Employee Dental Plans
Member Guidebook
Pensions & Benefits
HD-0379-0124
The Dental Plan Organizations and The Dental Expense Plan
For the State Health Benets Program and the School Employees’ Health Benets Program
Employee Dental Plans — Member Guidebook January 2024 Page 2
State Health Benets Program School Employees’ Health Benets Program
TABLE OF CONTENTS
Introduction ................................4
Employee Dental Plans Eligibility .............4
State Employees .........................4
Local Employees .........................4
Eligible Dependents .......................5
Retirees ................................5
COBRA Coverage ..........................5
Employee Dental Plans ......................5
General Conditions of the Dental Plans ........5
Enrollment ..............................5
Limitation On Changing Dental Plans .........5
Dual Dental Enrollment Is Prohibited ..........5
Other Enrollment Information ................5
Dental Plan Choices ........................6
Levels of Coverage .........................6
Dental Plan Premiums. . . . . . . . . . . . . . . . . . . . . . . 6
State Employees .........................6
Local Government and
Local Education Employees .................6
Extension of Coverage Provisions ............6
If Eligibility Ends While Undergoing
Treatment ...............................6
For Children Over the Age of
26 With Disabilities ........................6
Transition of Care .........................6
Orthodontics Takeovers —
From Previous Insurance Carrier .............6
Special Provisions of the
Employee Dental Plans ......................7
Coordination of Benets With
Other Insurance Plans .....................7
Third Party Liability .........................7
Repayment Agreement .....................7
Recovery Right ...........................7
HIPAA Privacy .............................8
Audit of Dependent Coverage ................8
Health Care Fraud ..........................8
The Dental Plan Organizations ................8
Considerations in Choosing a DPO ............8
Covered Services ..........................9
Orthodontics ............................17
More Expensive Services ..................17
Emergency Services — Out of Area ..........18
Services Not Covered by the DPO ............18
The Dental Expense Plan ...................18
Annual Deductible. . . . . . . . . . . . . . . . . . . . . . . . 18
Reasonable and Customary Charges. . . . . . . . . 18
Dental Expense Plan Benets (Chart) ........19
Covered Services .........................19
Annual and Lifetime Benet Maximums .......19
In-Network and Out-of-Network Integration ....19
In-Network Claims (Chart) ..................20
Out-of-Network Claims (Chart) ..............20
Additional Provisions of the DEP ............20
How Payments Are Made ..................20
Filing Deadline — Proof of Loss .............20
Itemized Bills Are Necessary ...............20
Predetermination of Benets ...............20
Alternative Procedures ....................21
Services Eligible For Reimbursement .........21
Orthodontic Services
Eligible For Reimbursement .................21
Orthodontic Benets .......................22
Services Not Eligible
for Reimbursement ........................22
Orthodontic Charges Not
Eligible Under the DEP .....................22
Appendix I
Claim Appeal Procedures ...................23
Appendix II
Glossary .................................24
Appendix III
Available Dental Plans (Chart) ...............25
Appendix IV
Tax$ave ..................................26
Appendix V
Notice of Privacy Practices to Enrollees .......26
Protected Health Information ...............26
Uses and Disclosures of PHI ...............26
Restricted Uses .........................27
Member Rights ..........................27
Questions and Concerns ..................28
Page 3 January 2024 Employee Dental Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
Health Benets Contact Information ..........29
Addresses .............................29
Telephone Numbers ......................29
Health Benets Publications ................29
General Publications .....................29
Health Benet Fact Sheets ................29
Health Plan Member Guidebooks ...........29
Employee Dental Plans — Member Guidebook January 2024 Page 4
State Health Benets Program School Employees’ Health Benets Program
INTRODUCTION
The State Health Benets Program (SHBP) was es-
tablished in 1961. It oers medical, prescription drug,
and dental coverage to qualied State and local gov-
ernment public employees, retirees, and eligible de-
pendents. Local employers must adopt a resolution to
participate in the SHBP.
The State Health Benets Commission (SHBC) is
the executive organization responsible for overseeing
the SHBP.
The State Health Benets Program Act is found in the
New Jersey Statutes Annotated, Title 52, Article 14-
17.25 et seq. Rules governing the operation and admin-
istration of the program are found in Title 17, Chapter 9
of the New Jersey Administrative Code.
The School Employees’ Health Benets Program
(SEHBP) was established in 2007. It oers medical,
prescription drug, and dental coverage to qualied lo-
cal education public employees, retirees, and eligible
dependents. Local education employers must adopt a
resolution to participate in the SEHBP.
The School Employees’ Health Benets Commis-
sion (SEHBC) is the executive organization responsi-
ble for overseeing the SEHBP.
The School Employees’ Health Benets Program Act is
found in the New Jersey Statutes Annotated, Title 52,
Article 14-17.46 et seq. Rules governing the operation
and administration of the program are found in Title 17,
Chapter 9 of the New Jersey Administrative Code.
The New Jersey Division of Pensions and Benets
(NJDPB), specically the Health Benets Bureau and
the Bureau of Policy and Planning, are responsible for
the daily administrative activities of the SHBP and the
SEHBP.
The Employee Dental Plans consist of the Dental
Plan Organizations (DPOs) and the Dental Expense
Plan (DEP). The Employee Dental Plans are available
to full-time employees of the State of New Jersey, State
colleges and universities, certain independent State
agencies, and adopting local government and local
education employers. Before making any enrollment
decision, you should carefully review the standards
of eligibility and the conditions, limitations, and exclu-
sions of the benet coverage oered under each plan.
The complete terms of Employee Dental Plans cover-
age are described in the DPO and DEP contracts with
amendments.
Every eort has been made to ensure the accuracy
of the Employee Dental Plans Member Guidebook.
However, State law and the New Jersey Administrative
Code govern the SHBP and SEHBP. If there are dis-
crepancies between the information presented in this
guidebook and/or plan documents and the law, regula-
tions, or contracts, the law, regulations, and contracts
will govern. Furthermore, if you are unsure whether a
dental service or procedure is covered, contact your
dental plan before you receive services to avoid any
denial of coverage issues that could result.
If, after reading this guidebook, you have any questions,
comments, or suggestions regarding the information
presented, please write to the New Jersey Division of
Pensions & Benets, P.O. Box 295, Trenton, NJ 08625-
0295, call us at (609) 292-7524, or send email to:
pensions.nj@treas.nj.gov
EMPLOYEE DENTAL PLANS ELIGIBILITY
Eligibility for coverage is determined under the provi-
sions of the SHBP. Enrollments, terminations, chang-
es to coverage, etc. must be presented through your
employer to the Health Benets Bureau of the NJDPB.
If you have any questions concerning eligibility pro-
visions, you should see your employer’s benets ad-
ministrator. You can also contact the NJDPB Oce
of Client Services at (609) 292-7524 or by email at:
pensions.nj@treas.nj.gov
State Employees
To be eligible for State Employee coverage, you must
work full-time for the State of New Jersey or be an ap-
pointed or an elected ocial of the State of New Jersey
(this includes employees of a State agency or authori-
ty and employees of a State college or university). For
State employees, full-time requires 35 hours per week
or more if required by contract or resolution.
State part-time employees covered under P.L. 2003,
c. 172 (Chapter 172), and State intermittent employees
covered by negotiated agreements between the State
of New Jersey and the Communications Workers of
America (CWA) are not eligible for coverage under the
Employee Dental Plans.
Local Employees
To be eligible for Employee Dental Plans local employ-
er coverage, you must be a full-time employee or an
appointed or elected ocial receiving a salary from a
local government/education employer (county, munic-
ipality, county or municipal authority, board of educa-
tion, etc.) that participates in the SHBP or the SEHBP
and has adopted a resolution to provide dental benets
under the Employee Dental Plans.
Each participating local employer denes, in its reso-
lution, the minimum hours required to be considered a
full-time employee, but it can be no less than 25 hours
per week or more if required by contract. Employment
must also be for 12 months per year except for employ-
ees whose usual work schedule is 10 months per year
(the standard school year).
Local part-time employees covered under Chapter 172
are not eligible for coverage under the Employee Den-
tal Plans.
Page 5 January 2024 Employee Dental Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
Eligible Dependents
Your eligible dependents are your spouse, civil union
partner, or eligible same-sex domestic partner and/or
your eligible children. See the NJDPB website for de-
nitions of eligible dependents and required documenta-
tion: www.nj.gov/treasury/pensions
Note: There is no provision for dental coverage under
P.L. 2005, c. 375 (Chapter 375), which provides medi-
cal and/or prescription drug coverage to over age chil-
dren until age 31.
Retirees
The Employee Dental Plans are not available to retir-
ees. At retirement, retirees who are eligible for enroll-
ment into the Retired Group of the SHBP or SEHBP
may elect to enroll for coverage in the Retiree Dental
Plans.
Note: Employees who, at retirement, are eligible to en-
roll in the Retired Group of the SHBP or SEHBP can-
not continue Employee Dental Plan coverage under
COBRA. See the “COBRA Coverage” section.
For more information about the Retiree Dental Plans,
see the Dental Plans – Retirees Fact Sheet, or the Re-
tiree Dental Plans Member Guidebook. See the “Health
Benets Publications” section.
COBRA COVERAGE
Continuing Coverage When it Would Normally End
The Consolidated Omnibus Budget Reconciliation Act
of 1985 (COBRA) is a federally regulated law that gives
employees and their eligible dependents the opportuni-
ty to remain in their employer’s group coverage when
they would otherwise lose coverage. COBRA coverage
is available for limited time periods, and the member
must pay the full cost of the coverage plus an adminis-
trative fee.
Under COBRA, you may elect to continue in any or
all of the coverages you had as an active employee or
dependent (health, prescription drug, dental, and vi-
sion). You may also change your health or dental plan
when enrolling in COBRA. You may elect to cover the
same dependents that you covered while an active
employee, or delete dependents from coverage. How-
ever, you cannot add dependents who were not covered
while an employee, except during the annual Open En-
rollment period or unless a qualifying event (marriage,
birth or adoption of a child, etc.) occurs within 60 days
of the COBRA event.
The rules and plan provisions that govern COBRA cov-
erage for the Employee Dental Plans are the same as
those for the SHBP/SEHBP medical plans. Please re-
fer to the Summary Program Description for additional
information about your rights and responsibilities under
COBRA. See the “Health Benets Publications” sec-
tion for information on how to obtain this publication.
EMPLOYEE DENTAL PLANS
All benets listed in this guidebook may be subject to
limitations and exclusions as described in subsequent
sections. Services or supplies not listed in this guide-
book may still be eligible under this plan.
GENERAL CONDITIONS OF THE DENTAL PLANS
Enrollment
Enrollment in a dental plan is optional. If you do not
enroll when rst eligible, you will have the option to en-
roll each year during the annual SHBP/SEHBP Open
Enrollment Period.
In deciding whether to enroll and which plan to choose,
you should consider the dierences in out-of-pocket
costs, the covered services between a Dental Plan Or-
ganization (DPO) and the Dental Expense Plan (DEP),
and the degree of exibility that you may want in select-
ing a dentist.
Eligibility for coverage is determined under the provi-
sions of the SHBP/SEHBP. Enrollments, terminations,
changes to coverage, etc. must be presented through
your employer to the Health Benets Bureau of the
NJDPB.
Limitation on Changing Dental Plans
If you choose to enroll in a dental plan, you must remain
in the dental plan you select for at least 12 months.
Dual Dental Enrollment is Prohibited
SHBP/SEHBP regulations prohibit two members who
are married to each other, civil union partners, or eli-
gible same-sex domestic partners, and who are both
enrolled in the SHBP or SEHBP, from enrolling under
more than one of the dental plans. An individual may
belong to a dental plan as an employee or as a depen-
dent but not as both. Furthermore, two SHBP and/or
SEHBP members cannot both cover the same children
as dependents under their dental plan coverage.
In cases of divorce or single parent coverage of depen-
dents, there is no coordination of benets under two
dental plans. That is, once a claim has been submitted
for payment under one plan it is not eligible for addition-
al payment under another dental plan.
Other Enrollment Information
Except as indicated above, the rules for enrollment and
information on maintaining coverage in the Employee
Dental Plans are the same as those for the SHBP/SE-
HBP medical plans. Please refer to the Summary Pro-
gram Description for additional information about enroll-
ment, dates of coverage, and other coverage provisions
under the SHBP and SEHBP.
Employee Dental Plans — Member Guidebook January 2024 Page 6
State Health Benets Program School Employees’ Health Benets Program
DENTAL PLAN CHOICES
You may choose to enroll in one of two dierent types
of dental plans:
• The Dental Plan Organizations (DPOs) are com-
panies that contract with a network of providers for
dental services. There are several DPOs participat-
ing in the Employee Dental Plans from which you
may choose. You must use providers participating
with the DPO you select to receive coverage. Be
sure you conrm that the dentist or dental facility
you select is taking new patients and participates
with the Employee Dental Plans, since DPOs also
service other organizations.
• The Dental Expense Plan (DEP) is a traditional
indemnity plan that allows you to obtain services
from any dentist. After you satisfy the $50 annual
deductible (the deductible applies to non-preven-
tive services only), you are reimbursed a percent-
age of the reasonable and customary charges for
the services that are covered under the DEP. This
plan is administered under a contract between the
SHBC and Aetna Life Insurance Company (Aetna).
LEVELS OF COVERAGE
There are four levels of coverage:
• Single: covers the employee only;
• Member and Spouse/Partner: covers the employ-
ee and spouse, civil union partner, or eligible do-
mestic partner;
• Parent and Child(ren): covers the employee and
all enrolled eligible children; or
• Family: covers employee, spouse or partner, and
all enrolled eligible children.
DENTAL PLAN PREMIUMS
The cost for participation in a dental plan is shared by
the State or local employer and dental plan participants.
For a current list of premium rates and payroll deduction
schedules, please see your benets administrator.
State Employees
For State employees paid through the State’s Central-
ized Payroll Unit, premium payments are made through
biweekly payroll deductions.
For all other State employees, premium payments are
made through a deduction schedule determined by your
employer.
State employee premiums can be paid on a pre-tax
basis through participation in the Premium Option Plan
(POP) of the State’s IRC Section 125 Program, Tax-
$ave. Participation in POP is automatic unless you spe-
cically decline enrollment. See the “Tax$ave” section
for more information.
Local Government and Local Education Employees
For local employees, premium payments are made
through a deduction schedule determined by your em-
ployer.
Note: The State Tax$ave program is not available to lo-
cal employees. Contact your employer to nd out if you
are eligible to pay premiums on a pre-tax basis through
an IRC Section 125 Program oered by your employer.
EXTENSION OF COVERAGE PROVISIONS
If Eligibility Ends While Undergoing Treatment
If your coverage is terminated voluntarily or due to
non-payment of premiums, there is no extension of on-
going treatment for you or your dependents.
Once coverage is terminated for you or any of your
dependents, there is no eligibility for continuation of the
Employee Dental Plans under the provisions of CO-
BRA. There is also no conversion to an individual policy
authorized under this plan.
If you die, and your dependent does not elect to con-
tinue Employee Dental Plans coverage under their own
account and is undergoing treatment, your dependent’s
coverage will be extended to cover the following proce-
dures for up to 30 days following the end of their cov-
erage:
• Production of an appliance or modication of an
appliance for which the impression was taken while
the person was covered;
• Preparation of a crown or restoration for which a
tooth was prepared while the person was covered;
and
• Root canal therapy for which the pulp chamber was
opened while the person was covered.
For Children Over the Age of 26 With Disabilities
In certain circumstances, coverage can be continued
for a dependent child over the age of 26. See the
NJDPB website at: www.nj.gov/treasury/pensions for
more information about extending coverage for children
with disabilities.
Transition of Care
The dental plan shall ensure that all members currently
undergoing dental treatment for any condition be transi-
tioned into the new plan without any disruption in cover-
age or access to providers.
ORTHODONTICS TAKEOVERS
FROM PREVIOUS INSURANCE CARRIER
When a member chooses to elect the SHBP/SEHBP
Dental Plan, the following items need to occur for or-
thodontics procedures to be considered eligible under
the plan:
• The member must have been covered by an insur-
ance carrier;
• The treatment is only eligible for consideration
Page 7 January 2024 Employee Dental Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
under the SHBP/SEHBP Plan if the prior carrier
covered and considered the member’s orthodontic
treatment plan;
• The treatment must have started prior to the SHBP/
SEHBP Plan eective date;
• The member must provide the new carrier with the
banding date, treatment plan, and length of treat-
ment;
• The member must provide the new carrier with the
amount the prior carrier paid to date by submitting
the necessary documentation;
• Bands need to be placed on the patient’s teeth be-
fore reaching the plan’s specied age limit; and
• Any amounts paid by the prior carrier will be up-
dated to the SHBP/SEHBP orthodontic maximums.
The entire amount paid out will be subject to the
SHBP/SEHBP plan maximum rather than the prior
carrier’s maximum.
Note: If the new plan does not cover orthodontia, no
benets will be paid.
SPECIAL PROVISIONS OF THE
EMPLOYEE DENTAL PLANS
Coordination of Benets
With Other Insurance Plans
There is no coordination of benets between two SHBP/
SEHBP dental plans because no individual is eligible for
coverage in more than one dental plan.
If you and your dependents are also covered for dental
expenses by other plans, certain rules apply that de-
termine which plan provides the primary coverage and
how much each plan will reimburse you. The purpose
of these rules is to prevent a combined reimbursement
from both plans that exceeds the expenses that you ac-
tually incur. Although there may be special cases not
described here, the usual determination of which plan
provides primary coverage is as follows:
• The employee’s primary dental coverage is provid-
ed by the DEP or the DPO;
• If your spouse/partner is enrolled as your depen-
dent and is also covered by a dental plan through
his or her employer, your spouse/partner’s primary
coverage is through the dental plan oered by his
or her employer;
• If your children are enrolled as dependents in your
plan and your spouse/partner’s plan, their primary
coverage is provided by the dental plan of the par-
ent whose birthday falls earlier in the year. If your
spouse/partner’s plan does not follow this rule, then
the rule in the other program will determine the or-
der of benets; or
• In the case of a separation, divorce, dissolution of a
civil union or domestic partnership, or parents who
are not married, the primary coverage for a child
is provided in this order: by the plan of the parent
who is legally responsible for the dental expenses
of the child; by the plan of the parent with custody
of the child; by the plan of the spouse/partner of the
parent with custody of the child; or by the plan of
the non-custodial parent.
THIRD PARTY LIABILITY
Repayment Agreement
If you have received benets from your dental plan for
services that are related to either an automobile acci-
dent or your work, the Employee Dental Plans have the
right to recover those payments. This means that if your
dental expenses are also reimbursed by a third party
through a settlement, satised by a judgment, or oth-
er means, you are required to return any benets paid
for illness or injury to the Employee Dental Plans. The
repayment will only be equal to the amount paid by the
Employee Dental Plans.
This provision is binding whether the payment received
from the third party is the result of a legal judgment,
an arbitration award, a compromise settlement, or any
other arrangement, whether or not the third party has
admitted liability for the payment.
Recovery Right
You are required to cooperate with the Employee Den-
tal Plans in recovering any benets paid by the plan that
may also be payable by a third party. The Employee
Dental Plans may:
• Assume your right to receive payment for benets
from the third party;
• Require you to provide all information and sign and
return all documents necessary to exercise the Em-
ployee Dental Plans’ rights under this provision, be-
fore any benets are provided under your group’s
policy; or
• Require you to give testimony, answer interrogato-
ries, attend depositions, and comply with all legal
actions which the Employee Dental Plans may nd
necessary to recover money from all sources when
a third party may be responsible for damages or
injuries.
Employee Dental Plans — Member Guidebook January 2024 Page 8
State Health Benets Program School Employees’ Health Benets Program
HIPAA PRIVACY
The SHBP and SEHBP make every eort to safeguard
the health information of their members and comply with
the privacy provisions of the federal Health Insurance
Portability and Accountability Act (HIPAA) of 1996. HI-
PAA requires medical and dental plans to maintain the
privacy of any personal information relating to its mem-
bers’ physical or mental health. the “Notice of Privacy
Practices” section for further information.
AUDIT OF DEPENDENT COVERAGE
Periodically the NJDPB performs an audit using a ran-
dom sample of members to determine if enrolled de-
pendents are eligible under plan provisions. Proof of
dependency such as a marriage, civil union, birth certif-
icates, or tax returns are required and coverage for inel-
igible dependents will be terminated. Failure to respond
to the audit will result in the termination of all coverage
and may include nancial restitution for claims paid.
Members who are found to have intentionally enrolled
an ineligible person for coverage will be prosecuted to
the fullest extent of the law.
HEALTH CARE FRAUD
Health care fraud is an intentional deception or misrep-
resentation that results in an unauthorized benet to a
member or to some other person. Any individual who
willfully and knowingly engages in an activity intended
to defraud the SHBP or SEHBP will face disciplinary
action that could include termination of employment
and may result in prosecution. Any member who re-
ceives monies fraudulently from a health plan will be
required to fully reimburse the plan.
THE DENTAL PLAN ORGANIZATIONS
A Dental Plan Organization (DPO) is similar to a medi-
cal Health Maintenance Organization (HMO) program.
The full cost for most services is prepaid to your dentist,
but certain services require an additional copayment
from you. Also, if you choose a more expensive treat-
ment than deemed appropriate by your dental provider,
you must pay the extra cost. Further, you will not be
covered for services if you go to a dentist who is not a
member of your DPO, unless you are referred by your
DPO dentist. There are several DPOs included among
the Employee Dental Plans. Among these organiza-
tions, there are two types of plans – Dental Center and
Individual Practice Associations (IPA).
• Dental Centers employ a group of dentists and
technicians who are located at a central oce. In a
Dental Center Plan, you do not have the option to
select a particular dentist unless permitted by the
Dental Center. However, some DPOs oer both a
Dental Center and a list of participating dentists,
thereby giving you the option of selecting a center
or a particular dentist.
• Individual Practice Associations (IPA) consist
of a network of participating dentists who work in
their own oces. If you choose an IPA, you must
select a specic dentist in the IPA who will treat
you and your dependents.
The DPO dentist is responsible for providing all of the
services that are listed as covered in this guidebook.
If the participating dentist that you have selected does
not provide a specic service, then the DPO must refer
you to another participating dentist located within 10
miles of your dentist’s oce (or 20 miles for orthodontic
service). If you agree, the DPO may also refer you to a
dentist located beyond these limits.
If the DPO has no participating dentist who can provide
the service in your geographical area, the DPO must
refer you to a nonparticipating dentist within the 10- or
20-mile limit. If there is no dentist within this area, you
must be referred to the dentist closest to your dentist’s
oce.
If the DPO dentist refers you to another dentist and that
referral is approved by the DPO, you will have the same
coverage for the service as if you had been treated by
your dentist. However, if you select an outside dentist
on your own, the service will not be covered.
CONSIDERATIONS IN CHOOSING A DPO
• Obtain information about the DPOs and participat-
ing dentists from your benets administrator or the
NJDPB website. If you choose a dentist rather than
a Dental Center, check with the DPO and the den-
tist to be sure that the dentist: is a member of the
DPO; services members of the Employee Dental
Plans; and will accept you as a new patient.
• If you choose a dentist, you should check with the
dentist to make sure that he or she plans to stay
in the DPO. If the dentist leaves, you will have to
select another dentist who participates with that
DPO.
• You should check to determine that the DPO den-
tist or center can serve the needs of your entire
family and whether the days and hours of opera-
tion are convenient for you and your family.
• If your dentist leaves the DPO, and there are no
other dentists in the DPO within 30 miles of your
home, you may switch to another dental plan (ei-
ther another DPO or the DEP).
Page 9 January 2024 Employee Dental Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
COVERED SERVICES
The following is a list of covered services and, if ap-
plicable, required copayments. Copayments are your
portion of the cost for the service.
Codes
Description of
Covered Services Copayments
D0100-D0999 I. Diagnostic
Clinical Oral Evaluations
Oral evaluations are limited to two in a calendar year.
Emergency or limited oral evaluations are covered, limited
to one evaluation per patient, per dentist, per calendar
year. There are no copayments for diagnostic services.
D0120 Periodic Oral Evaluation $0
D0140 Limited Oral Evaluation —
Problem Focused
$0
D0145 Oral Evaluation for Patient
Under Three Years of Age
and Counseling With Primary
Caregiver
$0
D0150 Comprehensive Oral Evaluation
— New or Established Patient
$0
D0160 Detailed and Extensive Oral
Evaluation — Problem Fo-
cused, by Report
$0
Radiographs
Bitewing X-rays are limited to two series of up to four lms
in a calendar year; set of full mouth X-rays are limited to
once per 36 month interval; no more than 18 lms per set
of mouth X-rays.
D0210 Intraoral — Complete Series of
Radiographic Images
$0
D0220 Intraoral — Periapical — First
Radiographic Image
$0
D0230 Intraoral — Peripical — Each
Additional Radiographic Image
$0
D0240 Intraoral — Occlusal Radio-
graphic Image
$0
Codes
Description of
Covered Services Copayments
D0250 Extraoral — 2D Projection Ra-
diographic Image created using
a Stationary Radiation Source,
and Detector
$0
D0251 Extraoral — Posterior Dental
Radiographic Image
$0
D0270 Bitewings — Single Radio-
graphic Image
$0
D0272 Bitewings — Two Radiographic
Images
$0
D0273 Bitewings — Three Radio-
graphic Images
$0
D0274 Bitewings — Four Radiographic
Images
$0
D0277 Vertical Bitewings — Seven to
Eight Radiographic Images
$0
D0330 Panoramic Radiographic Image $0
D0340 2D Cephalometric Radio-
graphic Image — Acquisition,
Measurement and Analysis
$0
D0391 Interpretation of Diagnostic
Image by a Practitioner Not
Associated With the Capture of
the Image, Including Report
$0
Test and Laboratory Examinations
D0414 Laboratory Processing of
Microbial Specimen to Include
Culture and Sensitivity Studies,
and Preparation and Transmis-
sion of Written Report
$0
D0415 Collection of Microorganisms
for Culture and Sensitivity
$0
D0416 Viral Culture $0
D0425 Caries Susceptibility Tests $0
D0460 Pulp Vitality Tests $0
D0470 Diagnostic Casts $0
Codes
Description of
Covered Services Copayments
D0600 Non-ionizing Diagnostic Pro-
cedure Capable of Quantifying,
Monitoring, and Recording
Changes in Structure of Enam-
el, Dentin, and Cementum
$0
D1000-D1999 II. Preventive
Dental Prophylaxis
Limited to two in a calendar year
D1110 Prophylaxis — Adult $0
D1120 Prophylaxis — Child $0
Topical Fluoride Treatment (Oce Procedure)
Limited to two in a calendar year, and only for eligible
dependent children under the age of 19 years.
D1206 Topical Application of Fluoride
Varnish
$0
D1208 Topical Application of Fluoride $0
Other Preventive Services
Sealants are limited to once per lifetime for permanent
molars of eligible dependent children under the age of 19
years.
D1330 Oral Hygiene Instruction $0
D1351 Sealant — Per Tooth $0
D1352 Preventive Resin Restoration in
a Moderate to High Caries Risk
Patient - Permanent Tooth
$0
D1353 Sealant Repair — Per Tooth $0
D1354 Interim Caries Arresting
Medicament Application
$0
Space Maintenance (Passive Appliances)
D1510 Space Maintainer — Fixed —
Unilateral Excludes a Distal
Shoe Space Maintainer - Per
Quadrant
$0
D1515 Space Maintainer — Fixed —
Bilateral
$0
D1520 Space Maintainer —
Removable — Unilateral - Per
Quadrant
$0
Employee Dental Plans — Member Guidebook January 2024 Page 10
State Health Benets Program School Employees’ Health Benets Program
Codes
Description of
Covered Services Copayments
D1525 Space Maintainer —
Removable — Bilateral
$0
D1551 Re-Cement or Re-Bond Bilater-
al Space Maintainer - Maxillary
$0
D1552 Re-Cement or Re-Bond
Bilateral Space Maintainer -
Mandibular
$0
D1553 Re-Cement or Re-Bond Bilat-
eral Space Maintainer - Per
Quadrant
$0
D1556 Removal of Fixed Unilateral
Space Maintainer - Per Quad-
rant
$0
D1557 Removal of Fixed Unilateral
Space Maintainer - Maxillary
$0
D1558 Removal of Fixed Unilateral
Space Maintainer - Mandibular
$0
D1575 Distal Shoe Space Maintain-
er — Fixed — Unilateral - Per
Quadrant
$0
D2000-D2999 III. Restorative
The replacement of a crown is covered only after a ve-year
period measured from the date on which the crown was pre-
viously placed.
Amalgam Restorations (Including Polishing)
D2140 Amalgam — One Surface —
Primary or Permanent
$0
D2150 Amalgam — Two Surfaces —
Primary or Permanent
$0
D2160 Amalgam — Three Surfaces —
Primary or Permanent
$0
D2161 Amalgam — Four or More Sur-
faces — Primary or Permanent
$0
Resin Restorations
D2330 Resin-Based Composite —
One Surface — Anterior
$0
D2331 Resin-Based Composite —
Two Surfaces — Anterior
$0
Codes
Description of
Covered Services Copayments
D2332 Resin-Based Composite —
Three Surfaces — Anterior
$0
D2335 Resin-Based Composite —
Four or More Surfaces or In-
volving Incisal Angle — Anterior
$0
D2390 Resin-Based Composite Crown
— Anterior
$35
D2391 Resin-Based Composite —
One Surface — Posterior
$15
D2392 Resin-Based Composite —
Two Surfaces — Posterior
$25
D2393 Resin-Based Composite —
Three Surfaces — Posterior
$35
D2394 Resin-Based Composite
— Four or More Surfaces —
Posterior
$45
Inlay/Onlay Restorations
D2510 Inlay — Metallic —
One Surface
$100
D2520 Inlay — Metallic —
Two Surfaces
$100
D2530 Inlay — Metallic —
Three or More Surfaces
$100
D2542 Onlay — Metallic —
Two Surfaces
$100
D2543 Onlay — Metallic — Three
Surfaces
$100
D2544 Onlay — Metallic — Four or
More Surfaces
$100
D2610 Inlay — Porcelain/Ceramic —
One Surface
$115
D2620 Inlay — Porcelain/Ceramic —
Two Surfaces
$115
D2630 Inlay — Porcelain/Ceramic —
Three or More Surfaces
$115
D2642 Onlay — Porcelain/Ceramic —
Two Surfaces
$115
Codes
Description of
Covered Services Copayments
D2643 Onlay — Porcelain/Ceramic —
Three Surfaces
$115
D2644 Onlay — Porcelain/Ceramic —
Four or More Surfaces
$115
D2650 Inlay — Resin-Based
Composite — One Surface
$115
D2651 Inlay — Resin-Based
Composite — Two Surfaces
$115
D2652 Inlay — Resin-Based
Composite — Three or More
Surfaces
$115
D2662 Onlay — Resin-Based Com-
posite — Two Surfaces
$115
D2663 Onlay — Resin-Based
Composite — Three Surfaces
$115
D2664 Onlay — Resin-Based
Composite — Four or More
Surfaces
$115
Crowns — Single Restorations Only
D2710 Crown — Resin-Based
Composite (Indirect)
(See Note)
$115
D2720 Crown — Resin With High
Noble Metal
$150
D2721 Crown — Resin With
Predominantly Base Metal
$150
D2722 Crown — Resin With Noble
Metal
$150
D2740 Crown — Porcelain/Ceramic
Substrate
$200
D2750 Crown — Porcelain Fused to
High Noble Metal
$225
D2751 Crown — Porcelain Fused to
Predominantly Base Metal
$200
D2752 Crown — Porcelain Fused to
Noble Metal
$200
D2753 Crown - Porcelain Fused to
Titanium and Titanium Alloys
$200
Page 11 January 2024 Employee Dental Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
Codes
Description of
Covered Services Copayments
D2780 Crown — 3/4 Cast High Noble
Metal
$225
D2781 Crown — 3/4 Cast
Predominantly Base Metal
$200
D2790 Crown — Full Cast High Noble
Metal
$225
D2791 Crown — Full Cast
Predominantly Base Metal
$200
D2792 Crown — Full Cast Noble Metal $200
D2794 Crown — Titanium and
Titanium Alloys
$225
Note: There is no copayment for procedure D2710 when
performed in conjunction with a permanent crown on the
same tooth.
Codes
Description of
Covered Services Copayments
Other Restorative Services
D2910 Recement Inlay, Onlay, or
Partial Coverage Restoration
$0
D2915 Recement Cast or
Prefabricated Post and Core
$0
D2920 Recement Crown $0
D2921 Reattachment of Tooth
Fragment Incisal Edge or Cusp
$0
D2929 Prefabricated Porcelain/
Ceramic Crown —
Primary Tooth
$49
D2930 Prefabricated Stainless Steel
Crown — Primary Tooth
$35
D2931 Prefabricated Stainless Steel
Crown — Permanent Tooth
$35
D2932 Prefabricated Resin Crown $35
D2933 Prefabricated Stainless Steel
Crown With Resin Window
$35
D2934 Prefabricated Esthetic Coated
Stainless Steel Crown —
Primary Tooth
$35
D2940 Protective Restoration $0
D2941 Interim Therapeutic Restoration
— Primary Dentition
$0
D2950 Core Buildup, Including any
Pins
$0
D2951 Pin Retention — Per Tooth in
Addition to Restoration
$0
D2952 Cast Post and Core in Addition
to Crown
$40
D2954 Prefabricated Post and Core in
Addition to Crown
$40
D2955 Post Removal $0
D2971 Additional Procedures to
Construct New Crown under
Existing Partial Denture
Framework
$0
Codes
Description of
Covered Services Copayments
D2980 Crown Repair Necessitated by
Restorative Material Failure
$0
D2981 Inlay Repair Necessitated by
Restorative Material Failure
$0
D2982 Onlay Repair Necessitated by
Restorative Material Failure
$0
D2983 Veneer Repair Necessitated by
Restorative Material Failure
$0
D2990 Resin Inltration of Incipient
Smooth Surface Lesions
$0
D3000-D3999 IV. Endodontics
Pulp Capping
D3110 Pulp Capping — Direct —
Excluding Final Restoration
$0
D3120 Pulp Capping — Indirect —
Excluding Final Restoration
$0
Pulpotomy
D3220 Therapeutic Pulpotomy —
Excluding Final Restoration
$25
D3222 Partial Pulpotomy for
Apexogenesis — Permanent
Tooth With Incomplete Root
Development
$25
Endodontic Therapy on Primary Teeth
D3230 Pulpal Therapy (Resorbable
Filling) — Anterior-Primary
Tooth — Excluding Final Res-
toration
$20
D3240 Pulpal Therapy (Resorbable
Filling) — Posterior-Primary
Tooth — Excluding Final Res-
toration
$20
Endodontic Therapy
D3310 Anterior (Excluding Final
Restoration)
$100
D3320 Bicuspid (Excluding Final
Restoration)
$125
D3330 Molar (Excluding Final Resto-
ration)
$150
Employee Dental Plans — Member Guidebook January 2024 Page 12
State Health Benets Program School Employees’ Health Benets Program
Codes
Description of
Covered Services Copayments
Endodontic Retreatment
D3346 Retreatment of Previous Root
Canal Therapy — Anterior
$125
D3347 Retreatment of Previous Root
Canal Therapy — Bicuspid
$150
D3348 Retreatment of Previous Root
Canal Therapy — Molar
$175
Apexication/Recalcication Procedures
D3351 Apexication/Recalcication —
Initial Visit
$35
D3352 Apexication/Recalcication —
Interim Medication
Replacement
$35
D3353 Apexication/Recalcication —
Final Visit
$35
Apicoectomy/Periapical Services
D3410 Apicoectomy/Periradicular
Surgical — Anterior
$90
D3421 Apicoectomy/Periradicular
Surgical — Bicuspid First Root
$90
D3425 Apicoectomy/Periradicular
Surgical — Molar First Root
$90
D3426 Apicoectomy/Periradicular
Surgical — Each Additional
Root
$40
D3427 Periradicular Surgical —
Without Apicoectomy
$90
D3430 Retrograde Filling — Per Root $20
D3450 Root Amputation — Per Root $40
Other Endodontic Procedures
D3910 Surgical Procedure for Isolation
of Tooth With Rubber Dam
$0
D3920 Hemisection (Including any
Root Removal) — Not Including
Root Canal Therapy
$60
Codes
Description of
Covered Services Copayments
D4000-D4999 V. Periodontics
Coverage for surgical periodontal procedures, excluding
scaling and root planing, is limited to one surgical periodon-
tal treatment per quadrant every 36 months; coverage for
scaling and root planing is limited to one nonsurgical peri-
odontal treatment per quadrant every 12 months.
Surgical Services
D4210 Gingivectomy or
Gingivoplasty — Four or more
Contiguous Teeth or Tooth
Bounded Spaces per Quadrant
$85
D4211 Gingivectomy or Gingivoplasty
— One to Three Contiguous
Teeth or Tooth Bounded
Spaces per Quadrant
$30
D4212 Gingivectomy or Gingivoplasty
to Allow Access for Restorative
Procedure — Per Tooth
$12
D4240 Gingival Flap Procedure
Including Root Planing — Four
or more Contiguous Teeth or
Tooth Bounded Spaces per
Quadrant
$90
D4241 Gingival Flap Procedure
including Root Planing — One
to Three Contiguous Teeth or
Tooth Bounded Spaces per
Quadrant
$60
D4245 Apically Positioned Flap $90
D4249 Clinical Crown Lengthening —
Hard Tissue
$90
D4260 Osseous Surgery (Including
Flap Entry and Closure) — Four
or more Contiguous Teeth or
Tooth Bounded Spaces per
Quadrant
$175
D4261 Osseous Surgery (Including
Flap Entry and Closure) — One
to Three Contiguous Teeth or
Tooth Bounded Spaces per
Quadrant
$100
Codes
Description of
Covered Services Copayments
D4263 Bone Replacement Graft —
Retained Natural Tooth — First
Site in Quadrant Site
$100
D4264 Bone Replacement Graft —
Retained Natural Tooth — Each
Additional Site in Quadrant
$50
D4266 Guided Tissue Regeneration —
Resorbable Barrier per Site
$90
D4267 Guided Tissue Regeneration —
Non-resorbable Barrier per Site
(Includes Membrane Removal)
$90
D4270 Pedicle Soft Tissue Graft
Procedure
$175
D4273 Autogenous Connective Tissue
Graft Procedures (Including
Donor and Recipient Surgical
Sites) — First Tooth, Implant,
or Edentulous Tooth Position
in Graft
$175
D4274 Mesial/Distal Procedure —
Single Tooth (When not Per-
formed in Conjunction With
Surgical Procedures in the
same Anatomical Area)
$40
D4275 Non-Autogenous Connective
Tissue Graft (Including
Recipient Site and Donor Ma-
terial) — First Tooth, Implant,
or Edentulous Tooth Position
in Graft
$175
D4276 Combined Connective Tissue
and Double Pedicle Graft —
Per Tooth
$175
D4277 Free Soft Tissue Graft Proce-
dure (Including Recipient and
Donor Surgical Sites) — First
Tooth, Implant, or Edentulous
Tooth Position in a Graft
$70
Page 13 January 2024 Employee Dental Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
Codes
Description of
Covered Services Copayments
D4278 Free Soft Tissue Graft
Procedure (Including Recipient
and Donor Surgical Sites) —
Each additional Contiguous
Tooth, Implant, or Edentulous
Tooth Position in same Graft
Site
$35
D4283 Autogenous Connective Tissue
Graft Procedure (Including
Donor and Recipient Surgi-
cal Sites) — Each additional
Contiguous Tooth, Implant, or
Edentulous Tooth Position in
same Graft Site
$96
D4285 Non-Autogenous Connective
Tissue Graft Procedure (In-
cluding Recipient Surgical Site
and Donor Material) — Each
Additional Contiguous Tooth,
Implant, or Edentulous Tooth
Position in same Graft Site
$96
Non-Surgical Periodontal Services
D4320 Provisional Splinting —
Intracoronal
$0
D4321 Provisional Splinting —
Extracoronal
$0
D4341 Periodontal Scaling and Root
Planing — Four or More Teeth
per Quadrant
$55
D4342 Periodontal Scaling or Root
Planing — One to Three Teeth
per Quadrant
$40
D4346 Scaling in Presence of Gen-
eralized Moderate or Severe
Gingival Inammation — Full
Mouth, after Oral Evaluation
$28
D4355 Full Mouth Debridement to En-
able Comprehensive Periodon-
tal Evaluation and Diagnosis
$55
Other Periodontal Services
Codes
Description of
Covered Services Copayments
D4910 Periodontal Maintenance $30
D4920 Unscheduled Dressing Change
(By someone other than Treat-
ing Dentist)
$0
D5000-D5999 VI. Prosthodontics (Removable)
The replacement of an existing removable prosthetic appli-
ance is covered only after a ve-year period measured from
the date on which the appliance was previously placed.
Complete Dentures
Including Routine Post Delivery Care
D5110 Complete Denture — Maxillary $250
D5120 Complete Denture —
Mandibular
$250
D5130 Immediate Denture — Maxillary $275
D5140 Immediate Denture —
Mandibular
$275
Partial Dentures Including Routine Post Delivery Care
D5211 Maxillary Partial Denture —
Resin Base (Including any
Conventional Clasps, Rests,
and Teeth)
$250
D5212 Mandibular Partial Denture
— Resin Base (Including any
Conventional Clasps, Rests,
and Teeth)
$250
D5213 Maxillary Partial Denture —
Cast Metal Framework w/
Resin Denture Bases (Including
Retentive/Clasping Materials,)
$275
D5214 Mandibular Partial Denture —
Cast Metal Framework With
Resin Denture Bases (Including
Retentive/Clasping Materials)
$275
D5221 Immediate Maxillary Partial
Denture — Resin Base
(Including Retentive/Clasping
Materials)
$288
Codes
Description of
Covered Services Copayments
D5222 Immediate Mandibular Partial
Denture — Resin Base
(Including Retentive/Clasping
Materials)
$288
D5223 Immediate Maxillary Partial
Denture — Cast Metal
Framework With Resin Denture
Bases (Including Retentive/
Clasping Materials, Rests,
and Teeth) Includes limited
Follow-up Care Only; Does not
Include Future Rebasing
$316
D5224 Immediate Mandibular Partial
Denture — Cast Metal Frame-
work With Resin Denture Bases
(Including Retentive/Clasping
Materials, Rests, and Teeth)
$316
D5225 Maxillary Partial Denture —
Flexible Base (Including any
Clasps, Rests, and Teeth)
$300
D5226 Mandibular Partial Denture —
Flexible Base (Including any
Clasps, Rests, and Teeth)
$300
D5281 Removable Unilateral Partial
Denture — One Piece Cast
Metal (Including Clasps and
Teeth)
$125
D5284 Removable Unilateral Partial
Denture - One Piece Flexible
Base (Including Clasps and
teeth) - Per Quadrant
$150
D5286 Removable Unilateral Partial
Denture - One Piece Resin
(Including Clasps and teeth) -
Per Quadrant
$125
Adjustments to Removable Prostheses
D5 410 Adjust Complete Denture —
Maxillary
$0
Employee Dental Plans — Member Guidebook January 2024 Page 14
State Health Benets Program School Employees’ Health Benets Program
Codes
Description of
Covered Services Copayments
D5411 Adjust Complete Denture —
Mandibular
$0
D5421 Adjust Partial Denture —
Maxillary
$0
D5422 Adjust Partial Denture —
Mandibular
$0
Repairs to Complete Dentures
D5510 Repair Broken Complete
Denture Base
$35
D5520 Replace Missing or Broken
Teeth — Complete Denture —
Each Tooth
$35
Repairs to Partial Dentures
D5610 Repair Resin Denture Base $35
D5620 Repair Cast Framework $35
D5630 Repair or Replace Broken
Clasp — Per Tooth
$35
D5640 Replace Broken Teeth — Per
Tooth
$35
D5650 Add Tooth to Existing Partial
Denture
$35
D5660 Add Clasp to Existing Partial
Denture — Per Tooth
$35
Denture Rebase Procedures
D5710 Rebase Complete Maxillary
Denture
$85
D5711 Rebase Complete Mandibular
Denture
$85
D5720 Rebase Maxillary Partial
Denture
$85
D5721 Rebase Mandibular Partial
Denture
$85
Denture Reline Procedures
D5730 Reline Complete Maxillary
Denture — Chairside
$40
Codes
Description of
Covered Services Copayments
D5731 Reline Complete Mandibular
Denture — Chairside
$40
D5740 Reline Maxillary Partial Denture
— Chairside
$40
D5741 Reline Mandibular Partial Den-
ture — Chairside
$40
D5750 Reline Complete Maxillary
Denture — (Lab Process)
$40
D5751 Reline Complete Mandibular
Denture — (Lab Process)
$40
D5760 Reline Maxillary Partial Denture
— (Lab Process)
$40
D5761 Reline Mandibular Partial Den-
ture — (Lab Process)
$40
Other Removable Prosthetic Services
D5810 Interim Complete Denture
(Maxillary)
$40
D5811 Interim Complete Denture
(Mandibular)
$40
D5820 Interim Partial Denture
(Maxillary)
$40
D5821 Interim Partial Denture
(Mandibular)
$40
D5850 Tissue Conditioning (Maxillary) $40
D5851 Tissue Conditioning
(Mandibular)
$40
D6200-D6999 IX. Prosthodontics, Fixed
Fixed Partial Denture Pontics
D6097
Abutment Supported Crown
- Porcelain Fused to Titani-
um and Titanium Alloys
$200
D6210 Pontic — Cast High Noble
Metal
$225
Codes
Description of
Covered Services Copayments
D6211 Pontic — Cast Predominantly
Base Metal
$200
D6212 Pontic — Cast Noble Metal $200
D6214 Pontic — Titanium $225
D6240 Pontic — Porcelain Fused to
High Noble Metal
$225
D6241 Pontic — Porcelain Fused to
Predominantly Base Metal
$200
D6242 Pontic — Porcelain Fused to
Noble Metal
$200
D6243 Pontic - Porcelain Fused to
Titanium and Titanium Alloys
$200
D6245 Pontic — Porcelain/Ceramic $200
D6250 Pontic — Resin With High
Noble Metal
$150
D6251 Pontic — Resin With
Predominantly Base Metal
$150
D6252 Pontic — Resin With Noble
Metal
$150
Fixed Partial Denture Retainers — Inlays/Onlays
D6545 Retainer — Cast Metal for Res-
in Bonded Fixed Prosthesis
$100
D6549 Resin Retainer — For Resin
Bonded Fixed Prosthesis
$75
D6602 Inlay — Cast High Noble Metal
— Two Surfaces
$75
D6603 Inlay — Cast High Noble Metal
— Three or More Surfaces
$175
D6604 Inlay — Cast Predominantly
Base Metal — Two Surfaces
$100
D6605 Inlay — Cast Predominantly
Base Metal — Three or More
Surfaces
$100
D6606 Inlay — Cast Noble Metal —
Two Surfaces
$155
Page 15 January 2024 Employee Dental Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
Codes
Description of
Covered Services Copayments
D6607 Retainer Inlay — Cast Noble
Metal — Three or More
Surfaces
$155
D6610 Retainer Onlay — Cast High
Noble Metal — Two Surfaces
$185
D6611 Retainer Onlay — Cast High
Noble Metal — Three or More
Surfaces
$185
D6612 Retainer Onlay — Cast Pre-
dominantly Base Metal — Two
Surfaces
$100
D6613 Retainer Onlay — Cast
Predominantly Base Metal —
Three or More Surfaces
$100
D6614 Retainer Onlay — Cast Noble
Metal — Two Surfaces
$175
D6615 Retainer Onlay — Cast Noble
Metal — Three or More
Surfaces
$175
D6624 Retainer Inlay — Titanium $175
D6634 Retainer Onlay — Titanium $185
Fixed Partial Denture Retainers — Crown
D6720 Retainer Crown — Resin With
High Noble Metal
$150
D6721 Retainer Crown — Resin With
Predominantly Base Metal
$150
D6722 Retainer Crown — Resin With
Noble Metal
$150
D6740 Retainer Crown — Porcelain/
Ceramic
$200
D6750 Retainer Crown — Porcelain
Fused to High Noble Metal
$225
D6751 Retainer Crown — Porcelain
Fused to Predominantly Base
Metal
$200
D6752 Retainer Crown — Porcelain
Fused to Noble Metal
$200
Codes
Description of
Covered Services Copayments
D6753 Retainer Crown - Porcelain
Fused to Titanium and Titanium
Alloys
$200
D6780 Retainer Crown — 3/4 Cast
High Noble Metal
$225
D6781 Retainer Crown — 3/4 Cast
Predominantly Base Metal
$200
D6782 Retainer Crown — 3/4 Cast
Noble Metal
$200
D6783 Retainer Crown — 3/4
Porcelain/Ceramic
$200
D6784 Retainer Crown 3/4- Titanium
and Titanium Alloys
$200
D6790 Retainer Crown — Full Cast
High Noble Metal
$225
D6791 Retainer Crown — Full Cast
Predominantly Base Metal
$200
D6792 Retainer Crown — Full Cast
Noble Metal
$200
D6794 Retainer Crown — Titanium $225
Other Fixed Partial Denture Services
D6930 Recement Fixed Partial
Denture
$15
D6980 Fixed Partial Denture Repair
Necessitated by Restorative
Material Failure
$25
D7000-D7999 X. Oral and Maxillofacial Surgery
Extractions Includes local anesthesia, suturing, if needed,
and routine post-operative care.
D7111 Extraction — Coronal
Remnants — Deciduous Tooth
$10
Codes
Description of
Covered Services Copayments
D7140 Extraction — Erupted Tooth or
Exposed Root (Elevation and/
or Forceps Removal) Includes
Removal of Tooth Structure,
Minor Smoothing of Socket
Bone, and Closure, as
Necessary
$20
Surgical Extractions Includes local anesthesia, suturing, if
needed, and routine post-operative care.
D7210 Extraction — Erupted Tooth
Requiring Removal of Bone
and/or Sectioning of Tooth,
and Including Elevation of
Mucoperiosteal Flap if Indicated
$30
D7220 Removal of Impacted Tooth —
Soft Tissue
$55
D7230 Removal of Impacted Tooth —
Partially Bony
$55
D7240 Removal of Impacted Tooth —
Completely Bony
$65
D7241 Removal of Impacted Tooth —
Completely Bony With
Complications
$65
D7250 Removal of Residual Tooth
Roots — Cutting Procedure
$30
D7251 Coronectomy — Intentional
Partial Tooth Removal
$33
Other Surgical Procedures
D7260 Oroantral Fistula Closure $100
D7261 Primary Closure of a Sinus
Perforation
$100
D7270 Tooth Reimplantation/
Stabilization
$60
D7280 Exposure of an Unerupted
Tooth
$60
Employee Dental Plans — Member Guidebook January 2024 Page 16
State Health Benets Program School Employees’ Health Benets Program
Codes
Description of
Covered Services Copayments
D7282 Mobilization of Erupted or
Malpositioned Tooth to Aid
Eruption
$60
D7283 Placement of Device to
Facilitate Eruption of Impacted
Tooth
$0
D7285 Biopsy of Oral Tissue — Hard
(Bone, Tooth)
$60
D7286 Biopsy of Oral Tissue — Soft $25
D7287 Exfoliative Cytology — Sample
Collection
$13
D7291 Transseptal Fiberotomy Supra
Crestal Fiberotomy — By
Report
$20
Codes
Description of
Covered Services Copayments
Alveoloplasty — Surgical Preparation of the Ridge for
Dentures
D7310 Alveoloplasty in Conjunction
With Extractions — Four or
More Teeth or Tooth Spaces,
per Quadrant.
The Alveoloplasty is Distinct
(Separate Procedure) from
Extractions. Usually in
Preparation for a Prosthesis
or Other Treatments Such as
Radiation Therapy and
Transplant Surgery
$30
D7311 Alveoloplasty in Conjunction
With Extractions — One to
Three Teeth or Tooth Spaces,
per Quadrant.
The Alveoloplasty is Distinct
(Separate Procedure) from
Extractions. Usually in
Preparation for a Prosthesis or
Other Treatments Such as
Radiation Therapy and Trans-
plant Surgery
$15
D7320 Alveoloplasty not in
Conjunction With Extractions
— Per Quadrant
$35
D7321 Alveoloplasty not in Conjunc-
tion With Extractions — One to
Three Teeth or Tooth Spaces
per Quadrant
$20
Removal of Cysts, Tumors, and Neoplasms
D7450 Removal of Benign Odontogen-
ic Cyst or Tumor — Lesion up
to 1.25 cm Diameter
$60
D7451 Removal of Benign Odonto-
genic Cyst or Tumor — Lesion
Greater than 1.25 cm Diameter
$60
D7460 Removal of Benign Non-Odon-
togenic Cyst or Tumor — Le-
sion up to 1.25 cm Diameter
$60
Codes
Description of
Covered Services Copayments
D7461 Removal of Benign Non-Odon-
togenic Cyst or Tumor —
Lesion Greater than 1.25 cm
Diameter
$60
Excision of Bone Tissue
D7471 Removal of Lateral Exostosis
— Maxilla or Mandible
$90
D7472 Removal Torus Palatinus $90
D7473 Removal Torus Mandibularis $90
D7485 Reduction of Osseous
Tuberosity
$90
Surgical Incision
D7510 Incision and Drainage of
Abscess — Intraoral — Soft
Tissue
$25
D7511 Incision and Drainage of
Abscess — Intraoral — Soft
Tissue — Complicated
(Includes Drainage of Multiple
Facial Spaces)
$30
D7520 Incision and Drainage of
Abscess — Extraoral — Soft
Tissue
$35
D7521 Incision and Drainage of
Abscess — Extraoral — Soft
Tissue — Complicated
(Includes Drainage of Multiple
Facial Spaces)
$40
Other Repair Procedures
D7922 Placement of Intra-Socket
Bilolgical Dressing to Aid In
Hemostasis or Clot Stabiliza-
tion, Per Site
$0
D7953 Bone Replacement Graft for
Ridge Preservation — Per Site
$75
Page 17 January 2024 Employee Dental Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
Codes
Description of
Covered Services Copayments
D7960 Frenulectomy — Also Known
as Frenectomy or Frenotomy
— Separate Procedure not
Incidental to Another Proce-
dure. Removal or Release of
Mucosal and Muscle Elements
of a Buccal, Labial, or Lingual
Frenum that is Associated
with a Pathological Condition,
or Interferes with Proper Oral
Development or Treatment
$60
D7963 Frenuloplasty $65
D7970 Excision of Hyperplastic Tissue
— Per Arch
$60
D7971 Excision of Pericoronal Gingiva
Removal of Inammatory or
Hypertrophied Tissues
Surrounding Partially Erupted/
Impacted Teeth
$30
D7972 Surgical Reduction of Fibrous
Tuberosity
$60
Miscellaneous Services
D9110 Palliative (Emergency) Treat-
ment of Dental Pain — Minor
Procedure
$0
D9211 Regional Block Anesthesia $0
D9212 Trigeminal Division Block
Anesthesia
$0
D9215 Local Anesthesia $0
D9219 Evaluation for Deep Sedation
or General Anesthesia
$0
D9223 Deep Sedation/General An-
esthesia — Each 15-Minute
Increment
$20
D9230 Analgesia, Anxiolysis,
Inhalation of Nitrous Oxide
$0
D9243 Intravenous Moderate (Con-
scious) Sedation/Analgesia —
Each 15-Minute Increment
$20
Codes
Description of
Covered Services Copayments
D9310 Consultation (Diagnostic
Service Provided by a Dentist
or Physician other than
Practitioner Providing
Treatment)
$0
D9311 Treating Dentist Consults with
a Medical Health Care
Professional Concerning
Medical Issues that May Aect
Patient’s Planned Dental
Treatment
$0
D9430 Oce Visit Observation $0
D9440 Oce Visit After Hours $0
D9610 Therapeutic Drug Injection —
By Report
$0
D9612 Therapeutic Paternal Drug,
Two or more Administrations
Dierent Medications
$0
D9630 Drugs or Medicaments
Dispensed in the Oce for
Home Use
$0
D9910 Application of Desensitizing
Medication
$0
D9930 Treat Complications — By
Report
$0
D9932 Cleaning and Inspection of
Removable Complete Denture,
Maxillary
$0
D9933 Cleaning and Inspection of
Removable Complete Denture,
Mandibular
$0
D9934 Cleaning and Inspection of
Removable Partial Denture,
Maxillary
$0
D9935 Cleaning and Inspection of
Removable Partial Denture,
Mandibular
$0
D9940 Occlusal Guard — By Report $40
Codes
Description of
Covered Services Copayments
D9942 Repair and/or Reline of
Occlusal Guard
$20
D9943 Occlusal Guard Adjustment $5
D9951 Occlusal Adjustment — Limited $0
D9952 Occlusal Adjustment —
Complete
$60
D9997 Dental Case Management -
Patients With Special Health
Care Needs
$0
Orthodontics
Treatment plan maximum of 24 months.
1. Patient under 18 years of age at the start of treat-
ment — Class I, II, and III malocclusion (copay-
ment required of $1,000 or 50 percent of reason-
able and customary charges, whichever is less).
2. Patient 18 years of age or over at the start of treat-
ment — Class I, II, and III malocclusion (copay-
ment required of $1,750 or 50 percent of reason-
able and customary charges, whichever is less).
Includes Invisalign as an optional treatment pro-
cedure — this procedure may fall under the “More
Expensive Services” option and as such, the mem-
ber choosing this option would be responsible for
the dierence between Invisalign charges and the
standard adult orthodontic charge.
More Expensive Services
A covered individual may elect a more expensive pro-
cedure than an appropriate procedure recommended
by the dentist. The covered individual shall pay any
copayment required for the less expensive procedure,
plus the dierence in cost between the two procedures,
on the basis of the reasonable and customary dental
charges for the procedures.
Employee Dental Plans — Member Guidebook January 2024 Page 18
State Health Benets Program School Employees’ Health Benets Program
Emergency Services — Out-of-Area
Emergency Treatment is dened as when a covered
SHBP (or SEHBP) member or dependent is at least 50
miles from home, any necessary service or procedure
which is rendered as the direct result of an unforeseen
occurrence and requires immediate, urgent action or
remedy. Examples are: acute pain, bleeding, fractured
tooth, broken lling, broken front tooth, broken denture,
and lost or loose crown. The reimbursement shall be at
the full amount of the charge, up to a maximum of $100
per episode.
SERVICES NOT COVERED BY THE DPO
• A service started before the person became a cov-
ered individual under the plan.
• Replacement of lost, stolen, or damaged prostho-
dontic devices within two years of the date of initial
installation.
• A service not reasonably necessary for the dental
care of a covered individual or provided solely for
cosmetic purposes.
• Providing supplies of a type normally intended
for home use, such as toothpaste, toothbrushes,
waterpicks, and mouthwash.
• A service required because of war or an act of war.
• A service made available to a covered individual
or nanced by the federal, State, or local govern-
ment. This includes the federal Medicare program
and any similar federal program, any Workers’
Compensation law or similar law, any automobile
no-fault law, or any other program or law under
which the covered individual is, or could be, cov-
ered. The exclusion is applicable whether or not
the covered individual receives the service, makes
a claim or receives compensation for the service,
or receives a recovery from a third party for dam-
ages.
• A service not furnished by a dentist or physician
licensed to provide the dental service, except for
a service performed by a licensed dental hygienist
under the direction of a dentist.
• General anesthesia, except when medically
necessary in connection with covered oral and
periodontal surgery procedures.
• Hospitalization.
• Any dental implant including any crowns, prosthe-
ses, devices, or appliances attached to implants.
• Experimental procedures.
• Appliances, restorations, and procedures to alter
vertical dimension and/or restore occlusion, in-
cluding temporomandibular joint dysfunction, ex-
cept oral splints.
• Procedures that are not listed.
• A service covered under any medical, surgical,
or major medical plan (including a Health Mainte-
nance Organization — HMO) provided by the em-
ployer.
• Services and supplies provided in connection with
treatment or care that is not covered under the
plan.
THE DENTAL EXPENSE PLAN
The Dental Expense Plan (DEP) is an indemnity plan
that reimburses for a portion of the expenses incurred
for dental care provided by dentists or physicians li-
censed to perform dental services in the state in which
they are practicing. Not all dental services are eligible
for reimbursement, and some services are eligible only
up to a limited amount (for example, orthodontic ser-
vices are reimbursed dierently than other services)
Diagnostic/preventive and orthodontic services are not
subject to an annual deductible. For all other services
an annual deductible amount must be met before bene-
ts are payable. You are responsible for making the full
payment of all charges to your dentist.
The DEP has been established by the State as a
self-funded plan. The State currently contracts with
Aetna Dental to act as the administrative agent for the
Dental Expense Plan.
As a DEP member, you may be able to take advan-
tage of a special Aetna network of participating dental
providers. In this network, participating dental provid-
ers contract with Aetna for a discounted fee sched-
ule. When using a participating dental provider, you
only pay the provider any applicable deductible and
the appropriate coinsurance based on the discounted
fee, thereby reducing your out-of-pocket cost. In many
cases the participating dental provider will submit the
claims directly to Aetna, eliminating the necessity of l-
ing claim forms.
To nd out if your provider participates in the
discounted network, call Aetna at 1-877-STATENJ
(1-877-782-8365) or visit Aetna’s website at:
www.aetna.com
Annual Deductible
Diagnostic/preventive and orthodontic services are not
subject to a deductible amount.
For other services, the rst $50 of covered expenses
that you or your dependent(s) incur in a calendar year
is not eligible for reimbursement. However, if there are
four or more members of your family in the DEP, no ad-
ditional deductibles are charged after any three mem-
bers have each met their $50 deductible.
Reasonable and Customary Charges
The DEP covers only that part of a provider’s charge for
a service or supply that is reasonable and customary.
Generally speaking, a charge by your dentist, or by any
other provider of services or supplies, is considered
reasonable and customary if it doesn’t exceed the pre-
vailing charge for the same service or supply made by
similar providers in the same geographic area; it may
Page 19 January 2024 Employee Dental Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
dier from the actual amount that your dentist charges.
You are responsible for the amount the dentist charges
above the reasonable and customary allowances.
Dental Expense Plan Benets
In-Network Out-of-Network
Deductible /
Calendar Year
$50 / Individual
$100 / Family
Waived for
Preventive Care
$75 / Individual
$150 / Family
Waived for
Preventive Care
Coinsurance
(as percentage
of reasonable
and customary
charges)
100% Preventive
80% Basic
Restorative
65% Major
Restorative
50%
Periodontics &
Prosthodontics
90% Preventive
70% Basic
Restorative
55% Major
Restorative
40%
Periodontics &
Prosthodontics
Maximum
Annual Benet /
Individual
$3,000 $2,000;
maximum of
$3,000 combined
in- and
out-of-network
Orthodontic
Services Under
Age 19
50% to $1,000
lifetime maxi-
mum; not subject
to deductible;
maximum not
combined with
Annual
Maximum
40% to $750
lifetime;
maximum of
$1,000 combined
in- and
out-of-network;
not subject to
deductible;
maximum not
combined with
Annual
Maximum
COVERED SERVICES
A general description of each category of service is
provided below. Refer to the “Services Eligible for Re-
imbursement” section for any limitations that may apply
to these services.
Diagnostic and Preventive Services are precautionary
services, and are intended to maintain oral health and
reduce the eects of tooth decay or gum disease which
could lead to an increased need for more costly restor-
ative services. They include the following:
• Oral Evaluations (includes comprehensive,
periodic, limited, and specialist oral evaluations);
• Prophylaxis (cleaning of the teeth, including
scaling and polishing procedures);
• Fluoride Treatments (topical application of uoride
for children under age 19);
• X-rays (limitations may apply); and
• Laboratory and other diagnostic tests.
Basic Services include:
• Emergency Treatment (Palliative only);
• Space Maintainers (i.e., passive appliances —
xed or removable);
• Simple Extractions;
• Surgical Extractions;
• Oral Surgery;
• Anesthesia Services;
• Basic Restorations (i.e., amalgam restorations
and resin restorations);
• Endodontics (i.e., treatment of diseases of the
dental pulp, including root canal and associated
therapy); and
• Repairs to removable dentures.
Major Restorative Services include those services
that restore existing teeth. These services are utilized
only if a tooth cannot be restored with an amalgam,
acrylic, synthetic porcelain, or composite lling resto-
ration. Inlays, onlays, and crowns are typical examples
of major restorative services.
Periodontal Services include those services involv-
ing the maintenance, reconstruction, regeneration,
and treatment of the supporting structures surrounding
teeth, including bone, gum tissue, and root surfaces.
Prosthodontic Services include both removable and
xed dentures (bridges) replacing missing teeth.
Orthodontic Services include services to correct ab-
normalities in tooth position (malposition) or abnormal
bite (malocclusion), using appliances such as retainers
or braces.
Annual and Lifetime Benet Maximums
The most the Dental Expense Plan will pay for any one
person in any one calendar year is $3,000 — combined
in-network and out-of-network. This maximum applies
to all eligible services except orthodontic, which has a
separate $1,000 lifetime benet maximum.
In-Network and Out-of-Network Integration
The in-network maximum is $3,000 and the out-of-net-
work maximum is $2,000, and the two maximums are
integrated. This means that if you receive services out-
of-network and reach the out-of-pocket maximum of
$2,000, the $2,000 carries forward towards the $3,000
in-network maximum, leaving only $1,000 remaining
for in-network services. Examples of how in-network
and out-of-network claims are paid are shown in the
following charts.
Employee Dental Plans — Member Guidebook January 2024 Page 20
State Health Benets Program School Employees’ Health Benets Program
ADDITIONAL PROVISIONS
OF THE DEP
How Payments Are Made
Normally, any reimbursements will be made to the DEP
subscriber. The DEP subscriber may, however, autho-
rize Aetna to send the reimbursement directly to the
dental provider by completing the appropriate part of
the claim form.
Additionally, whenever a law or court order requires
the payment of dental expense benets under the DEP
to be made to a person or facility other than the DEP
subscriber, the payment will be made to that person or
facility upon proper notication (letter and a copy of the
order/law).
Filing Deadline — Proof of Loss
Aetna must be given written proof that a dental service
has been performed for which a claim is made under
the coverage. This proof must cover the occurrence,
character, and extent of the service. It must be fur-
nished within 27 months of the date of service. For ex-
ample, if a service were incurred on February 1, 2021,
you would have until April 30, 2023, to le the claim.
A claim will not be considered valid unless proof of
the service is furnished within the time limit indicated
above. If it is not possible for you to provide proof within
the time limit, the claim may be considered valid upon
appeal if the reason the proof was not provided in a
timely basis was reasonable.
Itemized Bills Are Necessary
You must obtain itemized bills from the providers of ser-
vices for all dental expenses. The itemized bills must
include the following:
• Name and address of provider;
• Provider’s tax identication number;
• Name of patient;
• Subscriber’s identication number;
• Date of service;
• Type of service;
• Procedure code (CDT-2020 Code); and
• Charge for each service.
Predetermination of Benets
Predetermination is voluntary and allows you to know
what services are covered and what payments will be
made for treatment before the work is done. If you or
one of your dependents are likely to incur dental ex-
penses over $300, it is strongly recommended that you
ask your dentist to le for predetermination of benets.
This feature of the DEP ensures that both you and the
dentist will know in advance what part of the dentist’s
charges the DEP will pay. If possible, treatment should
be completed within 90 days of receiving the approved
predetermination.
The predetermination of benets provision of the DEP
is important, because under the alternative procedures
provision (see the “Alternative Procedures” section),
Aetna has the right to pay the reasonable and custom-
ary allowance for the method of treatment that is proper
and is economically sound.
How Predetermination of Benets Works — Your den-
tist submits a treatment plan and Aetna determines
the amount the DEP will pay, and informs you and the
In-Network Claims
Procedure Provider
Charge
DEP Allowance Deductible Coinsurance Plan Pays Member Pays
Abutment $1,250.00 $785.00 $50.00 50% $ 367.5 0 $417. 50
Pontic $1,250.00 $785.00 $0.00 50% $392.50 $392.50
Abutment $1,250.00 $726.00 $0.00 50% $363.00 $363.00
Totals $3,750.00 $2,296.00 $50.00 — $1,123.00 $1,173.00
Out-of-Network Claims
Procedure DDS Charge PPO Allowance Deductible Coinsurance Plan Pays Member Pays
Abutment $1,250.00 $1,150.0 0 $75.00 40% $430.00 $820.00
Pontic $1,250.00 $1,150.0 0 $0.00 40% $500.00 $750.00
Abutment $1,250.00 $1,150.0 0 $0.00 40% $500.00 $750.00
Totals $3,750.00 $3,450.00 $75.00 — $1,430.00 $2,320.00
Page 21 January 2024 Employee Dental Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
dentist of its payment decision. You and your dentist
should discuss the predetermination before the work
is started.
Predetermination of benets will help you avoid sur-
prises. Most dentists are familiar with predetermi-
nation procedures; if not, they should call Aetna at
1-877-STATENJ (1-877-782-8365). If your dentist sub-
mits a treatment plan for predetermination of benets
and then alters the course of treatment, Aetna will ad-
just its payments accordingly. If the dentist makes a
major change in the treatment plan, he or she should
send in a revised plan.
Alternative Procedures
Usually there are several ways to treat a particular den-
tal problem. Payment will be based on the least costly
treatment as determined by Aetna so long as the treat-
ment meets acceptable dental standards. If you and the
dentist decide you want a more costly treatment meth-
od, you are responsible for the charges beyond those
for the less costly, appropriate treatment.
SERVICES ELIGIBLE FOR REIMBURSEMENT
Even though a service or supply may not be described
or listed in this handbook, that does not make the ser-
vice or supply eligible for a benet under this plan.
• Oral evaluations (limited to twice in a calendar
year). Emergency or limited oral evaluations are
limited to once in a calendar year, per patient —
covered at 100 percent of the reasonable and cus-
tomary charges.
• X-rays (horizontal bitewing X-rays limited to two
series of up to four lms in a calendar year; ver-
tical bitewing X-rays limited to two series of up to
eight lms per calendar year; set of full mouth or
panoramic X-rays limited to once per 36-month in-
terval; no more than 18 lms per set of full mouth
periapical X-rays).
• Oral prophylaxis, including scaling (not including
scaling performed by a periodontist) and polishing
(limited to twice in a calendar year).
• Topical application of uoride for children under
age 19 limited to twice in a calendar year.
• Sealants (limited to once per lifetime for perma-
nent molars of eligible dependent children under
the age of 19 years).
• Prosthodontic procedures (the replacement of an
existing xed or removable prosthetic appliance
is covered only after a ve-year period, measured
from the date on which the appliance was previ-
ously placed).
• Periodontic procedures (reimbursement for peri-
odontal surgical procedures and follow-up main-
tenance, usually provided for a specic quadrant,
is limited to one surgical-type procedure every 36
months). Reimbursement for periodontal scaling
and root planing procedures per specic quadrant
is limited to one procedure per 12-month interval.
• Restorative procedures, including llings, inlays,
onlays, and crowns (the replacement of a crown
is covered only after a ve-year period measured
from the date on which the crown was previously
placed).
• Emergency palliative treatment.
• Extractions of teeth.
• Endodontic services, such as pulpotomy and root
canal therapy.
• Space maintainers.
• Oral surgery for surgical extractions, treatment of
fractures, removal of lesions of the mouth, alveo-
lectomy, and biopsy of hard and soft tissue.
• Apicoectomy.
• General anesthesia (including conscious sedation
coverage) when medically necessary and in con-
nection with covered oral and periodontal surgical
procedures.
ORTHODONTIC SERVICES
ELIGIBLE FOR REIMBURSEMENT
Certain charges for orthodontic procedures are eligible
if:
• You have been a full-time employee for at least 10
months;
• The orthodontic treatment is for a child covered
under the DEP who is less than 19 years old;
• The procedure involves the use of active applianc-
es to move teeth in order to correct the faulty posi-
tion of teeth (malposition) or abnormal bite (maloc-
clusion);
• The service or supply is part of a treatment plan
submitted by the dentist and approved by Aetna
with an estimate of the benets that are payable;
• The service or supply is furnished before the end
of the estimated duration of the treatment as re-
corded in the treatment plan; and
• An active appliance for the procedure is inserted
while the person is eligible for benets in this pro-
gram.
Employee Dental Plans — Member Guidebook January 2024 Page 22
State Health Benets Program School Employees’ Health Benets Program
Orthodontic Benets
In-Network Eligible orthodontic services will be cov-
ered at 50 percent, up to a lifetime benet maximum
of $1,000.
Out-of-Network orthodontic services will be covered at
40 percent, up to a lifetime benet maximum of $750
(maximum of $1,000 combined in- and out-of-network).
There is no deductible for orthodontic services. See
the “Orthodontic Charges Not Eligible Under the DEP”
section.
SERVICES NOT
ELIGIBLE FOR REIMBURSEMENT
• Any orthodontic service prior to the employee at-
taining 10 months of employment, or for any mem-
ber over 19 years of age.
• Gold restorations other than crowns, inlays, and
onlays.
• Any service or item not reasonably necessary for
the dental care of the patient.
• Endosteal, subperiosteal, and transosteal tooth
implants.
• Protective devices such as athletic mouth guards,
plaque control, or myofunctional therapy.
• Services and/or appliances that are for the prima-
ry purpose of altering vertical dimension (change
the way natural teeth meet), including full mouth
rehabilitation (crowning all or most of the teeth),
splinting teeth with crowns, llings, appliances, or
any method or service that restores occlusion or
incisal tooth structure lost from attrition, erosion,
abrasion, or any other cause.
• Crowns, inlays, and onlays if used in splinting pro-
cedures during periodontal treatment.
• A service for cosmetic purposes.
• Any charge for a supply that is normally for home
use such as toothpaste, toothbrushes, water-pick,
or mouthwash.
• A dental examination when required as a condi-
tion of employment by an employer, a government
agency, or the terms of a labor agreement.
• Charges for services that are not reasonably nec-
essary made to produce a professionally accept-
able result.
• A service or supply due to a war or any act of war.
• A service not furnished by a dentist or physician
licensed to provide the dental service, except for
a service performed by a licensed dental hygienist
under the direction of a dentist.
• A service rendered by a provider that is beyond the
scope of the provider’s license.
• A charge made by a dentist for a failure of the pa-
tient to keep an appointment.
• A charge for the completion of any claim forms.
• A charge in connection with any procedure started
before the patient was eligible for reimbursement
in this program; except that a procedure will not
have been considered to have started with an oral
prophylaxis or a diagnostic procedure.
• Any service or supply other than those specically
covered under this program.
• Hospitalization.
• Experimental procedures.
• A service covered under any medical, surgical,
or major medical plan (including a Health Main-
tenance Organization (HMO) provided by the em-
ployer.
• A service made available to a covered individual or
nanced by the federal, State, or local government.
This includes the federal Medicare program and
any similar federal program, any Workers’ Com-
pensation law or similar law, any automobile no-
fault law, or any other program or law under which
the covered individual is, or could be, covered. The
exclusion is applicable whether or not the covered
individual receives the service, makes a claim or
receives compensation for the service, or receives
a recovery from a third party for damages.
• Any charge incurred after the patient is no longer
covered, except in the case of an Extension of
Coverage.
• Any charge for a service that is more than the rea-
sonable and customary dental charge.
• Any charge for a service rendered by a member of
the patient’s immediate family (including you, your
spouse or civil union/domestic partner, your child,
brother, sister, or parent of you or spouse/partner).
• Charges for sterilization or asepsis.
• Services and supplies provided in connection with
treatment or care that is not covered under the
plan.
Orthodontic Charges Not
Eligible Under the DEP
• Charges that are eligible for coverage under the
regular dental care portion of the program.
• Charges for an orthodontic procedure started prior
to the day on which the person became covered
under the program or eligible for orthodontic bene-
ts.
• Charges not reasonably necessary for orthodontic
care.
• Any charges incurred for orthodontic procedures
or treatment begun on or after the date the person
attains age 19.
Page 23 January 2024 Employee Dental Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
APPENDIX I
CLAIM APPEAL PROCEDURES
You or your authorized representative may appeal and
request that your dental plan reconsider any claim or
any portion(s) of a claim for which you believe bene-
ts have been erroneously denied based on the plan’s
limitations and/or exclusions. This appeal may be of an
administrative or dental nature. Administrative appeals
might question eligibility or plan benet decisions such
as whether a particular service is covered or paid ap-
propriately. Dental appeals refer to the determination of
dental need, appropriateness of treatment, or experi-
mental and/or investigational procedures.
The following information must be given at the time of
each inquiry:
• Name(s) and address(es) of patient and
employee;
• Employee’s identication number;
• Date(s) of service(s);
• Provider’s name and identication number;
• The specic remedy being sought; and
• The reason you think the claim should be
reconsidered.
If you have any additional information or evidence
about the claim that was not given when the claim was
rst submitted, be sure to include it.
Any member of the DEP who disagrees with a nal de-
cision of Aetna may request, in writing, that the mat-
ter be considered by the SHBC. Requests for consid-
eration must be directed to the Appeals Coordinator,
State Health Benets Commission, P.O. Box 299, Tren-
ton, NJ 08625-0299, and must contain the reason for
the disagreement and a copy of all relevant correspon-
dence. Appeals are considered at regular meetings of
the Commission. It is the responsibility of the member
to provide the Commission with any medical or other
information that the Commission may require in order
to make a decision.
Upon request, your DPO will supply you with its appeal
procedures. Any member of a DPO who disagrees with
a determination of the appropriateness of a procedure
made by a DPO, or any member of a DPO who feels
that the DPO has violated the terms and conditions of
its contract with the SHBP, may request in writing that
the matter be considered by the Commission. Such an
appeal can only be considered after the member has
exhausted the DPO’s grievance process. Requests for
consideration must be directed to the Appeals Coor-
dinator, State Health Benets Commission, P.O. Box
299, Trenton, NJ 08625-0299, and must contain the
reason for the disagreement and a copy of all relevant
correspondence and supporting documentation.
Notication of all Commission decisions will be made
in writing to the member. If the Commission denies the
member’s appeal, the member will be informed of fur-
ther steps that may be taken in the denial letter from
the Commission. Any member who disagrees with the
Commission’s decision may request, within 45 days
and in writing to the Commission, that the case be for-
warded to the Oce of Administrative Law (OAL). The
Commission will then determine if a factual hearing is
necessary. If so, the case will be forwarded to the OAL.
An Administrative Law judge will hear the case and
make a recommendation to the Commission, which the
Commission may adopt, modify, or reject. If a factual
hearing is not necessary, the administrative appeal
process involving the Commission is ended. When the
administrative process is completed, further appeals
may be made to the Superior Court of New Jersey, Ap-
pellate Division.
If your case is forwarded to the OAL, you will be re-
sponsible for the presentation of your case and for sub-
mitting all evidence. You will be responsible for any ex-
penses involved in gathering evidence or material that
will support your grounds for appeal. If you take your
appeal to Superior Court, you will be responsible for
any court ling fees or similar related costs that may
be necessary during the appeal process. If you require
an attorney or expert medical testimony, you will be re-
sponsible for any fees or costs incurred.
Employee Dental Plans — Member Guidebook January 2024 Page 24
State Health Benets Program School Employees’ Health Benets Program
APPENDIX II
GLOSSARY
Alveolectomy — Surgical excision of a portion of the
dentoalveolar process, for re-contouring the
tooth socket ridge at the time of tooth remov-
al in preparation for a dental prosthesis (den-
ture).
Amalgam — An alloy used in dental restoration.
Apicoectomy — Surgical removal of a dental root
apex. Root resection.
Bitewing X-Ray — X-rays taken with the lm holder
held between the teeth and the lm parallel to
the teeth.
Calendar Year — A year starting January 1 and ending
on December 31.
Coinsurance — The portion of an eligible charge
which is the member’s nancial responsibility.
Coordination of Benets — The practice of correlat-
ing the payments a plan makes with payments
provided by other insurance covering the
same charges or expenses, so that (1) the
plan with primary responsibility pays rst, (2)
reimbursement by the two plans does not ex-
ceed 100 percent of the allowable expense,
and (3) the dental plan does not pay more than
it would if no other insurance existed.
Copayment — The portion of an eligible charge un-
der a DPO which is the member’s nancial
responsibility.
Crossbite — An abnormal relation of one or more teeth
of one arch to the opposing tooth or teeth of
the other arch.
Crown — That part of a tooth that is covered with
enamel or an articial substitute for that part.
Deductible — The rst eligible expense, or portion
thereof, incurred within each calendar year
that the member is required to pay before re-
imbursement for eligible expenses begins.
Dependent Coverage — Coverage of an eligible fami-
ly member of an enrolled member.
Employer — The State, or a local public employer
which participates in the SHBP or SEHBP.
Endodontics — Concerned with the biology and pa-
thology of the dental pulp and surrounding tis-
sues. Root canal treatment.
Gingivectomy — Removal of gum tissue.
Gingivoplasty — A surgical procedure that reshapes
and recontours the gum tissue in order to at-
tain functional form.
Inlay — A cast metallic or ceramic lling for a dental
cavity.
Mandibular — Relating to the lower jaw.
Maxillary — Relating to the upper jaw.
Member — With respect to the Employee Den-
tal Plans, employees and any dependents
who are eligible to enroll in the SHBP/
SEHBP Active Group, Retired Group, or CO-
BRA.
Myofunctional — Relating to the role of muscle func-
tion in the correction of oral problems.
Onlay — A type of metal or ceramic restoration that
overlays the tooth to provide additional
strength to that tooth.
Orthodontic — Concerned with the correction and
prevention of irregularities of the teeth. Dental
orthopedics.
Osteoplasty — Resection of the bony structure to
achieve acceptable gum contour.
Palliative Treatment — Alleviation of symptoms with-
out curing the underlying disease.
Periodontics — Concerned with the treatment of ab-
normal conditions and diseases of the tissues
that surround and support the teeth.
Pontic — An articial tooth on a xed partial denture.
Prophylaxis — A series of procedures whereby cal-
culus (calcied deposits), stain, and other ac-
cretions are removed from the clinical crowns
of the teeth and the enameled surfaces are
polished.
Prosthodontics — The science of and art of providing
suitable substitutes for crowns of teeth, or for
replacing lost or missing teeth.
Pulpotomy — Removal of a portion of the pulp struc-
ture of a tooth, usually the coronal portion.
Reasonable and Customary — A charge by a den-
tist, or by any other provider of services or
supplies, that does not exceed the prevailing
charge for the same service or supply made
by similar providers in the same geograph-
ic area. The member is responsible for any
amount a dentist or provider charges above
the reasonable and customary allowance.
Resin — A material used in dental restoration.
Scaling and Root Planing — The removal of subgingi-
val calcied deposits around the teeth and the
cleaning of the gingival pocket.
Temporomandibular — Denoting the joint of the lower
jaw.
Page 25 January 2024 Employee Dental Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
APPENDIX III
AVAILABLE DENTAL PLANS
Plan Number Plan Name
Web Addresses and Membership
Services Phone Number
305 CIGNA Dental Health, Inc. www.cigna.com/sites/stateofnjdental
1-800-564-7642
317 Horizon Dental Choice www.horizonblue.com
1-800-433-6825
319 Aetna DMO www.aetna.com/statenj
1-877-STATENJ (1-877-782-8365)
320 MetLife www.metlife.com/dental
1-866-880-2984
399 Dental Expense Plan
(PPO Administered by Aetna)
www.aetna.com/statenj
1-877-STATENJ (1-877-782-8365)
Employee Dental Plans — Member Guidebook January 2024 Page 26
State Health Benets Program School Employees’ Health Benets Program
APPENDIX IV
TAX$AVE
Tax$ave is a benet program, dened by Section 125
of the federal Internal Revenue Code (IRC), for eligible
New Jersey State employees to use pre-tax dollars to
pay for qualied medical, dental, and dependent care
expenses and thereby increase their take-home pay.
The pre-tax deduction eectively reduces the salary on
which taxes are computed by the amount of the health,
dental, or dependent care deduction.
Note: The Tax$ave program is not available to local
employees. Contact your employer to nd out if you are
eligible to pay premiums on a pre-tax basis through an
IRC Section 125 Program oered by your employer. For
more information, see the Tax$ave Fact Sheet.
APPENDIX V
NOTICE OF PRIVACY PRACTICES TO ENROLL-
EES
This Notice describes how medical (and
dental) information about you may be
used and disclosed and how you can
get access to this information.
Please review it carefully.
Protected Health Information
The State Health Benets Program and School Em-
ployees’ Health Benets Program (Programs) are re-
quired by the federal Health Insurance Portability and
Accountability Act (HIPAA) and State laws to main-
tain the privacy of any information that is created or
maintained by the programs that relates to your past,
present, or future physical or mental health. This Pro-
tected Health Information (PHI) includes information
communicated or maintained in any form. Examples
of PHI are your name, address, Social Security num-
ber, birth date, telephone number, fax number, dates
of health care service, diagnosis codes, and procedure
codes. PHI is collected by the Programs through var-
ious sources, such as enrollment forms, employers,
health care providers, federal and State agencies, or
third-party vendors.
The Programs are required by law to abide by the
terms of this Notice. The Programs reserve the right to
change the terms of this Notice. If material changes are
made to this Notice, a revised Notice will be sent.
Uses and Disclosures of PHI
The Programs are permitted to use and to disclose
PHI in order for our members to obtain payment for
health care services and to conduct the administrative
activities needed to run the Programs without specic
member authorization. Under limited circumstances,
we may be able to provide PHI for the health care oper-
ations of providers and health plans. Specic examples
of the ways in which PHI may be used and disclosed
are provided below. This list is illustrative only and not
every use and disclosure in a category is listed.
• The Programs may disclose PHI to a doctor or a
hospital to assist them in providing a member with
treatment.
• The Programs may use and disclose member PHI
so that our Business Associates may pay claims
from doctors, hospitals, and other providers.
• The Programs receive PHI from employers, includ-
ing the member’s name, address, Social Security
number, and birth date. This enrollment informa-
tion is provided to our Business Associates so that
they may provide coverage for health care benets
to eligible members.
• The Programs and/or our Business Associates
may use and disclose PHI to investigate a com-
plaint or process an appeal by a member.
• The Programs may provide PHI to a provider, a
health care facility, or a health plan that is not our
Business Associate that contacts us with ques-
tions regarding the member’s health care cover-
age.
• The Programs may use PHI to bill the member for
the appropriate premiums and reconcile billings
we receive from our Business Associates.
• The Programs may use and disclose PHI for fraud
and abuse detection.
• The Programs may allow use of PHI by our Busi-
ness Associates to identify and contact our mem-
bers for activities relating to improving health or
reducing health care costs, such as information
about disease management programs or about
health-related benets and services, or about
treatment alternatives that may be of interest to
them.
• In the event that a member is involved in a lawsuit
or other judicial proceeding, the Programs may
use and disclose PHI in response to a court or ad-
ministrative order as provided by law.
• The Programs may use or disclose PHI to help
evaluate the performance of our health plans. Any
such disclosure would include restrictions for any
other use of the information other than for the in-
tended purpose.
• The Programs may use PHI in order to conduct an
analysis of our claims data. This information may
be shared with internal departments such as audit-
ing or it may be shared with our Business Associ-
ates, such as our actuaries.
Except as described above, unless a member specif-
ically authorizes us to do so, the Programs will pro-
Page 27 January 2024 Employee Dental Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
vide access to PHI only to the member, the member’s
authorized representative, and those organizations
who need the information to aid the Programs in the
conduct of its business (our “Business Associates”).
An authorization form may be obtained online at:
www.nj.gov/treasury/pensions or by sending an
email to: [email protected]v A member may re-
voke an authorization at any time.
Restricted Uses
• PHI that contains genetic information is prohibited
from use or disclosure by the Programs for under-
writing purposes.
• The use or disclosure of PHI that includes psy-
chotherapy notes requires authorization from the
member.
When using or disclosing PHI, the Programs will make
every reasonable eort to limit the use or disclosure
of that information to the minimum extent necessary to
accomplish the intended purpose. The Programs main-
tain physical, technical, and procedural safeguards that
comply with federal law regarding PHI. In the event of
a breach of unsecured PHI the member will be notied.
Member Rights
Members of the Program have the following rights re-
garding their PHI.
Right to Inspect and Copy: With limited exceptions,
members have the right to inspect and/or obtain a copy
of their PHI that the Programs maintain in a designated
record set, which consists of all documentation relating
to member enrollment and the Programs’ use of this
PHI for claims resolution. The member must make a
request in writing to obtain access to their PHI. The
member may use the contact information found at the
end of this Notice to obtain a form to request access.
Right to Amend: Members have the right to request
that the Programs amend the PHI that we have created
and that is maintained in our designated record set.
We cannot amend demographic information, treatment
records, or any other information created by others. If
members would like to amend any of their demographic
information, please contact your personnel oce. To
amend treatment records, a member must contact the
treating physician, facility, or other provider that created
and/or maintains these records.
The Programs may deny the member’s request if: 1) we
did not create the information requested on the amend-
ment; 2) the information is not part of the designated
record set maintained by the Programs; 3) the member
does not have access rights to the information; or 4) we
believe the information is accurate and complete. If we
deny the member’s request, we will provide a written
explanation for the denial and the member’s rights re-
garding the denial.
Right to an Accounting of Disclosures: Members
have the right to receive an accounting of the instanc-
es in which the Program or our Business Associates
have disclosed member PHI. The accounting will re-
view disclosures made over the past six years. We will
provide the member with the date on which we made a
disclosure, the name of the person or entity to whom
we disclosed the PHI, a description of the information
we disclosed, the reason for the disclosure, and certain
other information. Certain disclosures are exempted
from this requirement (e.g., those made for treatment,
payment or health benets operation purposes, or
made in accordance with an authorization) and will not
appear on the accounting.
Right to Request Restrictions: The member has the
right to request that the Programs place restrictions on
the use or disclosure of their PHI for treatment, pay-
ment, or health care operations purposes. The Pro-
grams are not required to agree to any restrictions and
in some cases will be prohibited from agreeing to them.
However, if we do agree to a restriction, our agreement
will always be in writing and signed by the Privacy Of-
cer. The member request for restrictions must be in
writing. A form can be obtained by using the contact
information found at the end of this Notice.
Right to Restrict Disclosure: The member has the
right to request that a provider restrict disclosure of PHI
to the Programs or Business Associates if the PHI re-
lates to services or a health care item for which the in-
dividual has paid the provider in full. If payment involves
a exible spending account or health savings account,
the individual cannot restrict disclosure of information
necessary to make the payment but may request that
disclosure not be made to another program or health
plan.
Right to Receive Notication of a Breach: The mem-
ber has the right to receive notication in the event that
the Programs or a Business Associate discover unau-
thorized access or release of PHI through a security
breach.
Right to Request Condential Communications:
The member has the right to request that the Programs
communicate with them in condence about their PHI
by using alternative means or an alternative location,
if the disclosure of all or part of that information to an-
other person could endanger them. We will accommo-
date such a request if it is reasonable, if the request
species the alternative means or locations, and if it
continues to permit the Programs to collect premiums
and pay claims under the health plan.
Employee Dental Plans — Member Guidebook January 2024 Page 28
State Health Benets Program School Employees’ Health Benets Program
To request changes to condential communications,
the member must make their request in writing and
must clearly state that the information could endanger
them if it is not communicated in condence as they
requested.
Right to Receive a Paper Copy of the Notice: Mem-
bers are entitled to receive a paper copy of this Notice.
Please contact us using the information at the end of
this Notice.
Questions and Concerns
If you have questions or concerns, please contact the
Programs using the information listed at the end of this
Notice (local county, municipal, and board of education
employees should contact the HIPAA Privacy Ocer
for their employer).
If members think the Programs may have violated their
privacy rights, or they disagree with a decision made
about access to their PHI, in response to a request
made to amend or restrict the use or disclosure of their
information, or to have the Programs communicate with
them in condence by alternative means or at an al-
ternative location, they must submit their complaint in
writing. To obtain a form for submitting a complaint, use
the contact information found at the end of this Notice.
Members also may submit an online complaint to the
U.S. Department of Health and Human Services, at:
www.hhs.gov/hipaa/ling-a-complaint
The Programs support member rights to protect the pri-
vacy of PHI. It is your right to le a complaint with the
Programs or with the U.S. Department of Health and
Human Services.
Contact Oce:
New Jersey Division of Pensions & Benets
HIPAA Privacy Ocer
Address:
New Jersey Division of Pensions & Benets
Bureau of Policy and Planning
P.O. Box 295
Trenton, NJ 08625-0295
Email: hipaaform@treas.nj.gov
Page 29 January 2024 Employee Dental Plans — Member Guidebook
School Employees’ Health Benets Program State Health Benets Program
HEALTH BENEFITS CONTACT INFORMATION
Addresses
Our mailing address is:
New Jersey Division of Pensions & Benets
Health Benets Bureau
P.O. Box 299
Trenton, NJ 08625-0299
Our website address is:
www.nj.gov/treasury/pensions
Our email address is
pensions.nj@treas.nj.gov
Telephone Numbers
Division of Pensions & Benets
Oce of Client Services .............. (609) 292-7524
Relay Operator (Hearing Impaired)
Dial 711 and provide
operator with: .............................. (609) 292-6683
State Employee Advisory Service (EAS)
1-866-327-9133
Rutgers University Personnel Counseling Service
RBHS-Newark ............................. (973) 972-5429
RBHS-Piscataway .......................(732) 235-5930
Rutgers-Camden .........................(856) 770-5750
New Jersey State Police
Oce of Employer and
Organization Development .........1-800-367-6577
New Jersey Department of Banking and Insurance
Individual Health Coverage
Program Board ........................... 1-800-838-0935
Consumer Assistance for
Health Insurance .......................... (609) 292-5316
Independent Health Care
Appeals Program ........................1-800-466-7467
New Jersey Department of Human Services
Pharmaceutical Assistance to the
Aged and Disabled (PAAD) ........1-80 0-792-9745
Division on Senior Aairs ............ 1-800-792-8820
Insurance Counseling .................1-800-792-8820
Centers for Medicare and Medicaid Services
New Jersey Medicare —
Part A and Part B ....................1-800-MEDICARE
HEALTH BENEFITS PUBLICATIONS
Publications and fact sheets available from the NJD-
PB provide information on a variety of subjects. Fact
sheets, guidebooks, applications, and other publica-
tions are available for viewing or downloading on our
website.
General Publications
Summary Program Description — An overview of
SHBP/SEHBP eligibility and plans
Plan Design Comparison Charts — Out-of-pocket cost
comparison charts for State employees, local govern-
ment employees, local education employees, and all
retirees
Health Benet Fact Sheets
• Health Benets Coverage — Enrolling as a
Retiree
• Health Benet Programs and Medicare Parts A &
B for Retirees
• Termination of Employment through Resignation,
Dismissal, or Layo
• COBRA — The Continuation of Health Benets
• Dental Plans — Active Employees
• Health Benets Retired Coverage under Chapter
330
• Family Status Changes - Employees
• Family Status Changes - Retirees
• Health Benets Coverage Continuation for Over
Age Children With Disabilities
• Health Benets Coverage for Part-Time Employ-
ees
• Health Benets Coverage for State Intermittent
Employees
• Dental Plans — Retirees
• Health Benets Coverage of Children until Age 31
under Chapter 375
• Civil Unions and Domestic Partnerships
Health Plan Member Guidebooks
• NJ DIRECT/CWA Unity DIRECT Member Guide-
book
• Horizon HMO Member Guidebook
• Horizon OMNIA Member Guidebook
• Prescription Drug Plans Member Guidebook
• NJ DIRECT HDHP Member Guidebook
• Employee Dental Plans Member Guidebook
• Retiree Dental Plans Member Guidebook
