Page 2 - Golden Health Choice Small Business

Small Business Plan
Small Business Plan
ANNUAL MAXIMUM
General Dentistry: UNLIMITED
COSMETICS
• Zoom Bleaching - $299.00 ($700.00 value) contact GDP for participating providers
• Veneers and Implants – a 25% discount contact GDP for participating providers
SPECIALTY CARE
ANNUAL MAXIMUM for Specialty Care: $1,000.00 WAITING PERIOD: 6 Months from enrollment COVERAGE LEVEL: 35%
• Member must be enrolled for six consecutive months
• Member must obtain referral from Primary Dentist.
• Member must utilize an In-Network Specialist (Contact GDP for list of providers).
• Member is responsible for 65% of the Specialist’s fee for listed procedures, including evaluations and x-rays.
• Pedodontics is covered at 65% for dependents up to age 7 without a referral.
*Once every 6 months at a general dentist. Adult cleanings are covered 3 per contract year; 3rd adult cleaning is covered at 50%.
**Procedure must be performed by a general dentist
***Crowns and Dentures are covered once every 5 years. Porcelain on crowns posterior to the 1st and 2nd premolars are considered cosmetic dentistry and therefore are not a covered benefit. Patient may incur additional out-of-pocket charges for lab work and/or upgraded materials for fillings, crowns, bridges, partial or complete dentures, space maintainers, appliances and any repairs to stated items.
****Member must have twelve (12) months of continuous coverage for Orthodontic Benefit.
All Specialty appointments must accompany primary care referral
See Member Handbook for complete list of limitations and exclusions
Frequently
Frequently
asked questions:
asked questions:
How do I choose a provider?
Check the Dental Rider Option on the HealthChoiceofMichiganApplication. Oncethe application is processed by HCM, you will receive your GDP welcome letter and Enrollee Handbook within two weeks.
How do I join?
Complete the enrollment application and return to HealthChoice of Michigan along with your first monthlypayment. Oncetheapplicationis processed by HCM, you will receive your GDP Welcome Packet within two weeks.
How soon will my benefits take effect?
Applications received prior to the 15th of the month will become eligible the 1st of the following month.
Who are eligible dependents?
Dependents are children up to the age of 26. An adult child (age 19 and older) is not eligible for coverage if the adult child has another offer of employer-sponsored coverage.
What are my out-of-pocket costs?
Upon enrollment, members will receive a detailed co-payment schedule that describes the covered benefits and related co-payment amounts.
What services are excluded?
Dental procedures that are not on the co-payment schedule are not a covered benefit.
What if I have an out-of-town emergency?
If the member is more than 50 miles away from an In-network provider, they can be seen by an Out- of-Network Provider for the treatment of pain and GDP will reimburse the member up to $100.00. The member will need to follow-up with their Primary General Dentist for further treatment.
Who can I contact if I have questions about my plan?
Contact GDP Customer Service at 1-800-451-5918 Monday-Friday from 9am-5pm.