DentalThe MTA Benefit Fund
c/o Administrative Services Only, Inc. P.O. Box 9005 Lynbrook, NY 11563 1.800.537.1238 ASO Member Portal |
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The Mahopac Teachers Association Benefit Fund provides COMPREHENSIVE DENTAL BENEFITS through its own self funded dental plan. Enrollment is in March. If you elect payments, they are due March 31st, April 30th & May 31st.
WHO IS ELIGIBLE?
WHAT DOES THE PLAN PAY?
Your Comprehensive Dental Benefits program pays a set amount for covered expenses you have for preventive, basic, and major dental services up to a maximum benefit of $ 1,800 per plan year (July 1 through June 30) per each covered person. You may use one of the plans Participating Providers or go to a dentist of your own choosing. If you elect to go to a dentist who is not on the Participating Providers the Fund will pay according to the MTABF fee schedule. Any additional costs that you incur are your responsibility. (For example, if the fee schedule says it pays $100.00 for procedure X & your dentist charges $125 for procedure X, then the Fund pays the first $100 & your are responsible for the remaining $25.)
WHAT IS THE PARTICIPATING PROVIDER OPTION (PPO)?
Participating Providers are dental care providers who have agreed to provide Covered dental procedures at no out-of pocket expense to Fund members and their eligible dependents.
We have selected providers in the dental care panel who have agreed to accept the Fund's fee schedule. In addition, we have sought out providers who have treated Fund members in the past. The Fund does not recommend the services of any particular provider. Before receiving services from a panel provider, you should confirm that he/she is still on the panel by calling the Fund's third-party administrator, ASO at 1.800.537.1238. If you make use of a dentist who is not a PPO, please let the Fund know & it will see what can be done about enrolling your dentist.
Please remember that Fund members and their dependents are still subject to annual and lifetime coverage limits as specified in the dental plan description. The only time that you will have to make a payment is for procedures that are not covered and for procedures performed after you have reached an applicable maximum (e.g., exceeding a frequency limitation or the annual maximum).
If, for any reason you encounter any irregularity or trouble with the services provided by a participating dentist, please contact our Dental Plan Administrator, ASO, at 1.800.537.1238.
Also, contact the Dental Plan Administrator if you are charged by a participating dentist for any covered service. DO NOT PAY ANY SUCH CHARGE.
WHAT IS PRE-TREATMENT AUTHORIZATION?
When a dentist's charges for a course of treatment will amount to $ 500 or more, dental services must be authorized by the Fund before treatment is provided. Pre-treatment authorization by the Fund's dental consultant is required for any proposed course of treatment in which a dentist's charges will amount to $ 500 or more. X-rays must be included with treatment plans submitted for pre-treatment authorization. Pre-treatment authorization by the Fund's dental consultant is limited to the approval of the course of treatment proposed. Pre-treatment authorization means that the services are warranted. It is not a guarantee of payment.
The covered member's or eligible dependent's dentist is required to submit x-rays and a treatment plan to the Fund Office for review by the Fund's dental consultant no later than 30 days after the initial examination. A claim submitted for pre-treatment authorization will be returned to the dentist indicating the pre-treatment authorization decision. Your dentist should contact you upon receipt of the claim form.
The dentist may proceed to provide dental services as soon as the treatment plan has been authorized by the Fund. The Fund reserves the right to modify or deny payment of claims amounting to $500 or more which have not been authorized by the Fund before the beginning of treatment.
WHO IS ELIGIBLE FOR THE ORTHODONTIC BENEFIT?
If enrolled in the family plan, eligible dependent children up to their 26th birthday and eligible adult participants in the plan.
HOW DOES THE ORTHODONTIC BENEFIT WORK?
Orthodontic services are reimbursed according to a fee schedule up to a Lifetime Maximum of $ 2,200.00 for eligible participants. A period of orthodontic treatment starts on the first day you or your dependent incurs a covered expense for orthodontia and extends for a period of consecutive months until the maximum has been reached, the case is complete, or you or your dependent's eligibility ends. The orthodontic benefit is not included in the yearly dental maximum. Please be aware that a fee to the orthodontist providing service (including preferred providers) may be incurred by the individual receiving services. Please discuss these potential fees with your orthodontist before you receive service(s).
WHAT ARE COVERED ORTHODONTIC EXPENSES?
HOW DO YOU SUBMIT A CLAIM?
When you have a claim, you should promptly submit the completed claim form.
Mail the forms to:
MTA Benefit Fund
c/o Administrative Services Only, Inc.
P.O. Box 9005
Lynbrook, NY 11563
HOW ARE YOUR BENEFITS AFFECTED BY THE ALTERNATE BENEFIT PROVISION?
When more than one dental service would provide suitable treatment, your benefits will be based on the treatment determined by the Fund to be best suited to your condition by accepted standards of dental practice. If two services provide satisfactory results according to accepted standards of dental practice and one service is less expensive than the other, the Fund will reimburse up to the scheduled allowance for the less expensive treatment.
EXCLUSIONS:
Benefits will not be paid for charges for:
WHO IS ELIGIBLE?
- Members who are properly enrolled in the Fund are automatically eligible for dental benefits.
- Coverage runs from July 1 - June 30th.
- Members may pay for & enroll their eligible dependents. Plans to enroll dependents may be purchased in March. The Variable Benefit may be used to defray the cost of any of these plans.
- Eligible dependents include a legally married spouse &/or dependent children. Dependent children are covered up to their 26th birthday.
- Dependents who are enrolled one year & then dropped the following year must wait 3 years before they can be re-enrolled.
WHAT DOES THE PLAN PAY?
Your Comprehensive Dental Benefits program pays a set amount for covered expenses you have for preventive, basic, and major dental services up to a maximum benefit of $ 1,800 per plan year (July 1 through June 30) per each covered person. You may use one of the plans Participating Providers or go to a dentist of your own choosing. If you elect to go to a dentist who is not on the Participating Providers the Fund will pay according to the MTABF fee schedule. Any additional costs that you incur are your responsibility. (For example, if the fee schedule says it pays $100.00 for procedure X & your dentist charges $125 for procedure X, then the Fund pays the first $100 & your are responsible for the remaining $25.)
WHAT IS THE PARTICIPATING PROVIDER OPTION (PPO)?
Participating Providers are dental care providers who have agreed to provide Covered dental procedures at no out-of pocket expense to Fund members and their eligible dependents.
We have selected providers in the dental care panel who have agreed to accept the Fund's fee schedule. In addition, we have sought out providers who have treated Fund members in the past. The Fund does not recommend the services of any particular provider. Before receiving services from a panel provider, you should confirm that he/she is still on the panel by calling the Fund's third-party administrator, ASO at 1.800.537.1238. If you make use of a dentist who is not a PPO, please let the Fund know & it will see what can be done about enrolling your dentist.
Please remember that Fund members and their dependents are still subject to annual and lifetime coverage limits as specified in the dental plan description. The only time that you will have to make a payment is for procedures that are not covered and for procedures performed after you have reached an applicable maximum (e.g., exceeding a frequency limitation or the annual maximum).
If, for any reason you encounter any irregularity or trouble with the services provided by a participating dentist, please contact our Dental Plan Administrator, ASO, at 1.800.537.1238.
Also, contact the Dental Plan Administrator if you are charged by a participating dentist for any covered service. DO NOT PAY ANY SUCH CHARGE.
WHAT IS PRE-TREATMENT AUTHORIZATION?
When a dentist's charges for a course of treatment will amount to $ 500 or more, dental services must be authorized by the Fund before treatment is provided. Pre-treatment authorization by the Fund's dental consultant is required for any proposed course of treatment in which a dentist's charges will amount to $ 500 or more. X-rays must be included with treatment plans submitted for pre-treatment authorization. Pre-treatment authorization by the Fund's dental consultant is limited to the approval of the course of treatment proposed. Pre-treatment authorization means that the services are warranted. It is not a guarantee of payment.
The covered member's or eligible dependent's dentist is required to submit x-rays and a treatment plan to the Fund Office for review by the Fund's dental consultant no later than 30 days after the initial examination. A claim submitted for pre-treatment authorization will be returned to the dentist indicating the pre-treatment authorization decision. Your dentist should contact you upon receipt of the claim form.
The dentist may proceed to provide dental services as soon as the treatment plan has been authorized by the Fund. The Fund reserves the right to modify or deny payment of claims amounting to $500 or more which have not been authorized by the Fund before the beginning of treatment.
WHO IS ELIGIBLE FOR THE ORTHODONTIC BENEFIT?
If enrolled in the family plan, eligible dependent children up to their 26th birthday and eligible adult participants in the plan.
HOW DOES THE ORTHODONTIC BENEFIT WORK?
Orthodontic services are reimbursed according to a fee schedule up to a Lifetime Maximum of $ 2,200.00 for eligible participants. A period of orthodontic treatment starts on the first day you or your dependent incurs a covered expense for orthodontia and extends for a period of consecutive months until the maximum has been reached, the case is complete, or you or your dependent's eligibility ends. The orthodontic benefit is not included in the yearly dental maximum. Please be aware that a fee to the orthodontist providing service (including preferred providers) may be incurred by the individual receiving services. Please discuss these potential fees with your orthodontist before you receive service(s).
WHAT ARE COVERED ORTHODONTIC EXPENSES?
- The initial work-up/examination, once up to $125.
- The reconstruction, diagnosis and insertion of the initial appliance: Once, up to $440.
- $50 per active monthly visit.
- $40 per passive treatments (once per six months; maximum of three visits)
HOW DO YOU SUBMIT A CLAIM?
When you have a claim, you should promptly submit the completed claim form.
Mail the forms to:
MTA Benefit Fund
c/o Administrative Services Only, Inc.
P.O. Box 9005
Lynbrook, NY 11563
- Claims submitted 90 days after completion of dental services will be denied. The forms themselves provide instructions concerning proper filing. Read these forms carefully and entirely.
It may become necessary to require additional proof or information concerning a particular claim, and therefore the Fund reserves the right to require such proof or information, including but not limited to any or all of the following:- A dental chart showing work done before the treatment for which claim is made.
- X-rays, lab or hospital reports.
- Cast molds or other evidence of the dental condition or treatment.
- Post-treatment examination of the patient, at the Fund's expense, by a dentist it selects
HOW ARE YOUR BENEFITS AFFECTED BY THE ALTERNATE BENEFIT PROVISION?
When more than one dental service would provide suitable treatment, your benefits will be based on the treatment determined by the Fund to be best suited to your condition by accepted standards of dental practice. If two services provide satisfactory results according to accepted standards of dental practice and one service is less expensive than the other, the Fund will reimburse up to the scheduled allowance for the less expensive treatment.
EXCLUSIONS:
Benefits will not be paid for charges for:
- Treatment from anyone other than a licensed dentist or physician, except routine cleaning of teeth and fluoride application which is performed by a licensed dental hygienist under the direct supervision of, and billed by, a dentist or physician
- Facings, veneers, or similar material placed on molar crowns or pontics
- Services performed by a member of your or your spouse's immediate family, unless acceptable proof of payment is provided for those services
- Services or supplies that are cosmetic in nature or directed toward a cosmetic end
- Any service or supplies incurred, installed, or delivered before you or your dependent(s) become eligible for benefits from this Fund
- Replacing a lost, missing or stolen prosthetic appliance
- Broken appointment
- Services received from a medical department, clinic or any facility provided or furnished by your spouse's employer
- Service that is not medically necessary or is not normally performed for proper dental care of the condition or any service that is not approved by the attending dentist
- Services or supplies that do not meet accepted standards of dental practice including experimental or investigational services or supplies,
- Services or supplies received as a result of dental disease, defect, or injury due to an act of war, declared or undeclared
- Any duplicate prosthetic appliance except as specifically provided
- Completing claim forms
- Oral hygiene, or dietary instruction or plaque control programs
- Implants
- Wiring or bonding teeth or crowns to act as a splint for any reason
- An injury arising from employment
- Illness covered by Workers' Compensation
- Services or supplies for which you are not required to pay
- Appliances, restorations, or any procedure to alter vertical dimension for cosmetic purposes
- Services or supplies not specifically listed under covered expenses
Helpful Links:
- Dental Claim Form
- Find a Dentist
- Dental Schedule of Covered Rates
- Dental Enrollment Announcement 2024
- Dental Enrollment Form 2024 - Mail with the Variable Claim Form to ASO
- Variable Claim Form - use for the next school year to defray the cost of your dental enrollment cost. Not applicable if retiring before the following school year.
