ProCare Idaho. You re telling me my teeth can really last a lifetime?

Transcription

1 You re telling me my teeth can really last a lifetime? ProCare Idaho THE POLICY PROVIDES DENTAL BENEFITS ONLY. 006PRO-ID(1/19) Underwritten by Willamette Dental of Idaho, Inc NE Campus Way, Hillsboro, OR For Policy No. 001PRO-ID(1/19)

2 Personal care for your individual needs Willamette Dental of Idaho, Inc. is pleased to offer you ProCare Idaho. This policy is true individual dental insurance that offers two options for coverage for your dental care needs. With both options, you enjoy no maximum to the amount of dental services that this policy will cover and there are no deductibles that need to be met. Your coverage gives you simple access to dental care. On both plan options, routine and preventive services are covered with low copayments. Major services, such as crowns, bridges, and dentures are covered following a six-month waiting period at substantial savings with predictable costs*. Coverage for orthodontic treatment is also available to both adults and children after a six-month waiting period*. Participants do not need to fill out or submit claim forms. As an enrollee, you simply schedule your appointments, see the dentist and pay copayments. Willamette Dental Group, P.C., dentists make access to quality dental care easy, while the ProCare Idaho policy keeps that care affordable for you and your family. *For enrollees under age 19, waiting period does not apply to crowns, bridges, dentures or medically necessary orthodontia.

3 With more than 50 Locations throughout the Pacific Northwest, we re likely to have an office in your neighborhood. Idaho Locations Washington Oregon Boise Coeur d Alene Idaho Falls Meridian Twin Falls Eastern Washington Locations Idaho To receive benefits, you must receive your care at a Willamette Dental Group, P.C., dental office. An advance appointment is required to receive care. To schedule your dental appointments, call our Appointment Center at , Option 3. When you speak to a Willamette Dental Group representative or arrive at the dental office for your appointment, simply identify yourself as a ProCare Idaho member. You will then receive dental care in accordance with your policy. Most dental offices are open Monday through Friday, 7 AM to 6 PM, and occasional Saturdays. ProCare Idaho is available to residents in the following counties: Ada, Benewah, Bingham, Boise, Bonner, Bonneville, Canyon, Cassia, Clark, Elmore, Fremont, Gem, Gooding, Jefferson, Jerome, Kootenai, Latah, Lincoln, Madison, Minidoka, Nez Perce, Owyhee, Payette, Shoshone, and Twin Falls. Pullman Spokane Northpointe Spokane Valley

4 Benefit Summaries for Plan 1 IN-NETWORK Benefit Children under age 18 Adult Age 19 or Older Annual Child In-Network Out-of-Pocket Maximum The most you ll pay for in-network covered services. $350 per Child $700 for Multiple Children Once the annual child in-network out-of-pocket maximum is paid, in-network covered services for children under age 19 will be covered at 100% for the remainder of the calendar year, except cosmetic orthodontia treatment. Out of area emergency treatment by an out-of-network provider is reimbursed at $100 per visit. This plan covers the first $10 per visit for non-emergency treatment by out-of-network providers without a referral, subject to the exclusions. The annual child out-of-network out-of-pocket maximum is $10,000 per child. Be aware that your actual costs for covered services provided by an out-of-network provider may exceed the policy s out-of-network out-of-pocket maximum. Your costs for the following covered services do not accumulate toward the maximum out-of-pocket maximum: adult (age 19 or older) dental services and cosmetic orthodontia treatment. In addition, out-of-network providers can bill you for the difference between the amount charged by the out-of-network provider and the amount allowed by Willamette Dental of Idaho, Inc., and that amount does not accumulate toward the out-of-network out-of-pocket maximum. This is not a comprehensive list of benefits. Refer to the policy for a comprehensive list of covered services. Not Applicable Annual Maximum No Annual Maximum No Annual Maximum Deductible No Deductible No Deductible General Office Visit $20 Copay per Visit $20 Copay per Visit Specialty Office Visit $35 Copay per Visit $35 Copay per Visit DIAGNOSTIC, PREVENTIVE, AND RESTORATIVE SERVICES Routine Exams and X-rays $0 Copay $0 Copay Teeth Cleaning $5 Copay $5 Copay Fluoride Treatment $20 Copay $20 Copay Sealants per Tooth $20 Copay $20 Copay Amalgam Fillings $45 Copay $45 Copay Resin-based Composite Fillings Anterior $70 Copay $70 Copay Resin-based Composite Fillings Posterior $80 Copay $80 Copay MAJOR TREATMENTS (Limited to 1 per 60 months 6 month waiting period for Adults) Porcelain-Metal Crown $350 Copay $400 Copay Complete Upper or Lower Denture $350 Copay $600 Copay Bridge per Tooth $350 Copay $400 Copay ENDODONTICS, PERIODONTICS, AND ORAL SURGERY Root Canal Therapy Anterior $200 Copay $200 Copay Root Canal Therapy Biscupid $300 Copay $300 Copay Root Canal Therapy Molar $350 Copay $400 Copay Osseous Surgery per Quadrant $300 Copay $300 Copay Root Planing per Quadrant $100 Copay $100 Copay Routine Extraction (Single Tooth) $45 Copay $45 Copay Surgical Extraction $190 Copay $190 Copay ORTHODONTIA TREATMENT Pre-Orthodontia Treatment $150 Copay $150 Copay Cosmetic Orthodontia Treatment (6-month waiting period) $3,000 Copay $3,000 Copay Medically Necessary Orthodontia Treatment $350 Copay Not Covered MISCELLANEOUS Palliative (emergency) Treatment $0 Copay $0 Copay Nitrous Oxide Per Visit $40 Copay $40 Copay

5 Benefit Summaries for Plan 2 IN-NETWORK Benefit Children under age 18 Adult Age 19 or Older Annual Child In-Network Out-of-Pocket Maximum The most you ll pay for in-network covered services. $350 per Child $700 for Multiple Children Once the annual child in-network out-of-pocket maximum is paid, in-network covered services for children under age 19 will be covered at 100% for the remainder of the calendar year, except cosmetic orthodontia treatment. Out of area emergency treatment by an out-of-network provider is reimbursed at $100 per visit. This plan covers the first $10 per visit for non-emergency treatment by out-of-network providers without a referral, subject to the exclusions. The annual child out-of-network out-of-pocket maximum is $10,000 per child. Be aware that your actual costs for covered services provided by an out-of-network provider may exceed the policy s out-of-network out-of-pocket maximum. Your costs for the following covered services do not accumulate toward the maximum out-of-pocket maximum: adult (age 19 or older) dental services and cosmetic orthodontia treatment. In addition, out-of-network providers can bill you for the difference between the amount charged by the out-of-network provider and the amount allowed by Willamette Dental of Idaho, Inc., and that amount does not accumulate toward the out-of-network out-of-pocket maximum. This is not a comprehensive list of benefits. Refer to the policy for a comprehensive list of covered services. Not Applicable Annual Maximum No Annual Maximum No Annual Maximum Deductible No Deductible No Deductible General Office Visit $10 Copay per Visit $10 Copay per Visit Specialty Office Visit $30 Copay per Visit $30 Copay per Visit DIAGNOSTIC, PREVENTIVE, AND RESTORATIVE SERVICES Routine Exams and X-rays $0 Copay $0 Copay Teeth Cleaning $0 Copay $0 Copay Fluoride Treatment $5 Copay $5 Copay Sealants per Tooth $5 Copay $5 Copay Amalgam Fillings $20 Copay $20 Copay Resin-based Composite Fillings Anterior $30 Copay $30 Copay Resin-based Composite Fillings Posterior $40 Copay $40 Copay MAJOR TREATMENTS (Limited to 1 per 60 months 6 month waiting period for Adults) Porcelain-Metal Crown $350 Copay $350 Copay Complete Upper or Lower Denture $350 Copay $500 Copay Bridge per Tooth $350 Copay $350 Copay ENDODONTICS, PERIODONTICS, AND ORAL SURGERY Root Canal Therapy Anterior $200 Copay $200 Copay Root Canal Therapy Biscupid $250 Copay $250 Copay Root Canal Therapy Molar $300 Copay $300 Copay Osseous Surgery per Quadrant $200 Copay $200 Copay Root Planing per Quadrant $75 Copay $75 Copay Routine Extraction (Single Tooth) $40 Copay $40 Copay Surgical Extraction $150 Copay $150 Copay ORTHODONTIA TREATMENT Pre-Orthodontia Treatment $150 Copay $150 Copay Cosmetic Orthodontia Treatment (6-month waiting period) $2,800 Copay $2,800 Copay Medically Necessary Orthodontia Treatment $350 Copay Not Covered MISCELLANEOUS Palliative (emergency) Treatment $0 Copay $0 Copay Nitrous Oxide Per Visit $40 Copay $40 Copay

6 Premium Rates for Plan 1 & Plan 2 Premiums are paid on a monthly basis. Payment may be made by personal or cashier s check, money order, Auto Pay (checking account deduction) or credit card (Visa, Mastercard, Discover). For children under age 19, premiums will only be charged for the first three. If you select Auto Pay, we process payments by checking account on the 5 th of each month and payment by credit card on the 6 th of each month. Plan 1 Plan 2 Monthly Per Enrollee Under Age 18 $28.67 $33.14 Per Enrollee Age 19 or Older $43.58 $49.63 Contact Us For questions about your bill, to make a payment or to find out the status of your application, please call: , Option 1 If you are not a member yet and have questions about our insurance plan options, please call: , Option 2 To schedule an appointment, please call: , Option 3 For answers to frequently asked questions, visit our website at: willamettedental.com/procare-idaho

7 ProCare Idaho Enrollment Application You are eligible for individual coverage under the ProCare Idaho plan if you are an Idaho resident. Your eligible dependents include your spouse or domestic partner, child, and spouse s or domestic partner s child. Members may not be enrolled under any other insurance plan issued or offered by Willamette Dental of Idaho, Inc. or its affiliates. To enroll in the ProCare Idaho plan, complete both sides of this application, including your signature on the back. Please mailed the completed application and premium payment to the address below. Willamette Dental of Idaho, Inc. ProCare Idaho 6950 NE Campus Way Hillsboro, OR If we receive your application and premium payment between the 1st and 25th of the month, your coverage will be effective on the first day of the following month. If paying by Auto Pay or credit card, application and payment can be submitted by fax or to or pci@willamettedental.com. 1 Type of Enrollment Application I am a new applicant applying for coverage for myself only. I am applying for coverage for my child(ren) only. I am a new applicant applying for coverage for myself & the dependents listed below. 2 Premium Calculation Plan 1 Plan 2 # of Enrollees Age 18 and Under x $28.67 = $ $33.14 = $ # of Enrollees Age 19 and Above x $43.58 = $ $49.63 = $ Total Monthly Premium (# of Enrollees x Premium) $ $ (Select One) 3 Premium Payment please select Auto Pay or Check Auto Pay via checking account deduction. Please complete information below - we do not need a voided check. Checking Account Number: Routing Number: Auto Pay via Credit Card: Provide the card information below. Card Type: Visa Mastercard Discover Expiration Date: Cardholder s Signature: Credit Card Number: 3-Digit Security Code: If Auto-Pay is selected, I hereby authorize Willamette Dental of Idaho, Inc., to make reoccurring monthly withdrawals from the checking account / credit card listed for the then-current ProCare Idaho premium amount. This authorization will remain in effect until I have provided notice to Willamette Dental of Idaho, Inc., and my bank with a reasonable amount of time to act upon the notice. Personal check, cashier s check, or money order: Enclose the first month s premium with this application payable to Willamette Dental of Idaho, Inc. 4 Applicant Enrollment Information Self (Last, First, Middle Initial): Social Security Number (not required): Requested Effective Date: Gender: M F Date of Birth: Mailing Address: City: State: Zip: Home Phone: Address: 007PRO-ID(1/19) CONTINUE APPLICATION ON NEXT PAGE...

8 5 Dependent Enrollment Information Legal Spouse or Domestic Partner (Last, First, Middle Initial): Social Security Number (not required): Gender: M F Date of Birth: Dependent Child (Last, First, Middle Initial): Social Security Number (not required): Gender: M F Date of Birth: Dependent Child (Last, First, Middle Initial): Social Security Number (not required): Gender: M F Date of Birth: Dependent Child (Last, First, Middle Initial): Social Security Number (not required): Gender: M F Date of Birth: 6 Producer of Record Information. Please note: This section only applies to individuals applying with the help of an insurance agent. Producers are required to have and maintain an Idaho producer license and appointment with Willamette Dental of Idaho, Inc. Producer Name: Agency Name: Physical Address: City: State: Zip: Phone Number: Address: 7 Acknowledgments and Signature I hereby apply for coverage under the ProCare Idaho policy underwritten by Willamette Dental of Idaho, Inc., 6950 NE Campus Way, Hillsboro, OR 97124, for myself and my listed dependents. I authorize providers of services to give Willamette Dental of Idaho, Inc., upon request, any information concerning the health, condition, or treatment of any person included under such coverage whenever such information is considered necessary for the proper administration of benefits in fulfillment of obligations imposed on Willamette Dental of Idaho, Inc., by state or federal law. I understand if the application is declined and coverage is not issued, Willamette Dental of Idaho, Inc.'s only obligation will be to return any premium paid. If an incomplete application is received, a letter will be mailed to the applicant requesting the additional information. If the missing information is not received within two weeks, the application will be declined. I certify that all information supplied in this application form is true and complete to the best of my knowledge. I agree to advise Willamette Dental of Idaho, Inc., of any change in status within 31 days from the date of change. I understand that it may be a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. If I choose to sign this application by typing my name below, I acknowledge and agree that my typewritten signature has the same legal effect as my written signature on this application. This policy provides dental benefits only. Review your policy carefully. Applicant's Signature Date 007PRO-ID(1/19)

9 Language Assistance Services

10 Non-discrimination Statement Willamette Dental Group complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Willamette Dental Group does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Willamette Dental Group: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact If you believe that Willamette Dental Group has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Member Services Department, 6950 NE Campus Way Hillsboro, Oregon Fax memberservices@willamettedental.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, the Member Services Department is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at

11 Summary of Exclusions The following exclusions apply to ProCare Idaho: Athletic mouth guards. Charges for copies of records, charts or x-rays, or any costs associated with forwarding/mailing copies of records, charts or x-rays. Charges for failure to keep a scheduled appointment. Cosmetic orthodontic services provided to enrollees who have not met the benefit waiting period requirement. Duplicate devices, appliances, and services. Experimental or investigational services and treatment. Hospital costs or any additional fees that the dentist or hospital charges for treatment at the hospital (inpatient or outpatient). Oral sedation. Precision attachments, personalization, and other specialized techniques. Repair of damaged orthodontic appliances. Replacement of lost or missing appliances. Replacement of lost, stolen or misplaced dentures. Services and treatment for any illness or bodily injury, which occurs in the course of employment if a benefit or compensation is available, in whole or in part, under the provision of any law or regulation or any government unit. This exclusion applies whether or not the benefits or compensation are claimed. Services or treatment for injuries resulting from war or act of war, whether declared or undeclared, or from service in the armed forces or units auxiliary to it. Services or treatment for injuries suffered while participating in a felony, riot, or insurrection. Services and treatment incurred after the termination date of coverage unless otherwise indicated. Services and treatment performed prior to the enrollee s effective date of coverage. Services and treatment resulting from failure to comply with professionally prescribed treatment. Services and treatment which are not dentally necessary. Services for which the enrollee would have no obligation to pay in the absence of this or any similar coverage. Services not prescribed by or under the direct supervision of a dentist or denturist, except when provided by a dental hygienist as permitted within the scope of licensure and applicable state law. Services provided free of charge by any governmental unit, except where this exclusion is prohibited by law. Services related to the diagnosis and treatment of Temporomandibular Joint Dysfunction (TMD). Services that are considered strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances. Services to alter vertical dimension and/or restore or maintain the occlusion including, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation, and restoration for misalignment of teeth. Services which are for specialized procedures and techniques. Tooth bleaching. Treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid or payable under a plan or policy of motor vehicle insurance, including a self-insurance plan.