City of Houston Open Enrollment 2008

Highlights Contributions

HFSA Highlights Enrolling in the HFSA How to File a Claim Resources Examples of Eligible Expenses Questions & Answers SMART Employees HFSA worksheet

Health Plan Highlights Service Areas Contributions Medicare Advantage Plan Prescriptions Dental Plan Highlights Supplemental Plans Flexible Spending Account Wellness Section 125 Rules of the Game

MA Plan Highlights Service Areas Contributions Prescriptions Make a Game Plan Join in Wellness Rules to Know

Health Contributions Dental Contributions MA Contributions

Dental Contributions

Dental contributions
	Employee bi-weekly cost		Retiree monthly cost
	from	to	from	to
DHMO
Self only	$4.33	$4.50	$8.66	$9.00
Self + 1	$9.33	$9.70	$18.66	$19.40
Self + 2 or more	$13.20	$13.73	$26.40	$27.46
Dental Indemnity
Self only	$12.50	$13.62	$25.00	$27.24
Self + 1	$28.91	$31.50	$57.82	$63.00
Self + 2 or more	$39.41	$42.95	$78.82	$85.90

To help you decide which plan is right for you, the chart below gives you a comparison of sample copayments for some common dental procedures. Both plans offer free preventive services and are tailored to help keep your mouth healthy

Comparison of DHMO and dental indemnity plan features
Plan feature	DHMO Sample copayments	Dental Indemnity Sample copayments
Preventive services: Cleaning and oral examinations, bitewing X-rays	Preventive services - $0	The plan pays 100 percent of services up to usual and customary limits. $0 deductible.
Basic services: Extractions, root canals, oral surgery, restorative services (excluding gold fillings) and periodontal scaling	Extraction, Coronal remnants - $9 Periodontal scaling - $14-$24 Root canal therapy, molar - $162	After you pay the annual deductible, the plan will pay 80 percent of services, up to usual and customary limits.
Major services: Initial fixed bridgework, crowns and dentures, replacement of bridgework	Crown, titanium - $210 Complete denture, maxillary - $260 Immediate denture, maxillary - $270	After you pay the annual deductible, the plan will pay 50 percent of services, up to usual and customary limits.
Orthodontic services: Covered services up to two years	Adult, 24-month case - $2,000 Adolescent, 24-month case - $1,800 Interceptive ortho service - $1,000 (primary and transition dentition)	After you pay the annual deductible, the plan will pay 50 percent of services, up to usual and customary limits. The lifetime maximum benefit is $1,000 per individual.
Service area	Counties include: Anderson, Bowie, Brazoria, Brazos, Brown, Carson, Chambers, Collin, Dallas, Deaf Smith, Delta, Denton, Ellis, Fannin, Fort Bend, Galveston, Gray, Grayson, Grimes, Harris, Harrison, Hood, Hopkins, Hunt, Hutchinson, Jefferson, Johnson, Kaufman, Lamar, Liberty, Montgomery, Moore, Nacogdoches, Orange, Parker, Potter, Randall, Rockwall, Tarrant, Walker and Waller.	Anywhere in the United States.
Annual maximum benefit	No annual maximum benefit	$1,500 per individual
Annual deductible	No annual deductible	$50 for each individual/$150 family
Referrals for specialty care	PCD must refer patient to specialist	Not required
To receive reimbursement	Filing a claim is not required	Complete and submit a claim form

Home
Contact
Employee Fair
Enrollment Materials
Important Dates
Helpful Links
Mayor's Letter

Supplemental

Dental
Contributions
Highlights

Health
Contributions
Health Features
Highlights
Which plan is right for me?

Healthcare Flexible
Spending Account
Contributions
Highlights

Medicare Advantage
Join In
Make a Game Plan
Plan Contributions
Plan Highlights
Prescriptions
Rules to Know
Service Areas
Wellness

SMART
Employees
Examples of Eligible Expenses
HFSA Worksheet
How to File a Claim
Questions and Answers
Resources