UnitedHealthcare DHMO High

UnitedHealthcare Solstice Dental Health Maintenance Organization, or DHMO, is a network of Provider Groups who have agreed to offer specific services at negotiated rates to participating members.

UnitedHealthcare Solstice DHMO Plans

You do not need to select a dental facility at the time of enrollment; you elect your dentist at the time of service by selecting a participating provider and verifying their participation in the plan prior to the dental visit. Additionally, these plans provide you with certain services with set reimbursements when accessing care from non-participating providers.

The member pays a copayment at participating providers, however, most diagnostic and preventive care is covered at no cost. Additionally, there are no deductibles, and no claim forms are needed. The plans also provide reimbursement for services provided by an out-of-network provider for preventive and diagnostic services. Additionally the plan offers a 25% discount on all procedure codes not listed in the Services and Copayment pages.

The patient/Member is ultimately responsible for verifications to the accuracy and appropriateness of all fees applicable to any dental benefit provided by a network provider. We urge all of our Members to verify all fees for proposed treatment via the “Schedule of Benefits” and/or with UnitedHealthcare Solstice DHMO Member Services Department prior to treatment.

Summary of Benefits

Exam	You Pay
Office Visit	$0.00
Periodic Oral Evaluation	$0.00
Limited Oral Evaluation – Problem focused	$0.00
Comprehensive Oral Evaluation	$0.00
X-Rays	You Pay
Intraoral – Complete Series, including bitewings	$0.00
Intraoral – Periapical first film	$0.00
Intraoral – Periapical each additional film	$0.00
Bitewings – two films	$0.00
Bitewings – four films	$0.00
Panoramic	$0.00
Preventive Services	You Pay
Prophylaxis – adult cleaning	$0.00
Prophylaxis – child cleaning	$0.00
Fluoride – child	$0.00
Sealant – per tooth	$5.00
Silver Fillings	You Pay
Amalgam, 1 Surface, primary or permanent	$0.00
Amalgam, 2 Surface, primary or permanent	$0.00
White Fillings, Front Teeth	You Pay
Anterior Composite, 1 surface	$35.00
Anterior Composite, 2 surface	$40.00
Onlays and Crowns	You Pay
Crown, All Porcelain	$230.00 Additional cost for material and lab fees apply as follows: 1. Crown laboratory fees up to $155 2. All ceramic and/or porcelain crown material fees up to $155
Core Build Up	$45.00
Periodontal Care (For Gums)	You Pay
Periodontal Therapy, 4+ teeth/quadrant	$40.00
Periodontal Maintenance	$30.00
Extractions	You Pay
Extraction, erupted tooth or exposed root	$0.00
Surgical removal of erupted teeth	$30.00
Orthodontia Care	You Pay
Comprehensive Orthodontic treatment – adolescent (up to 24 months – including fixed/removable appliances) to age 19	$1,800.00
Comprehensive Orthodontic treatment – adult (up to 24 months – including fixed/removable appliances)	$1,800.00
Pre-orthodontic treatment visit (consult/records/exam)	$0.00
Orthodontic Retention (removal of appliances, construction and placement of retainer(s))	$300.00
Unspecified Orthodontic Procedure – By Report	$250.00

If differences exist between this Summary of Benefits and your Certificate of Coverage/benefits administrator, the certificate/benefits administrator will govern.

Plan Details

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Services and Copayments (PDF)

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Provider Directory (PDF)

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Implant Directory (PDF)

Tools and Resources

Create Your Online Account (PDF)

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UnitedHealthcare Dental Website

Know Your Dental Cost (PDF)

Protect Your Mouth from Gum Disease (PDF)

Preventing and Treating Dental Disease (PDF)

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Brainshark DHMO Video

Glossary of Dental Terms (PDF)

How Do Dental Implants Work? (PDF)

Dental DHMO Plan Comparison Chart (PDF)

Frequently Asked Questions

Click on the question to view the answer

Why choose a UnitedHealthcare Solstice DHMO plan?

The Dental Health Maintenance Organization, or DHMO, is a network of Provider Groups who have agreed to offer specific services at negotiated rates to participating members. There are many reasons to consider selecting one of the UnitedHealthcare Solstice DHMO plans:

No deductibles
No waiting periods
No office visits copays
No claim forms to submit
Out-of-Network Preventive and Diagnostic Reimbursement (25 procedure codes only)
No annual benefit dollar maximums
Coverage for pre-existing conditions
No primary dentist selection required
Ability to change dentist at any time
Specialist coverage at same general dentist copay level with authorization, or self-referral for a 25% discount
Defined copayment on over 400 procedures codes
Implant coverage at copayment level through network of implant specialists
Cosmetic procedures (teeth whitening, bonding, and veneers) are included
25% discount on all procedure codes not listed

Am I eligible for this coverage?

You may elect to enroll in the dental plan if you are an active, benefit-eligible employee working a minimum of 20 hours per week on a regularly scheduled basis.

Who is an eligible dependent for this coverage?

Eligible dependents for the dental plan include:

- Spouse/Domestic Partner
- Unmarried natural children, adopted children, and stepchildren under you or your spouse’s legal guardianship until the end of the calendar year in which the child reaches age 26
- Children of a Domestic Partner, as long as the Domestic Partner is also covered.
  NOTE: Children may be covered under this plan until the end of the calendar year in which the child reaches age 26, provided he/she is unmarried and resides in your home and depends upon you for support, or is registered as a full-time or part-time student. Children with a mental or physical handicap are also eligible for coverage beyond the age of 26.

How do I select or change my dental provider?

You may select a dental provider from the many offices in the Solstice network without prior authorization. Visit www.myuhcdental.com or call Member Services at phone number 1.800.955.4137 to choose a participating provider for the first time or to make changes. If you would like to keep the dentist you have under your prior plan and are now changing plans, you may maintain that same dentist as long as they are part of the UnitedHealthcare Solstice network.

How do I make an appointment with my UnitedHealthcare Solstice dentist?

To schedule an appointment, you simply call the dental office and identify yourself as a UnitedHealthcare Solstice member on or after your effective date of coverage.

When you see your dentist for the first time, you may be required to undergo an oral examination including diagnostic X-rays, before your routine cleaning is done. After the dentist has completed the evaluation, you should request a written treatment plan of care the dentist is recommending including the 4-digit ADA code for each treatment. Review this treatment plan and compare it with your Schedule of Benefits. It should match! For help analyzing your treatment plan and charges, you can call UnitedHealthcare Dental member services at 1.800.955.4137.

What if I need the services of a Specialist?

Should you need to use the services of a Specialist such as an Oral Surgeon, Endodontist, Periodontist, Orthodontist, Prosthodontist, or Pediatric Dentist, you may receive this care in either one of two ways:

- - You may go directly to a participating specialist with no referral and receive a 25% reduction off the provider’s reasonable and customary fees or
  - You need to get prior written authorization from Solstice Benefits and receive specialty treatment by an approved specialist at the copayments listed in the schedule of benefits.

What if I need services from an Implantologist (Implants)?

Members seeking implant treatment should refer to their participating implantologist, a select network of providers. Not all providers perform the implant procedures at the copay listed on the Schedule of Benefits. Please refer to the provider listing at www.myuhcdental.com under “ find a physician.”

What if I require dental services while I’m traveling out of state?

If you need the services of a dentist specifically for the relief of pain while traveling out of the state of Florida, UnitedHealthcare Solstice will reimburse up to $100.00 per occurrence. You should mail your receipt and treatment information from the dental office to UnitedHealthcare Dental Claims Unit.

What if I need a Pedodontist for my child?

With the DHMO plans you can choose a participating dentist that best satisfies the needs of each individual. Children are covered at the Pediatric Dentist up to age 16 and do not require a referral from as General Dentist. Visits to the participating Pediatric Dentist for covered routine preventive and diagnostic dental work (exams, X-rays, cleanings, fluoride, sealants, and space maintainers) are allowed without a pre-authorization. However, if additional treatment is needed, you may need pre-authorization. For additional treatment, you may receive this care in either of two ways: 1) You may go directly to a participating Pediatric Dentist and receive a 25% reduction off the provider’s Usual and Customary fee; or 2) You may obtain prior written authorization from Solstice and receive specialty treatment by an approved participating specialist at the listed copayments. With the open access provider network, you have the option to select a Pedodontist for your child without a pre-authorization or you may choose to have your child see a General Dentist.

Where may I call for inquiries or additional questions?

All inquiries and questions should be directed to Member Services at phone number 1.800.955.4137.

Pre-Treatment Plans

Your dental plan covers an extensive array of dental procedures at either a fixed copayment or at a discount off the dentist’s normal charges. It is highly recommended that prior to having dental work started; you request a pre-treatment plan or estimate, from your dentist on all treatment over $500. Should you have any questions regarding your treatment plan, you can always refer to your schedule of benefits or call UnitedHealthcare Dental so we can ensure that you receive the maximum benefit from your dental plan.

Are there additional cost(s) besides the copayment for procedures being received?

For most procedures you will only have to pay the copayment outlined in the schedule of copays. However, please note that there are additional cost(s) for materials and laboratory fees for some procedures under the following categories: Inlay/Onlay, Crowns, Veneers and Prosthetics (Bridge, Dentures and Implants).
Additional cost to patient is as follows:

- - High noble metal (precious) up to $145.00
  - Titanium metal up to $120.00 (covered with proof of allergy to other metals)
  - Noble metal (semi-precious) up to $120.00
  - Predominantly base metal (non-precious) up to $55.00
  - Crown laboratory fees up to $155.00
  - Laboratory fees on dentures up to $225.00
  - Porcelain laboratory fees for D2610-D2644, D2929, D2961, D2962, D6600, D6601, D6608 and D6609 up to $65.00
  - Denture repair laboratory fees up to $50.00
  - All ceramic and/or porcelain crown material fees up to $155.00
  - When crown, implant and/or bridgework exceed six (6) consecutive units, there will be an additional charge of $30.00 per unit.

Limitations/Exclusions

Limitations of Benefits

- 1. Any oral evaluation (excluding problem) is limited to One (1) time per consecutive six (6) months; comprehensive exams can only be covered one (1) time per 36 months, if and only if patient is considered to be new or an established patient. All subsequent oral evaluations will be at a 25% reduction off the dentist’s usual and customary fee without a frequency limitation.
  2. All bitewing X-rays are limited to one set in any twelve (12) consecutive month period.
  3. The dental prophylaxis or periodontal maintenance procedure is limited to one (1) time in any consecutive six (6) month period. Any additional procedures will follow D1110 and D4910 Member copayments as listed in the Schedule of Benefits.
  4. Fluoride treatment is limited to one (1) in any twelve (12) consecutive month period.
  5. Sealants are limited to one (1) time per tooth in any three (3) consecutive year period. This is only allowed for unrestored permanent molar teeth for children under the age of 16.
  6. Space maintainers and all adjustments are limited to children under the age of 16.
  7. Harmful habit appliances are limited to one (1) time per person under the age of 16.
  8. General anesthesia or IV sedation is available when listed on the Schedule of Benefits, medically necessary, and previously approvedby Solstice.
  9. New dentures include one (1) reline within the first six (6) months
  10. Replacement of crowns, implants, and fixed bridges or dentures is limited to one (1) time every consecutive five (5) years.
  11. When crown, implant and/or bridgework exceed six (6) consecutive units, there will be an additional charge of $30.00 per unit.
  12. Copayments marked by ‘*’ do not include the cost of material and laboratory fees. Additional cost to patient is as follows:
    - High noble metal (precious) up to $145.00
    - Titanium metal up to $120 (covered with proof of allergy to other metals)
    - Noble metal (semi-precious) up to $120.00
    - Predominantly base metal (non-precious) up to $55.00
    - Crown laboratory fees up to $155.00
    - Laboratory fees on dentures up to $225.00
    - Porcelain laboratory fees for D2610-D2644, D2929, D2961, D2962, D6600, D6601, D6608, and D6609 up to $65.00 Denture repair laboratory fees up to $50.00
    - All ceramic and/or porcelain crown material fees up to $155.00
  13. Copayments marked by “†” are not eligible at a specialist.
  14. Either D0210 or D0330 are reimbursable one (1) time every five(5) consecutive years.
  15. Copies of X-rays can be obtained for $2 per periapical image up to a maximum of $30. Panoramic X-ray can be obtained for a $15 fee.
  16. D0274, D0277 or D0210 are payable only when other inclusive image have not been taken (paid) within the last six (6) months.
  17. All denture adjustment fees are for dentures which were not fabricated at the present office; All denture adjustment for newdentures made within 12 months are at no fee to the member.
  18. Emergency treatment is available for palliative treatment for the abatement of pain up to $100.00 per occurrence.
  19. A broken appointment fee up to $20 may be charged by the dental office if 24 hour prior notice is not given.
  20. Surgical removal of wisdom tooth covered when pathology (disease) exists. Surgical removal of wisdom teeth/3rd molar when pathology does not exist will be covered at 25% off of the general dentists’ or specialists’ usual and customary fees. Orthodontic related surgeries (except D7280) needed to relieve crowding or to facilitate eruption are available at a 25% reduction off of the doctor’s usual and customary fees.
  21. Member may choose Invisalign in place of traditional Orthodontic treatment, and would pay the sum of the listed member Orthodontic copay plus the difference in cost for the enhanced treatment.
  22. Occlusal Guard(s) is limited to one (1) time in any consecutive thirty-six (36) months for the purposes of habitual grinding/Bruxism.
  23. D0364-D0395 is limited to one (1) time per sixty (60) months, covered only in a dental setting and not in a radiographic imaging center.

Exclusions of Benefits

- 1. Services performed by a dentist or dental specialist, not contracted with Solstice without prior approval.
  2. Any dental services or appliances which are determined to be not reasonable and/or necessary for maintaining or improving the Member’s dental health or experimental in nature, as determined by the participating Solstice dentist.
  3. Orthographic surgery or procedures and appliances for the treatment of myofunctional, myoskeletal or temporomandibular joint disorders unless otherwise specified as an orthodontic benefit on the Schedule of Benefits.
  4. Any inpatient/outpatient hospital charges of any kind including dentist and/or physician charges, prescriptions, or medications.
  5. Treatment of malignancies, cysts, or neoplasms, without proof of medical necessity and prior Solstice approval.
  6. Dental procedures initiated prior to the Member’s eligibility under this benefit plan or started after the Member’s termination from the plan.
  7. Any dental procedure or treatment unable to be performed in the dental office due to the general health or physical limitations of the Member, including but not limited to, physical or emotional resistance, in ability to visit the dental office, or allergy to commonly utilized local anesthetics.
  8. D9972 Excludes bleaching material for home use.

UnitedHealthcare (UHC) Dental
DHMO Dental Member Services:
Mon – Fri, 7 a.m. to 10 p.m. CDT
1-800-955-4137

Miami-Dade County Public Schools

Office of Risk and Benefits Management
1501 N.E. 2nd Avenue, Suite 335
Miami, Florida 33132
Mon - Fri, 8 a.m. to 4:30 p.m. ET
www.dadeschools.net

Benefits Inquiry:

FBMC Service Center
Mon - Fri,
7 a.m. to 7 p.m. ET
1-855-MDC-PS4U (1-855-632-7748)

Enrollment Helpline:

1-305-995-2777
7 a.m. to 7 p.m. ET /
Seven days a week