee or eligible dependent will be paid to the limit of Delta Dental’s liability for the services completed or in progress.
  12. The maximum amount payable per calendar year will be limited to $1,500 per person.
  13. Delta Dental will not be obligated to pay for, in whole or in part, any service to which the deductible applies until the specified plan deductible amount is met.
  14. Processing policies may limit treatment.

Questions and Answers About the Dental Plan

What is Delta Dental PPO?
Delta Dental PPO is Delta Dental’s national preferred provider organization program that provides access to two of the nation’s largest networks of participating dentists — the PPO network and the Delta Dental Premier network. Although you can go to any licensed dentist anywhere, your out-of-pocket costs are likely to be lower if you go to a dentist who participates in one of these networks.

More than 56,000 dentists throughout the United States and its territories participate in PPO, and nearly 117,000 dentists nationwide participate in Premier.

What are the advantages of choosing a PPO dentist?
You will receive the highest level of coverage for some services when you go to a PPO dentist. In addition, the PPO dentist will be paid directly for covered services based on his or her submitted fee or the amount in the local PPO dentist schedule, whichever is less. If the PPO dentist schedule amount is lower than the dentist’s submitted fee, the dentist cannot charge you the difference. This means you will be responsible only for your copayments and deductible, if any, when you go to a PPO dentist for covered services. PPO dentists will also fill out and file your claim forms, which means fewer hassles for you.

What are the advantages of choosing a Delta Dental Premier dentist?
Although you will receive a lower level of coverage for some services when you go to a Premier dentist, the dentist will be paid directly for covered services based on his or her submitted fee or the local Maximum Approved Fee, whichever is less. If the Maximum Approved Fee is lower than the dentist’s submitted fee, the dentist cannot charge you the difference.

As with PPO dentists, this means you will be responsible only for your copayments and deductible, if any, when you go to a Premier dentist for covered services. And, like PPO dentists, Premier dentists will fill out and file your claim forms for you.

How can I find a participating dentist?
To receive the names of participating dentists near you, call Delta Dental’s Customer Service Department toll-free at 1-866-349-1286. Delta’s Automated Service Inquiry (DASI) system is available 24 hours a day, seven days a week and can provide you with the names of PPO and Premier network dentists near you. To speak directly to a representative regarding provider options, say the word “REPRESENTATIVE.” You can also visit the Web site.

What if I go to a nonparticipating dentist?
If you go to a dentist who does not participate in PPO or Premier, you will still be covered, but you may have to pay more. Delta Dental will pay you directly for covered services based on the dentist’s submitted fee or the local nonparticipating dentist fee, whichever is less. You will be responsible for paying the dentist. You may also have to submit your own claims.

Do I need to tell my dentist my coverage has changed?
Yes. If you enroll in this plan, it would be helpful if you told your dentist that you have Delta Dental PPO coverage through Delta Dental Plan of Ohio, effective Jan. 1, 2007.

Do I need an ID card to receive care?
No. If you enroll in the dental plan, you will receive an ID card providing information that may be helpful to you, including Delta Dental’s Customer Service Department telephone number and Web site address. However, your dentist can verify your eligibility for coverage through Delta Dental’s DASI system. It is not necessary for you to present the ID card to your dentist.

What if I have other questions?
Please call Delta Dental’s Customer Service Department toll-free at 1-866-349-1286. Delta Dental’s DASI system is available 24 hours a day, seven days a week and can answer many of your questions. DASI can provide you with coverage, claims and eligibility information, mailing address and the names of PPO dentists near you. In addition, customer service representatives are available to assist you Monday through Friday, 8:30 a.m.–7:50 p.m. EST.

You can also check Delta Dental’s Web site.

Why do I have to be enrolled in the plan through Dec. 31, 2008?
This period protects the financial integrity of the plan to ensure that it will continue to be an optional coverage available to STRS Ohio benefit recipients in the future.

Important Contact Information
Delta Dental Customer Service Department: 1-866-349-1286 (for eligibility, claims and dental-related coverage questions, or to request that a list of participating dentists be mailed to your home)

STRS Ohio Member Services Center: 1-888-227-7877 (for all enrollment and eligibility questions)

STRS Ohio Web site: www.strsoh.org

Delta Dental Web site: www.deltadentaloh.com

Mail claims to:
Delta Dental
P.O. Box 9085
Farmington Hills, MI 48333-9085

Send written inquiries to:
Delta Dental
P.O. Box 30416
Lansing, MI 48909-7916