Generally, if you use in-network providers, your provider will submit your claims for you. Remember to present your Blue Shield of California PPO or Delta Dental PPO identification card each time you receive services and verify that the providers participate in the network.
If you enrolled in DeltaCare USA DHMO, make sure you go to your assigned dental office and present your DeltaCare USA ID card. If you need an ID card, contact Delta Dental USA at (800) 422-4234.
Once you enroll in Vision Service Plan (VSP), you do not need an ID card to make an appointment. Simply tell your provider you have VSP.
When you use non-network providers and pay in full upfront, you must submit an itemize bill or superbill, proof of payment and, if any, an Explanation of Benefits (EOB) from your primary plan.
If you use an out-of-network provider and you paid in full upfront, you must submit an itemize bill or superbill, your proof of payment and if any, an Explanation of Benefits from your primary plan to the Fund Office.
See the Prescription Drug Benefits section for instructions on how to file a Prescription Drug claim.
Important Note: Claims received more than 12 months from the service date will generally be denied. In some cases, Plan representatives will request more information from the patient or provider before the claim may be processed. Replies to Fund Office requests must be sent within 12 months.
If you need a Blue Shield of California ID card, contact the Fund Office.
If you enrolled in Delta Dental PPO and need an ID card, contact Delta Dental USA at (800) 422-4234.
If you enrolled in DeltaCare USA DHMO and need an ID card, contact Delta Dental USA at (800) 422-4234.
Once you enroll in Vision Service Plan (VSP) and need an ID card, contact VSP at (800) 877-7195. Note: you do not need a VSP ID card to make an appointment. Simply tell your provider you have VSP.
The Health & Welfare Plan has a $250 deductible per covered person (up to a $750 family maximum) for covered health care services each calendar year. Once the deductible is met, the Plan will pay for any further Medically Necessary covered services based on the Blue Shield of California PPO Network Rate or the Allowable Charge, whichever applies.
In addition, some benefits have separate deductibles:
Your Plan’s vision benefit does not have a deductible.
HRA allowances reimburse you (on a tax-free basis) for eligible health care expenses you and your covered dependents incurred that were not paid through your medical, dental, vision and prescription drug benefits or other coverage —such as deductibles, copayments, premiums and certain non-covered expenses. Note: Since January 1, 2020, non-prescription drugs and menstrual care products are also reimbursable via HRA.
Other examples of qualified expenses are non-covered prescription eyeglasses, contact lenses or hearing aid costs. Vitamins, supplements and holistic medicines are non-reimbursable via HRA. Refer to IRS Publication 502 for the most recent list of qualified expenses.
Refer to the Summary Plan Description (HRA section beginning on page 22) or contact the Fund Office for more information.
Your HRA claim may be missing an HRA Request for Reimbursement Form or additional supporting documentation such as the itemized bill or an Explanation of Benefits (EOB) from your primary insurance. Or your claim may first need to be processed through your primary benefits (such as your medical, dental or vision coverage). Contact the Fund Office for more information.
All eligible participants must enroll in one of two dental options to have dental coverage.
To enroll in dental coverage, complete a Dental Enrollment Form and submit to the Fund Office. On that form, you elect your choice of dental options—either Delta Dental PPO or DeltaCare USA DHMO. Covered dependents are automatically enrolled under the same dental option as you.
If you didn’t enroll within 60 days of when you became eligible under the Health & Welfare Fund, coverage under your choice of dental options begins the month following the date your properly completed form is received by the Fund Office. Note: Benefits are not retroactive to the date when you were first eligible.
After you enroll, you can change your dental option in the late fall during annual open enrollment for changes effective the following January 1. You will need to submit a new Dental Enrollment Form to the Fund Office via mail, fax or email by the annual open enrollment deadline. If you do not return a Dental Enrollment Form on time, your dental coverage will remain unchanged.
Note: You and your covered dependents must be enrolled under the same dental option.
Here is the customer service information for the two dental options:
- MetLife PPO: (800) 438-6388 or www.metlife.com/mybenefits- DeltaCare USA DHMO: (800) 422-4234 or deltadentalins.com
All services and referrals must be provided by your assigned DeltaCare USA network dentist. Benefits are not paid if services are performed by other dental providers (unless it’s an emergency). Referrals are required for some specialty care services.
Choose a DHMO network dentist when you sign up for the plan. There are several ways to find a DeltaCare USA network dentist near you.
- Go to deltadental.com after you enroll and register or log in to your account, or
- Go to the Find a Dentist link, or
- Call the DeltaCare USA customer service at (800) 422-4234. A representative will help you find a network dentist near you. It’s best to pick a network general dentist who is within 25 miles of your location to ensure adequate access.
Your share of out-of-pocket costs is clearly listed on the Benefit Summary. Your Benefit Summary lists the covered dental procedures. If a dental procedure is not listed, it’s not covered. If you have questions, you can take your Benefit Summary with you to dental appointments. You can use it to discuss treatment options and costs with your dentist.
You can use any dentist, but your out-of-pocket costs are lower when you choose a MetLife PPO network dentist. Check that your provider is in the PPO network before receiving services.
Choose a PPO network dentist when you sign up for the plan. There are several ways to find a Delta Dental PPO network dentist near you.
- Go to www.metlife.com/mybenefits after you enroll and register or log in to your account, or
- Call the MetLife PPO customer service at (800) 438-6388. A representative will help you find a network dentist near you. It’s best to pick a network general dentist who is within 25 miles of your location to ensure adequate access.
Under the MetLife PPO option, your Plan covers a wide range of services without pre-existing condition limitations. Your coverage offers cleanings three times per year (with dental exams twice per year). Diagnostic, preventive, basic restorative, endodontics, periodontics, oral surgery and orthodontia are covered at 100%, while major services like crowns, dentures and bridges are covered at 90%, subject to the MetLife PPO contracted fee schedule.
Under the DeltaCare USA DHMO option, your Plan covers more than 300 procedures without pre-existing condition limitations. You are not subject to copayments for covered services. Your coverage offers cleanings three times per year (with dental exams twice per year).
Under the MetLife PPO option, a $50 per patient (maximum $150 per family) deductible and $1,800 per patient maximum benefit applies each calendar year. Orthodontia has a lifetime benefit of $1,800 per patient and is not counted toward the $1,800 per patient calendar year maximum benefit.
Under the DeltaCare USA DHMO option, there are no calendar year deductibles or maximums.
Under the MetLife PPO option, you can visit any licensed dentist.
Under the DeltaCare USA DHMO option, you have a limited benefit to go out of network for emergency care.
Check out the Find a Dentist tool to search for dentists in your area. You can search by dentist or practice name, specialty, languages spoken, office hours and more.
Here are key advantages for choosing a Delta Dental network dentist:- Lower out-of-pocket costs than if you received care from an out-of-network dentist because network dentists have agreed to accept reduced fees.- Balance billing is not allowed. Network dentists agree to accept Delta Dental's fee and the patient co-payment or deductible (if applicable) as full payment. However, if you have reached your annual benefit maximum or frequency limitation for a given procedure, then you will be responsible for the remaining charges.- There are no forms to fill out because network dentists submit claims directly to Delta Dental. The dentist is paid directly so you don't have to wait for a reimbursement.
Under the MetLife PPO option, you may be reimbursed for services outside the United States. You will need to submit a claim to MetLife and include a copy of your itemized bill and proof of payment. MetLife converts the currency based on the exchange rate as of the date services were provided.
Under the DeltaCare USA DHMO option, you may only be reimbursed for emergency services outside the United States.
Contact Delta Dental for more information.
Most dentists submit claim forms on your behalf. If you do need to submit a claim yourself, Delta Dental has forms available for download. Log in to your Delta Dental account to access these forms.
One of your dental plans will be considered primary. Your primary plan must pay toward your dental care first. Then, your other dental plan(s) pay toward whatever portion is remaining. Your dental plan cannot pay more than 100% of the cost of your treatment. Contact Delta Dental for more information.
If the you have an accident resulting in your death or dismemberment while eligible under the Health & Welfare Fund, the Plan will pay a benefit to you or your beneficiary or eligible survivors. For more information, see your Health & Welfare Fund SPD, page 45.
Generally, if you use in-network providers, your provider will submit your claims for you. Remember to present your Blue Shield of California PPO identification card each time you receive services and verify that providers participate in the network.
If you are enrolled in DeltaCare USA DHMO, make sure you go to your assigned dental office and present your DeltaCare USA ID card. If you need an ID card, contact Delta Dental USA at (800) 422-4234.
If you are enrolled in Vision Service Plan (VSP), you do not need an ID card to make an appointment. Simply tell your provider you have VSP.
Important Note: Claims received more than 12 months from the service date will be denied. In some cases, Plan representatives will request more information from the patient or provider before the claim may be processed. Replies to any Fund Office requests must also be completed within 12 months.
If you are enrolled in DeltaCare USA DHMO and need an ID card, contact Delta Dental USA at (800) 422-4234.
If you are enrolled in Vision Service Plan (VSP) and need an ID card, contact VSP at (800) 877-7195. Note: you do not need a VSP ID card to make an appointment. Simply tell your provider you have VSP.
The Pensioners & Surviving Spouses Health Plan has a $250 deductible per covered person for covered health care services each calendar year. Once the deductible is met, the Plan will pay for any further Medically Necessary covered services based on the Blue Shield of California PPO network rate or the allowable charge, whichever applies.
- Prescription drugs have a separate $50 deductible per covered person each calendar year, and - Hearing aids have a separate $50 deductible per covered person per device each calendar year.
If enrolled, your Plan’s dental and vision benefits do not have deductibles.
The Plan partners with Blue Shield of California with the goal of lowering and controlling patient ot-of-pocket costs while expanding the network of contracted providers available. Blue Shield provides network access and some administrative services only. The Southern California Pipe Trades Pensioners & Surviving Spouses Health Fund determines, administers and pays Plan benefits. Note: Blue Shield of California does not administer the Fund’s prescription drug, dental, or vision benefits.
You and your spouse or domestic partner become eligible to purchase dental coverage at the same time you become eligible for Pensioners & Surviving Spouses Health Fund benefits. You may not purchase dental coverage without medical coverage. Contact the Fund Office for details.
Once you enroll in DeltaCare USA DHMO coverage, monthly premiums for your dental option must be deducted from your Southern California Pipe Trades Retirement Fund pension benefit, if any. If you are not receiving a pension benefit (or if the pension benefit is not enough to cover the premiums), your premiums must be automatically deducted from a bank account. Checks are not accepted. Contact the Fund Office for details.
All services and referrals must be provided by your assigned DeltaCare USA (DHMO) network dentist. Benefits are not paid if services are performed by other dental providers (unless it’s an emergency). Referrals are required for some specialty care services.
Your Benefit Summary (High Option, Medium Option) lists covered dental procedures and your share of out-of-pocket costs, if any. If a dental procedure is not listed, it’s not covered. If you have questions, you can take your Benefit Summary with you to dental appointments. You can use it to discuss treatment options and costs with your dentist.
Yes. Delta Dental refers to the DHMO Plan as DeltaCare USA. Both names refer to the DeltaCare USA (DHMO).
At the time you become eligible for Pensioners & Surviving Spouses Health Fund benefits, you may elect to purchase coverage in one of two dental options—and after that during the annual open enrollment period if still eligible. Both dental options—either the DeltaCare USA High DHMO or Medium DHMO option -- are listed on the Dental Enrollment Form. When you enroll, you may also choose to purchase DeltaCare USA DHMO coverage for your covered spouse or domestic partner under the same dental option as yours.
Note: Remember to select a network dentist near you and list the six-digit facility code on the Dental Enrollment Form. Some areas may not have as many network dentists.
- The DeltaCare USA High DHMO option offers extensive benefits for a higher monthly premium. - The DeltaCare USA Medium DHMO option offers less extensive benefits for a lower monthly premium.
For more details about your benefits, contact DeltaCare USA directly at (800) 422-4234 or deltadentalins.com.
Monthly premiums for the DeltaCare USA DHMO options are shown below. Keep in mind that premium amounts may change. Monthly premiums for the DeltaCare USA DHMO options are shown below. Keep in mind that premium amounts may change.
Pensioner or Survivor (Single Coverage)Medium Option: $11.70High Option: $17.03
Pensioner and Spouse/Domestic Partner (Dual Coverage)Medium Option: $23.25High Option: $33.99
Note: This amount is in addition to the monthly premium for your medical coverage. Both medical and dental premiums must be deducted from your Southern California Pipe Trades Retirement Fund pension benefit, if any. If you are not receiving a pension benefit (or if the pension benefit is not enough to cover the premiums), your premiums must be automatically deducted from a bank account. Checks are not accepted. Contact the Fund Office for details.
At the time you become eligible for Pensioners & Surviving Spouses Health Fund benefits, you may elect to purchase dental coverage. After that, coverage under your choice of dental options begins on the January 1 after the date when your properly completed Dental Enrollment Form is timely received by the Fund Office.
Remember to use your assigned DeltaCare USA (DHMO) dentist. Click here for more details about the initial and open enrollment process.
After your initial dental election, the only chance to begin or change your DeltaCare USA (DHMO) coverage occurs in the late fall during the annual open enrollment (for changes effective the following January 1). If you elect to also purchase dental coverage for your covered spouse or domestic partner, he or she must be covered under the same dental option as you. Eligible participants interested in enrolling or changing their dental option during open enrollment must return a properly completed Dental Enrollment Form to the Fund Office via mail, fax or email. Form must be received or postmarked by the deadline. All changes made during the open enrollment period will apply to you and your covered spouse or domestic partner beginning on January 1 of the next calendar year.
Important Note: If you do not return the form by the deadline, your dental coverage remains unchanged for the next calendar year.
You may cancel DeltaCare USA DHMO coverage at any time by sending a letter (signed and dated) to the Fund Office. The letter must be emailed or postmarked by the 15th of the month for the cancellation to take effect the following month.
Remember, if you cancel coverage, you may not re-enroll in DeltaCare USA DHMO coverage until the next open enrollment period. Any cancellation will apply to both you and your covered spouse or domestic partner.
Your survivor may continue dental coverage upon your death as long as they remain eligible for medical coverage. The DeltaCare USA DHMO premium will be deducted from his/her Southern California Pipe Trades Retirement Fund pension benefit, unless he or she is not receiving this benefit, in which case premium payments must be made by monthly electronic ACH transfer from a bank account, authorized in writing by the survivor. For more information, contact the Fund Office.
When you enroll, list the dentist’s 6-digit facility code on your Dental Enrollment Form. If left blank, DeltaCare USA (DHMO) will automatically assign you to the closest network dentist based on your home zip code. You may change your dentist by contacting DeltaCare USA (DHMO) after you enroll.
Under DeltaCare USA DHMO, your Plan covers more than 300 procedures without pre-existing condition limitations. Your Benefit Summary (High Option, Medium Option) lists covered dental procedures and your share of out-of-pocket costs, if any. If a dental procedure is not listed, it’s not covered. If you have questions, you can take your Benefit Summary with you to dental appointments. You can use it to discuss treatment options and costs with your dentist.
Log in to your account at deltadentalins.com to review your coverage or call DeltaCare USA DHMO (800) 422-4234.
There are no dental deductibles or calendar year maximums under either DeltaCare USA (DHMO) option. Under the High option, no copayments are due for covered procedures. Under the Medium option, copayments are due for certain covered procedures. Please see your Benefit Summary (High Option, Medium Option) for details. If a dental procedure is not listed, it’s not covered.
Note: you must visit your assigned primary care dentist to receive benefits.
Under DeltaCare USA (DHMO), you have a limited benefit to go out-of-network for emergency care. Contact DeltaCare USA by calling (800) 422-4234 for more information.
You can change your assigned dentist by logging in to your account at deltadentalins.com or by calling (800) 422-4234.
You may only be reimbursed for emergency services outside the United States. Contact DeltaCare USA by calling (800) 422-4234 for more information.
If you have dual coverage, one of your dental plans will be considered primary. Your primary plan must pay toward your dental care first. Then, your other dental plan(s) pay toward whatever portion is remaining. Your dental plan cannot pay more than 100% of the cost of your treatment. Contact DeltaCare USA by calling (800) 422-4234 for more information.
Register or log in to your account at deltadentalins.com. You can verify your benefits, track claims, find a dentist and more.
The Plan partners with Blue Shield of California with the goal of lowering and controlling patient out-of-pocket costs while expanding the network of contracted providers available. Blue Shield provides network access and certain administrative services only. The Southern California Pipe Trades Health & Welfare Fund determines, administers and pays Plan benefits. Note: Blue Shield of California does not administer the Fund’s prescription drug, dental, or vision benefits.
Once your application and all required documents are received and reviewed, the Fund Office mails your retirement packet, which includes your health and benefit enrollment forms. The Pensioners & Surviving Spouses Health Fund provides medical & prescription benefits that you pay for through monthly premium. This monthly premium is based on your individual score which is based on your age and pension credits at the time of your initial retirement. When enrolling in pensioner health fund benefits, eligible participants may also purchase coverage in pensioner dental and vision options.
Register or log in to your account at deltadentalins.com. You can verify your benefits, track claims, find a dentist and access dental care articles and resources.
Benefit information varies by Trust Funds. Please make a selection.
