Group Dental Insurance

Both the High Plan and the Low Plan cover preventive, basic, and major dental services. Specific services covered under each plan are outlined below. This website presents the majority of services within each category, but is not a complete description of the plan.

Preventive Services – Type A

• Prophylaxis (regular cleanings): Two per calendar year, separated by six months
• Oral examinations: Two exams per calendar year, separated by six months
• Examinations – problem focused: Combined with examinations limit
• Topical fluoride applications: One fluoride treatment per 12 months for dependent children up to age 14
• Periodontics: Total number of periodontal maintenance treatments and prophylaxis (regular cleanings) cannot exceed two treatments in a calendar year, separated by six months
• Full mouth x-rays: Once every 60 months
• Bitewing x-rays: One set per 12 months for adults; two sets per calendar year for children under age 19, separated by six months
• Space maintainers: One per lifetime for a child under age 14
   

Basic Services – Type B

• Fillings: One replacement per surface in 24 months
• Resin composite fillings: Excludes coverage for composite fillings on molars
• Simple extractions
• Oral surgery
• General anesthesia: When dentally necessary in connection with oral surgery, extractions, or other covered dental services
• Sealants: One application every three years for each non-restored, non-decayed first and second molar of a dependent child under age 16
   

Major Services – Type C

• Endodontics: Root canal treatment limited to once per tooth per 24 months
• Periodontics: Periodontal scaling and root planing once per quadrant, every 24 months
• Periodontal surgery: Once per quadrant, every 36 months
• Implant services/prosthetics: One per tooth every seven years
• Implant repairs: One per tooth in 12 months
• Bridges and dentures: Initial placement to replace one or more natural teeth, which are lost while covered by the plan
• Bridges and dentures – replacements: Once every seven calendar years; replacement of an existing temporary full denture if the temporary denture cannot be repaired and the permanent denture is installed within 12 months after the temporary denture was installed
• Crown, denture, and bridge repair/recommendations: Once every 24 months
• Crowns, inlays, and onlays: Replacement once per tooth every five calendar years
• Consultations: Two in 12 months
• Occlusal adjustments: One in 12 months
   

Is Orthodontia a Covered Service?
Your children, up to age 19, are covered for orthodontic diagnostics and treatment under the High Plan at a 50% reimbursement rate. The lifetime maximum is $1,000. Orthodontia is not covered under the Low Plan.

Your dental coverage will become effective following receipt of your enrollment form and first premium payment.

Your dental coverage will remain in effect unless you fail to pay the appropriate premium when due, or the group policy is discontinued. Coverage for dependents will end at age 26.

For services provided by an in-network dentist, benefits will be paid directly to the dentist. For services provided by an out-of-network dentist, you can request that benefits be paid either directly to your dentist or directly to you. Claims are payable immediately from the start date of your coverage.

No benefits will be paid for the following:

• Services which are not dentally necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which we deem experimental in nature
• Services for which you would not be required to pay in the absence of dental insurance
• Services or supplies received by you or your dependents before the dental insurance starts for that person
• Services which are primarily cosmetic (for Texas residents, see notice page section in Certificate of Insurance)
• Services which are neither performed nor prescribed by a dentist, except for those services of a licensed dental hygienist, which are supervised and billed by a dentist and which are for:

o   Scaling and polishing of teeth
o   Fluoride treatments

• Services or appliances which restore or alter occlusion or vertical dimension
• Restoration of tooth structure damaged by attrition, abrasion, or erosion
• Restorations or appliances used for the purpose of periodontal splinting
• Counseling or instruction about oral hygiene, plaque control, nutrition, and tobacco.
• Personal supplies or devices including, but not limited to: water picks, toothbrushes, or dental floss
• Decoration, personalization, or inscription of any tooth, device, appliance, crown or other dental work
• Missed appointments
• Services:

o   Covered under any workers’ compensation or occupational disease law;
o   Covered under any association liability law;
o   For which the association of the person receiving such services is not required to pay; or
o   Received at a facility maintained by the policyholder, labor union, mutual benefit association,  or VA hospital

• Services covered under other coverage provided by the policyholder
• Temporary or provisional restorations
• Temporary or provisional appliances
• Prescription drugs
• Services for which the submitted documentation indicates a poor prognosis
• Services, to the extent such services, or benefits for such services, are available under a government plan. This exclusion will apply whether or not the person receiving the services is enrolled for the government plan. We will not exclude payment of benefits for such services if the government plan requires that dental insurance under the group policy be paid first.
• The following when charged by the dentist on a separate basis:

o   Claim form completion;
o   Infection control such as gloves, masks, and sterilization of supplies; or
o   Local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide

• Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food
• Caries susceptibility tests
• Initial installation of a fixed and permanent denture to replace one or more natural teeth which were missing before such person was insured for dental insurance, except for congenitally missing natural teeth
• Other fixed denture prosthetic services not described elsewhere in the certificate
• Precision attachments, except when the precision attachment is related to implant prosthetics
• Adjustment of a denture made within 6 months after installation by the same dentist who installed it
• Duplicate prosthetic devices or appliances
• Replacement of a lost or stolen appliance, cast restoration, or denture
• Intra- and extra-oral photographic images
• Fixed and removable appliances for correction of harmful habits
• Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal guards and night guards
• Diagnosis and treatment of temporomandibular joint (TMJ) disorders. This exclusion does not apply to residents of Minnesota
• Orthodontia services in the Low Plan
• Repair or replacement of an orthodontic appliance
• Initial installation of a full or removable denture to replace one or more natural teeth which were missing before such person was insured for dental insurance, except for congenitally missing natural teeth
• Addition of teeth to a partial removable denture to replace one or more natural teeth which were missing before such person was insured for dental insurance, except for congenitally missing natural teeth
• Implants supported prosthetics to replace one or more natural teeth which were missing before such person was insured for dental insurance, except for congenitally missing natural teeth
   

Alternate Benefit

If we determine that a service less costly than the Covered Service the Dentist performed could have been performed to treat a dental condition, we will pay benefits based upon the less costly service if such service:

• would produce a professionally acceptable result under generally accepted dental standards
• also would qualify as a Covered Service

Coverage is provided under a group insurance policy (Policy Form GPNP99-TRUST (7/10)) issued by Metropolitan Life Insurance Company. Subject to the terms of the group policy, rates are effective for one year from your plan’s effective date. Once coverage is issued, the terms of the group policy permit Metropolitan Life Insurance Company to change rates during the year in certain circumstances.

Coverage terminates when you cease to be a member of TXCPA, when your dental contributions cease, upon termination of the group’s participation in the Trust, or insurance ends for your class.

Coverage for dependents ends if your insurance ends, on the date you die, the group policy ends, participation in the Trust ends, the date dependents’ insurance ends under the group policy, insurance for your dependents ends for your class, the person ceases to be a dependent or premium is not paid for the dependent when due.

There is a 31-day limit for the following services that are in progress: Completion of a prosthetic device, crown, or root canal therapy after individual termination of coverage.

For rate information and to receive an enrollment form, please call the plan administrator at 1-800-845-8941. Online enrollment for this plan will resume in February 2024.