Page 12 - KIPP NYC 2022 Benfits Summary

Dental Plan Benefits
KIPP NYC offers a choice of 3 dental plans — a High Dental PPO, a Low Dental PPO and a Dental HMO through Cigna. Our dental plan covers a wide variety of dental procedures. The cost of this plan is shared by you and KIPP NYC. Your contribution to the cost of coverage is deducted from your pay, each pay period (24 times), on a pre-tax basis.
PPO High and Low Plans
You have the option of seeing any provider within Cigna’s Total DPPO Network or you can use a non-network dentist. Claim forms are not required when utilizing in-network providers. Network participating providers accept negotiated rates which reduce your claim costs and out-of-pocket expenses. If you choose a non-network dentist, the plan will reimburse you a percentage of the allowable charge.
All services, except preventive services, are subject to the plan’s annual deductible. All benefits paid by Cigna accrue towards the plan’s calendar year maximum. Each family
Cigna Dental WellnessPlus
(Calendar Year Maximum Rollover – Applies to PPO Plans Only)
When you get preventive care, your annual maximum increases the next plan year. This lets you build your annual dollar maximum for other future needs. Your annual maximum will grow by $150 each year, up to $450 in year four, as long as you stay enrolled in the plan and keep getting preventive care.
Members of the same family could have different annual dollar maximums in future years. Family members who get preventive care also see an increase in their annual dollar maximum in the future years. If you do not get preventive care, your annual dollar maximum stays the same. This is
also true for your covered family members.
How to Enroll
Visit the Benefits tab on UKG during your benefit enrollment window.
ID Cards
You should typically receive your ID card(s) within 10–15 business days after you make your benefits elections.
member has their own calendar year maximum.
Dental Health Maintenance Organization (DHMO)
You are required, as a DHMO member, to select a primary care dentist (PCD) from participating dentists in the DHMO network. You must use your selected PCD for all dental services, or obtain a referral from your PCD to obtain services from a specialist. The amount you pay for services rendered is based on the plan’s benefit fee schedule.
Orthodontia coverage is offered for adults and children according to the plan’s fee schedule. Please contact the Benefit Advocate Center for a copy of the fee schedule.
12 KIPP NYC PUBLIC SCHOOLS