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M/C; Legislature Dental

This online publication has been updated to include the Preferred Dental Plan Non-Participating Provider Reimbursement Schedule as of January 1, 2016.

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.

Introduction

Your Coverage Under This Plan

The State of New York has entered into a Group Contract with Group Health Incorporated ("GHI") to provide you and your covered dependents with dental insurance benefits. The Group Contract covers New York State Management /Confidential (M/C) and Unrepresented Employees and their covered dependents.

This booklet is your Certificate of Insurance. It is evidence of your coverage under the Group Contract. It is not a contract between you and GHI. You should keep this booklet with your other important papers so that it is available for your future reference.

GHI's payments for covered services are based upon a Schedule(s) of Allowances. Payments for covered, but unlisted procedures will be made according to the category of coverage they fall under.

IMPORTANT: It is suggested that you obtain a Predetermination of Benefits from GHI in connection with certain services. Please be sure to review this booklet before you receive any dental services.

Criteria for Coverage.

GHI will not provide benefits for covered services unless they meet the conditions set forth:

  1. The services must meet generally accepted standards of dentistry or dental practice.
  2. The services must not be in excess of the normally required treatment.
  3. The services must be medically necessary for dental health and performed by a licensed dentist or physician. In determining medical necessity, GHI will examine the factors set forth below:
    1. Your treatment.
    2. Your condition.
    3. The reasons for providing or prescribing the care.
    4. Any unusual circumstances.
  4. Service must be considered a covered expense under the plan.

No service will be covered unless it is rendered by a dentist or physician. The dentist or physician must act within the scope of his/her license. The dentist or physician must be licensed or certified to perform the services in the jurisdiction in which the services are rendered.

GHI may require that a dentist or physician's statement be furnished to detail the nature and necessity of a rendered service. When this statement is required it must be provided in order for you to be eligible to receive benefits. It must be in a form acceptable to GHI.

The fact that your dentist or physician prescribed the care does not automatically mean that the care qualifies for payment under this plan.

In all instances, GHI reserves the right to determine benefits taking into account alternate procedures, services or courses of treatment.