Government Coverage
The New f oundland MediCare Program (MCP) provides a dent al program f or children 12 years of age and under, provided eligibilit y requirement s are met . The plan covers one cleaning per year and most dent al services considered essent ial in t he prevent ion of dent al disease and services necessary in t he
eradicat ion of exist ing dental disease. The plan also provides f or cert ain dent al surgical procedures for all resident s provided such services are perf ormed in hospit al.
Eligibility
All permanent , f ull-t ime employees are covered f rom t he f irst day of act ive employment . Contractual employees w hose init ial appointment is t o a posit ion of at least six mont hs durat ion requiring t hem t o w ork at least 20 hours per w eek are covered f rom t he f irst day of act ive employment . Furt her, contractual employees w ho are members of CUPE, Local 1615 and NAPE Locals, 7405, 7801, 7804, 7803 and 7850 w ho are not eligible f or coverage upon init ial appoint ment are covered f ollow ing complet ion of six mont hs cont inuous employment in a posit ion requiring t hem t o w ork at least 20 hours per w eek.
Ret ired employees and t heir surviving principal benef iciaries are eligible f or coverage provided t hey are in receipt of a pension f rom t he Memorial Universit y Pension Plan or ot her ret irement savings plan cont ribut ed t o by t he Universit y.
Coverage t erminat es on t erminat ion of employment . Ret iree/surviving principal benef iciary coverage t erminates on t he deat h of the ret iree/surviving principal benef iciary.
Eligible dependent s meet ing t he def init ions of spouse and unmarried dependent children may also be covered under t he dent al program. The t erm “ spouse” means a person w ho is eit her legally married t o t he employee/ret iree or has resided w it h t he employee/retiree in a conjugal relat ionship f or at least 12
consecut ive mont hs.
The t erm “ conjugal relat ionship” includes relat ionships bet w een persons of t he same sex.
“ “ Child” means a person w ho is a resident of Canada and is t he nat ural, adopt ed or st ep child of the Member or Spouse and is
f inancially reliant on t he Member or Spouse f or care, maintenance and support , is not married or in a common law relat ionship and meet s one of t he f ollow ing crit eria:
a) is under age 21;
b) is under age 25 and is at t ending an accredit ed educat ional inst it ut ion, college or universit y on a f ull-t ime basis; or
c) became ment ally or physically disabled w hile a child as def ined in (a) or (b) and has been cont inuously disabled since t hat t ime. The def init ion also includes a child over w hom t he Member or Spouse has been appoint ed as guardian w it h parent al aut horit y.
A child is considered t o be ment ally or physically disabled f or t he purposes of t his def init ion if they are incapable of engaging in any subst ant ially gainf ul act ivit y and are f inancially reliant on t he Member f or care, maint enance and support due to t his disabilit y. Blue Cross may require t he provision of w rit t en proof of a child' s disabilit y as of t en as is reasonably
necessary.
applicant s if coverage is applied f or more t han 45 days af t er becoming eligible f or benef its. In t he case of lat e applicant s, coverage is limit ed t o a maximum reimbursement of $100 per part icipant f or t he f irst 12 mont hs of coverage.
Amount of Benefit
The plan provides a w ide range of necessary dental t reat ment s. Your benef it f or covered expenses w ill consist of 80% reimbursement (no deduct ible) on basic expenses
(prevent at ive and minor rest orat ive) and endodont ic and periodont ic services. Major rest orat ive services are reimbursed at the rat e of 70% of t he eligible expense t o a maximum of $1,200 per part icipant per calendar year (prior t o June 1, 2013, t he maximum w as $1,000). The plan covers all eligible dent al expenses up t o t he amount prescribed in t he current New f oundland Dent al Societ y
Schedule of Fees and any subsequent
schedules w hich may be approved f rom t ime t o time f or t he operat ion of t he Memorial plan. To be considered as a " covered expense" , your t reat ment must be det ermined as " necessarily rendered" . The charge f or a part icular service must be reasonable and cust omary f or t he service provided in t he area w here t he expense is incurred, and w ill be limit ed t o t he applicable maximum fee level of your province of residence.
The plan covers necessary dent al t reat ment by a dent ist , physician or ot her qualif ied
personnel under the direct supervision of t he dental or medical prof ession.
Treatment Plan
Bef ore your dent ist st arts a course of t reat ment , he w ill, upon request , prepare a " t reat ment plan" - a w rit ten report describing his recommendations as to necessary
t reat ment and cost .
You are request ed t o submit a " t reat ment plan" t o Medavie Blue Cross bef ore t reat ment commences f or any t reat ment expect ed t o cost more than $500. This enables Medavie Blue Cross t o det ermine in advance it s share of t he cost of the proposed t reat ment , and t hus allow s you t o know t he ext ent of any part of t he cost you w ill have t o pay.
If you do not submit a " t reat ment plan" , w here required, you may find t hat your claim, or a port ion of it , may not be covered.
NOTE: If t he proposed course of treat ment does not commence w it hin 90 days, a new t reat ment plan should be provided bef ore benef it s w ill be paid.
Coverage under t he dent al plan w ill cease w hen you t erminate employment w it h t he Universit y and no benefits w ill be payable f or t reat ment rendered t o an employee or a dependent af t er the dat e of t erminat ion of coverage.
Plan Coverage
The f ollow ing are t he eligible expenses t hat are covered under t he plan:
Exams - Complet e oral examinat ion,
periodont al exam, emergency exam, specif ic oral exam, and recall oral examinat ion (limit ed t o once every six mont hs).
Diagnostic and Preventive Services
X-Rays - Complet e series int ra oral f ilms (once every 12 mont hs); periapical f ilms; occlusal f ilms* , post erior bit ew ing f ilms* , ext ra oral f ilms* (* f our of each t ype every f ive mont hs)
Temporomandibular joint f ilms; panoramic f ilm (once every 12 months); cephalomet ric f ilms (f ive every 24 mont hs).
Tracing of radiographs; int erpret at ion of radiographs f rom anot her source.
Tests and Laboratory Exams - Biopsy, sof t-hard t issue; diagnostic
phot ographs; diagnost ic cast s.
Case Presentation - Treatment planning; consult at ion w it h pat ient .
Preventive Services - Polishing (2 unit s t ime every 12 consecut ive mont hs; one unit of t ime every 5 consecut ive mont hs f or dependent s under 19), Scaling (80% of t he f irst and second scalings in a calendar year and 50% of subsequent scalings in that same calendar year), f luoride t reat ment (2 in any 12
consecutive mont hs), nut rit ional counselling, oral hygiene inst ruct ion, f inishing rest orat ions, pit and f issure sealant s, prot ect ive at hlet ic appliance (once in every 12 months), re- contouring of t eet h, space maint ainers, caries/t rauma/pain cont rol.
Restorative Services - Amalgam rest orat ions; pin reinf orcement , acrylic or composit e rest orat ions, porcelain repair on an exist ing single crow n, nat ural t ooth preparation, met al coping crow n, recement crow n or inlay, removal of crow n or inlay.
Periodontal Services (treatment of gum disease) - Diagnosis and t reat ment of gum t issue: applicat ion of displacement dressing; management of acut e inf ections and ot her oral lesions; desensit izat ion of t oot h surf ace.
Surgical Services- gingival curet t age; gingivolplast y; gingivect omy/f ibrot omy; osseous surgery; osseous graf t s; sof t tissue graf t s; post surgical t reat ment .
Abscess or pericoronit is surgery. Occlusal equilibrat ion.
Adjunctive Periodont al Services: provisional splint ing; periodont al scaling/root planing;
special periodontal appliances including occlusal guards (excluding TMJ relat ed problems); maint enance, adjust ment s and repair t o periodont al appliances (excluding TMJ related problems); direct reline. Post surgical evaluat ion.
Prosthetic Services - Denture adjust ment (af t er t hree mont hs f rom insert ion); denture repairs; dent ure rebasing and relining (once every 24 mont hs).
Endodontic Services (Root Canal) - Pulpot omy, root canal, apexif icat ion, periapical services, root amput at ion, explorat ory surgery, canal and/or pulp chamber enlargement .
Preparat ion of t oot h f or t reat ment : banding of t oot h t o maint ain st erile operat ing f ield; hemisection; int ent ional removal, apical f illing and reimplant at ion.
Surgical Services - Removal of erupt ed t oot h - uncomplicat ed; removal of erupt ed t oot h - complicated; removal of impacted t oot h; alveoplast y/alveolect omy; removal of root ; miscellaneous surgical services.
General Services
- Anaest hesia
- Consult at ion w it h anot her dent ist - Prof essional visit s
- Other services:
- bleaching of vit al t oot h
- commercial laborat ory charges - in-of fice laborat ory charges
Major Restorative Services:
Extensive Restorative Procedures
Inlays and onlays - met al - composit e - porcelain/ceramic Ret entive post s (f or crow ns)
- cast met al - pref abricat ed
Indirect overdent ure rest orat ive services - met al cast coping crow n w it h
or w it hout at tachment Crow ns
- acrylic/composit e - porcelain/ceramic - cast met al
Crow n made t o an existing part ial dent ure clasp
Metal/plast ic t ransf er copings Laborat ory processed veneers
- plast ic
- porcelain/ceramic
Prosthodontic Services – Removable
Complete Dent ures (limit ed t o one complet e upper and one complet e low er dent ure in any f ive Consecut ive Calendar Years)
- st andard - equilibrat ed - gnat hological - overdent ure
Transit ional Dent ures (limit ed t o one upper and one low er in any Five Consecut ive Calendar Years)
Part ial Dentures (limited t o one upper and one low er in any Five Consecut ive Calendar Years) Acrylic
- w it hout clasp
- w it h resilient clasps
- w it h metal w rought /cast clasp and/or rest s
- w it h metal w rought
palat al/lingual bar and clasp and/or rest s
- overdent ure w it h cast /w rought clasps and/or rest s
Cast w it h acrylic base
- f ree end w it h cast f rame connector, clasp and rest s - f ree end w it h sw ing
lock/connect or
- t oot h borne w it h cast f rame connector, clasp and rest s - cast w it h precision
at t achment s
- cast w it h semi-precision at t achment s
- cast w it h st ress breaker at t achment s
- cast , overdenture, removable
Prosthodontic Services – Fixed Bridge
Pont ics
- cast met al - porcelain/ceramic - acrylic/composit e - nat ural t oot h
Abut ment s
- acrylic/composit e - porcelain/ceramic - porcelain f used t o met al - cast met al
- met al, ¾ cast Ot her Fixed Prosthet ic Services
- abut ment preparat ion under existing part ial dent ure clasp - t elescoping crow n unit - f ixed porcelain prost hesis t o
t he alveolar process - splint ing, f or ext ensive or
complicat ed rest orat ive dent istry
- ret ent ive pins
- provisional coverage (in ext ensive or complicat ed restorat ive dent istry)
Claiming Benefits
If you are in doubt as t o w het her a particular course of t reat ment w ould be covered under t he dent al insurance plan, it w ould be
advisable t o contact Medavie Blue Cross at 1- 800-667-4511 f or pre-determinat ion of coverage.
If your dent ist does not allow assignment and you are required t o pay t he dent ist f or t he t reat ment perf ormed, submit your receipt s along w it h t he appropriat e claim f orm t o Medavie Blue Cross for reimbursement . Please include your subscriber number and policy number (act ive employees: 7355-000; ret ired Memorial employees: 7355-001; ret ired Marine Inst it ut e employees: 7355-002).
Exclusions
Covered expenses do not include and no payment is made for:
- int ent ional self -inf lict ed injuries or illness w hile sane or insane;
- any services t o w hich t he plan part icipant is ent it led under any Workers’
Compensation st at ut e or any ot her legislat ion;
- dent al t reat ment received f rom a dent al or medical depart ment maint ained by an employer, an associat ion, or a labour union;
- examinat ions required f or use of a t hird part y;
- physicians’ or dent ist s’ charges f or t ime spent travelling, broken appoint ment s, t ransport at ion cost s or advice given by t elephone or any ot her means of t elecommunicat ion;
- cosmetic surgery or treatment , w hen det ermined as such by Medavie Blue Cross, unless such surgery or t reat ment is f or accident al injury and commenced w it hin 90 days of t he accident ;
- injury result ing eit her direct ly or indirect ly f rom insurrect ion, w ar, service in t he armed f orces of any count ry or part icipat ing in a riot ;
- orthodont ic t reat ment
- services and supplies rendered f or a f ull mout h reconstruct ion, f or a vertical dimension correct ion, or for correct ion of t emporomandibular joint dysf unct ion.
Important Change in Coverage Effective November 15, 2007
(Applicable t o resident s of New f oundland and Labrador w ho have dependent children under t he age of 13)
Ef fect ive November 15, 2007, the dental plan w ill no longer provide coverage f or f illings and ext ract ions f or dependent children under t he age of 13. These services are covered under t he New f oundland and Labrador provincial dental program. Dentist s have been advised t o submit claims f or these procedures to t he provincial program.
Updat e - June, 2008
In t he case of w hit e f illings on primary t eet h, t he dent al plan w ill pay t he dif ferent ial in t he price of silver f illings versus w hit e f illings f or children under 13. In addit ion, f illings on primary ant erior teet h, w hich are not covered by t he government plan, w ill covered by t he dental plan.