Dental Coverage. Hoffman Enterprises

Transcription

1 Hoffma Eterprises Detal Coverage Here is your ew detal coverage, which icludes your erollmet form. Make sure you retur the completed form, if applicable, to your pla admiistrator. If you miss the deadlie, the coverage may be delayed or you may ot be eligible for erollmet this year. HIGHLIGHTS: Sigle ad family coverage available Visit ay detist Reliable detal claims paymet; 4 day average turaroud Fid out if your detist is i Guardia s etwork at

2 We re ready to get workig for you If you re like most employees, fidig eough time i the day to accomplish your legthy to-do list ca ofte be o easy task. As your Guardia coverage begis, we wat you to kow that we re here for you every step of the way ad are committed to providig you with the resources to obtai fast, accurate aswers to your beefits-related questios. Oe way i which we do this is through our olie member resource, Guardia Aytime sm, which allows you to maage your beefits whe it works best for you day or ight. Plus, it offers helpful resources to esure you get access to the quality care you eed. We ecourage you to take a couple miutes to check out ad register for Guardia Aytime sm at We promise it will be time well spet. Welcome to Guardia!

3 Prepared for Hoffma Eterprises Guardia Group Pla Number UNDERSTAND YOUR COVERAGE: Review your beefits Complete your erollmet form, if applicable Sig ad retur form to your pla admiistrator Pla Details This booklet explais your basic pla optios. Your detailed certificate of coverage alog with your detal card will be provided to you after you eroll. Welcome Dear Hoffma Eterprises Employee, We re pleased to tell you that Guardia will be our detal coverage provider. This booklet provides a highlight of your pla beefits. Please review this iformatio carefully, complete your erollmet/waiver form ad retur it to Huma Resources. Thak you. Hoffma Eterprises Fid a etwork detist i miutes Use our Provider Olie Search at Optioal pre-treatmet review If you expect your treatmet will cost $300 or more, you ca fid out how much your pla will pay before treatmet starts. Ask your pla admiistrator Chage your coverage or replace a lost ID card by cotactig your pla admiistrator. Uderstad your beefits Please fid a glossary for isurace terms icluded. Erollmet Kit , 0001, EN 1

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5 Prepared for Hoffma Eterprises Guardia Group Pla Number Why Detal Isurace? Good oral hygiee is importat, ot oly for looks, but for geeral health as well. A routie detal examiatio ca detect symptoms of more tha 125 diseases, icludig heart disease, diabetes, aemia, stomach ulcers, osteoporosis ad kidey disease. Regular check ups ad cleaigs ca save you the pai ad expese of future problems. Detal isurace will keep these visits affordable ad is a cost-effective way to miimize health care costs for you ad your family. The America Detal Hygieists Associatio estimates that for every $1 spet o prevetio or oral health care, as much as $8 to $50 is saved o future emergecy ad restorative procedures. Usig your detal isurace for regular detal check ups ca improve your health by helpig you: 1) Prevet Oral Cacer: Accordig to The Oral Cacer Foudatio, someoe dies from oral cacer every hour of every day i the Uited States aloe. Whe you have your detal cleaig, your detist is also screeig you for oral cacer, which is highly curable if diagosed early. 2) Prevet Gum Disease: Gum disease is a ifectio i the gum tissues ad boe that keep your teeth i place ad is oe of the leadig causes of adult tooth loss. If diagosed early, it ca be treated ad reversed. If treatmet is ot received, a more serious ad advaced stage of gum disease may follow. Regular detal cleaigs ad check ups, flossig daily ad brushig twice a day are key factors i prevetig gum disease. 3) Help Maitai Good Physical Health: Recet studies have liked heart attacks ad strokes to gum disease, resultig from poor oral hygiee. A detal cleaig every six moths helps to keep your teeth ad gums healthy ad could possibly reduce your risk of heart disease ad strokes, as well as may other serious coditios. 4) Keep Your Teeth: Sice gum disease is oe of the leadig causes of tooth loss i adults, regular detal check ups ad cleaigs, brushig ad flossig are vital to keepig as may teeth as you ca. Keepig your teeth meas better chewig fuctio ad ultimately, better health. 5) Prevet the Need for Advaced Treatmet: Your detist ad hygieist will be able to detect ay early sigs of problems with your teeth or gums that ca be easily treatable. If these problems go utreated, root caals, gum surgery ad removal of teeth could become the oly treatmet optios available. 6) Have a Bright ad White Smile: Your detal hygieist ca remove most tobacco, coffee ad tea stais. Durig your cleaig, your hygieist will also polish your teeth to a beautiful shie. 7) Protect your childre s health: Tooth decay is the most commo chroic childhood disease, five times more commo tha asthma ad results i a loss of 51 millio school hours each year. Regular check ups ca help prevet tooth decay i your childre. Sources: America Academy of Pediatrics Erollmet Kit , 0001, EN 3

6 Detal Plas With your PPO pla, you ca visit ay detist; but you pay less out-of-pocket whe you choose a PPO detist. UNDERSTAND YOUR PLAN Network PPO DetalGuard Preferred Caledar year deductible I-Network Out-Network Idividual $50 $100 Family limit 3 per family Waived for Prevetive Prevetive Charges covered for you (co-isurace) I-Network Out-Network Prevetive Care (e.g. cleaigs) 100% 100% Basic Care (e.g. filligs) 80% 80% Major Care (e.g. crows, detures) 50% 50% Orthodotia Not Covered Aual Maximum Beefit $1250 $750 Lifetime Orthodotia Maximum Depedet Age Limits(No-Studet/Studet) 20/26 Combied I-Network ad Out-of-Network maximum of $750 with a additioal $500 of beefit I-Network Not Applicable YOUR GUARDIAN PLAN OFFERS: If you eroll i Detal, you receive a Visio Access Pla at o additioal charge. Visit ay etwork doctor i your Access Pla ad you ll receive discouts o exams, glasses, cotact les professioal services ad laser visio surgery. No charge for prevetive care (subject to pla limits) Natioal PPO etwork of more tha 70,000 detist locatios Reliable claims paymet four days o average Fid out if your detist is i Guardia s etwork at Let Guardia put its 30-plus years of detal beefits experiece to work for you ad your family. 4

7 CATEGORY PLAN DETAILS PPO Pla pays (o average) I-etwork Out-of-etwork Prevetive Care Cleaig (prophylaxis) 100% 100% Frequecy: Oce Every 6 Moths Fluoride Treatmets 100% 100% Limits: Uder Age 14 Oral Exams 100% 100% Sealats (per tooth) 100% 100% X-rays 100% 100% Basic Care Aesthesia* 80% 80% Filligs 80% 80% Perio Surgery 80% 80% Periodotal Maiteace 80% 80% Frequecy: Oce Every 6 Moths (Stadard) Repair & Maiteace of Crows, Bridges & Detures 80% 80% Root Caal 80% 80% Scalig & Root Plaig (per quadrat) 80% 80% Simple Extractios 80% 80% Surgical Extractios 80% 80% Major Care Bridges ad Detures 50% 50% Ilays, Olays, Veeers** 50% 50% Sigle Crows 50% 50% This is oly a partial list of detal services. Your certificate of beefits will show exactly what is covered ad excluded. **Crows, Ilays, Olays ad Labial Veeers are covered oly whe eeded because of decay or ijury ad oly whe the tooth caot be restored with amalgam or composite filig material. Whe Orthodotia coverage is for "Child(re)" oly, the orthodotic appliace must be placed prior to the age of 19; If full-time status is required by your pla i order to remai isured after a certai age; the orthodotic maiteace may cotiue as log as full-time studet status is maitaied. If Orthodotia coverage is for "Adults ad Child(re)" this limitatio does ot apply. The total umber of cleaigs ad periodotal maiteace procedures are combied i a 12 moth period. *Geeral Aesthesia restrictios apply. Filligs restrictios may apply to composite filligs. Please ote: The pla details listed here are some of the most commo services related to detal coverage. The coisurace percetages for the PPO pla optios correspod to the coverage categories of Prevetive, Basic, Major ad Orthodotia listed i the table above. EXCLUSIONS AND LIMITATIONS Importat Iformatio about Guardia s DetalGuard Idemity ad DetalGuard Preferred PPO plas: This policy provides detal isurace oly. Coverage is limited to those charges that are ecessary to prevet, diagose or treat detal disease, defect, or ijury. Deductibles apply. The pla does ot pay for: oral hygiee services (except as covered uder prevetive services), orthodotia (uless expressly provided for), cosmetic or experimetal treatmets (uless they are expressly provided for), ay treatmets to the extet beefits are payable by ay other payor or for which o charge is made, prosthetic devices uless certai coditios are met, ad services acillary to surgical treatmet. The pla limits beefits for diagostic cosultatios ad for prevetive, restorative, edodotic, periodotic, ad prosthodotic services. The services, exclusios ad limitatios listed above do ot costitute a cotract ad are a summary oly. The Guardia pla documets are the fial arbiter of coverage. Cotract # GP-1-DG2000 et al. Special Limitatio: Teeth lost or missig before a covered perso becomes isured by this pla. A covered perso may have oe or more cogeitally missig teeth or have lost oe or more teeth before he became isured by this pla. We wo t pay for a prosthetic device which replaces such teeth uless the device also replaces oe or more atural teeth lost or extracted after the covered perso became isured by this pla. R3 DG2000 5

8 UNDERSTANDING YOUR BENEFITS DENTAL Basic care Co-isurace Claims Paymet Basis Deductible Family limit I-etwork charges Major care Out-of-etwork charges Pla year PPO (Preferred Provider Orgaizatio) Moderately complex detal services. Most plas cosider filligs ad extractios to be basic care. The portio of the covered charge paid by Guardia. PPO & NAP The usual cost for a specific detal service i your area. Amouts over the specified Usual Customary & Reasoable percetile (90%) are usually the patiet s resposibility: I-Network: Beefits are based o a egotiated cotracted fee schedule, ad o balace billig. Out-of-Network: Beefits are based o usual, reasoable, ad customary rates for a give area. The amout of charges you ad your family must pay each pla year before the pla pays you ay beefits. Maximum umber of deductibles your family must pay i each pla year before this pla starts payig beefits for all covered family members for the rest of the pla year. Charges for services provided by detists who are a member of your pla's etwork. More complex detal services. Most plas cosider crows ad detures to be major care. Charges for services provided by detists who are ot members of your pla's etwork. The 12 moth period used to apply this pla's deductible ad aual maximum. Your pla's pla year is the caledar year. Pla that lets you visit ay detist, but usually provides better beefits for the services of PPO etwork detists. PPO detists have agreed to accept discouted fees as paymet i full. Pre-determiatio Review Guardia will gladly assist you ad your detist by determiig what beefits could be payable for services ad procedures over $300. Have your detist fax your treatmet pla to Guardia, ote that it is a pre-determiatio review ad we will let your detist kow what beefits would be payable. This icludes orthodotic treatmet if your pla icludes it. Pre-determiatio applies to PPO ad Idemity plas oly. Prevetive care Most routie detal services. Most plas cosider checkups ad cleaigs to be prevetive care. 6

9 Good News! Your Detal Pla Is Eve Better Tha You Thik Savigs o i-network providers average 30% of what detists usually charge! I-etwork: Beefits are based o a egotiated cotracted fee Out-of-etwork: Beefits are based o usual, reasoable, ad schedule. No balace billig! customary rates for a give area. NAP & PPO Pla Example: Network vs. No-Network Savigs*N D ifferece i your out-of-p ocket ex p ese: $ 6 1 Network Care B eefits for a R oot C aal (o a m olar) No-Network Care T yp ical etwork detist fee: $ A verage o-etwork detist fee: $ P la P ays: $ ** P la P ays: $ ** Y ou P ay: $ Y ou P ay: $ *Savigs may be greater or less dep edig o your detist s locatio **A ssumes service is covered at a 8 0 % co-isurace level M ore R easos to U se Network C are O e of the idustry s largest P referred P rovider etworks highly skilled detal p rofessioals at over 1 2 8,0 0 0 locatios. Network detists are easy to locate. Simp ly use the O -L ie D etalg uard P rovider D irectory at uardial ife.com or call the umber o the back of your ID card. If your p rovider does ot p articip ate, G uardia s coveiet detist referral p rogram ca help add them to the etwork! No claim forms to comp lete. J ust p reset your ew D etalg uard P referred Network ID card to the p rovider. D etalg uard G eeral L im itatios ad E x clusios: T his p olicy p rovides detal isurace oly. C overage is limited to those charges that are ecessary to p revet, diagose or treat detal disease, defect, or ijury. D eductibles ap p ly. T he p la does ot p ay for: oral hygiee services (ex cep t as covered uder p revetive services), orthodotia (uless ex p ressly p rovided for), cosmetic or ex p erimetal treatmets, ay treatmets to the ex tet beefits are p ayable by ay other p ayor or for which o charge is made, p rosthetic devices uless certai coditios are met, ad services acillary to surgical treatmet, T he p la limits beefits for diagostic cosultatios ad for p revetive, restorative, edodotic, p eriodotic, ad p rosthodotic services. T he services, ex clusios ad limitatios listed above do ot costitute a cotract ad are a summary oly. T he G uardia p la documets are the fial arbiter of coverage. C otract # G P -1 -D G et al. 7

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11 Fidig a Provider How to Look Up DetalGuard Preferred Providers Olie Guardia s iovative web techology lets you look up a provider right from your computer. Our Fid a Provider Search fuctio is simple ad easy-to-use. Just follow these steps: Visit Guardia s web page at O the right side of your scree fid the Cotact Us sectio ad click o the words Fid A Provider Click o the box that says Fid a Detist O the ext web page, do the followig: Uder Select Your Detal Pla Choose PPO Uder Search by click the circle ext to Search by Locatio, Locatio & Detist s Name, or Locatio & Office Practice Name. Uder Your Locatio, eter Zip Code or Street Address iformatio Uder Distace select your mile radius Uder Select your Detal Network Choose DetalGuard Preferred Uder Type of Detist choose a optio from the drop-dow box (optioal) Uder About the Detist select the requested iformatio (optioal) I the drop-dow box select the umber of providers you wat to display per page Click Cotiue to view ad prit the list of etwork providers 9

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13 D e ta lg u a rd P re fe rre d D e tis t N o m i a tio F o rm I would like to omiate my detist for iclusio i the DetalGuard Preferred Provider Network. I uderstad that my ame may be used whe cotactig my detist to iform him/her of my desire for them to joi the etwork. For more iformatio, visit us olie at 11 DATE: Employer: Patiet: Address: City/State/Zip: D E N TIS T Phoe: Fax : ID E N T IS T IN F O Name: Address: City/State/Zip: Phoe: Specialty: Please submit completed form to: Guardia DetalGuard Preferred P.O. B ox Spokae, W A or FAX to:

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15 Your Guardia VSP Visio Access Program A eligible perso ca receive discouts o visio care services or supplies from a visio provider that is uder cotract with Visio Service Plas (VSP) Preferred Provider Orgaizatio (PPO) etwork. The eligible perso must pay the etire discouted fee directly to the VSP etwork doctor. Discouts are ot available from providers who are ot members of VSPs etwork. Average Discouts Eye Exams: 20% off the VSP doctors usual charge Frames, Stadard Leses ad Les Optios: 20% to 30% off VSP doctors usual charge, whe a complete pair of prescriptio glasses is purchased. Cotact Les Professioal Services: 15% off VSP doctors usual charge for professioal services. The cotact leses are ot discouted. Laser Surgery: a average of 15% off the laser surgeos usual charge or 5% off of ay promotioal price, if it is less tha the usual discouted price No ID cards are required, but the patiet must otify the VSP etwork doctor that they have the Guardia VSP Access Pla at the time of service to receive their discout. Discouts are oly available from the VSP etwork doctor that provided the eye exam to the patiet withi the last 12 moths. This is ot isurace. The eligible perso must pay the etire discouted fee directly to the VSP etwork doctor. There is o charge for the Discout Visio Access program. A perso must be erolled i a Guardia detal pla i order to be eligible for the Discout Visio Access program. Whe a perso is o loger erolled i a Guardia detal pla, access to the etwork discouts eds. To fid a VSP etwork doctor, visit or call VSP member services at

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17 Detal Care Iformatio Now at Your Figertips Itroducig ew olie tools, for Guardia members, to help you take better care of your oral ad overall health, available at ytime.com (see the M y B eefits tab) E stimate the cost of your detal care View estimates for out-of-pocket costs prior to receivig the actual treatmet See the estimated cost savigs if you use a Guardia etwork provider Access a detal glossary for defiitios of key detal terms R ead about tips for a H ealthy S mile Lear more about how to maitai good oral health ad its impact o their overall health ad well-beig Topics iclude tips o gettig the right care, childre s detal care, prevetio ad recogizig detal problems F id a detist q uickly ad easily Create a customized list of providers based o their prefereces, or look up a specific provider Uique features iclude side-by-side comparisos of provider iformatio, ability to create a short list of favorite providers for quick referece ad get maps ad directios to a office Have your results faxed or ed back to you 15

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19 The Guardia Life Isurace Compay of America Employer: Hoffma Eterprises 700 Coecticut Boulevard East Hartford, CT Please prit clearly to esure accurate processig Guardia Group Pla Number: EMPLOYER USE ONLY q New Applicatio q Add Depedet(s) q Drop Depedet(s) q Chage Address q Chage Name q Drop Coverage as of: Class Class 1 ABOUT YOURSELF First, Middle Iitial, Last Name q Add q Chage q Drop Hours Worked Divisio Beefits Effective Keep a copy for your records ad retur form to: Northeast Regioal Office, P.O. Box 26040, Lehigh Valley, PA Sex q M q F Prit clearly i black or blue ik. Date of Birth (mm/dd/yyyy) Social Security Number - - Address City State Zip Preferred Day Phoe Eve Phoe The best way to reach you: q q Day Phoe q Eve Phoe Job Title Work Status Date work status bega Are you married? q Yes q No ABOUT YOUR DEPENDENTS Spouse First, Middle Iitial, Last Name q Add q Chage q Drop Sex q Full-Time q Part-Time q Retired q COBRA/State Cotiuatio q M q F Do you have childre or other depedets? q Yes q No q A sheet with iformatio about additioal depedets is attached. Date of Birth (mm/dd/yyyy) Social Security Number Marriage Date (mm/dd/yyyy) - - Child 1 q Add q Chage q Drop State of Residece: Sex q M q F Date of Birth (mm/dd/yyyy) q Full-time studet, at (school): City/State: Attedig Sice Child 2 q Add q Chage q Drop Sex q M q F Date of Birth (mm/dd/yyyy) q Full-time studet, at (school): City/State: Attedig Sice State of Residece: Child 3 q Add q Chage q Drop Sex q M q F Date of Birth (mm/dd/yyyy) q Full-time studet, at (school): City/State: Attedig Sice State of Residece: Child 4 q Add q Chage q Drop State of Residece: Sex q M q F Date of Birth (mm/dd/yyyy) q Full-time studet, at (school): City/State: Attedig Sice To drop coverage for yourself or your depedets, check the box(es) to the right of the ame(s) ad select the coverage(s) to drop below. Attach a separate sheet if you wish to drop more tha oe depedet from differet coverages. q Detal A depedet is a perso that you, as a taxpayer, claim; who relies o you for fiacial support; ad for whom you qualify for a depedecy tax exemptio. Depedecy tax exemptios are subject to IRS rules ad regulatios. Additioal iformatio may be required for o-stadard depedets such as a gradchild, a iece or a ephew. CEF Erollmet Kit , 0001, EN 1 DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER DATE FORM PUBLISHED: Mar 28, 2012

20 CHOOSE YOUR DENTAL COVERAGE Employee aloe Employee ad Spouse Employee ad Child(re) Etire family If you or your family have lost detal coverage, please explai below. Late etry pealties may apply. PPO q q q q Reaso for Loss of coverage: q Termiatio of Employmet q Divorce q Death of Spouse q Termiatio or Expiratio of coverage Check oe box oly Date of coverage loss IMPORTANT NOTES Proof of isurability does ot apply to detal, but if you waive detal coverage ad later decide to eroll, you may be subject to a late etrat pealty ad your detal beefits may be limited for a period of time. Guardia may waive late-etrat pealties if you lose detal coverage due to termiatio of the pla, loss of employmet, death of spouse, divorce or where a court has ordered coverage be provided for a eligible spouse or eligible childre, provided you apply withi 30 days. Visio Discout Access is icluded with your detal pla at o charge. You must elect detal i order to qualify for Visio Discout Access. SIGNATURE I hereby apply for the group beefit(s) that I have chose above. I uderstad that I must meet eligibility requiremets for all coverages that I have chose above. I uderstad that my depedet(s) caot be erolled for a coverage if I am ot erolled for that coverage. I agree that my employer may deduct premiums from my pay or add premiums to my dues; if they are required for the coverage I have chose above. I ackowledge ad agree that Guardia may provide me iformatio cocerig beefits, icludig explaatio of beefit statemets ad other claims related iformatio soley i electroic format as permitted by law. I may chage this electio oly by providig Guardia thirty (30) day prior writte otice. I attest that the iformatio provided above is true ad correct to the best of my kowledge ad belief. Ay perso who with itet to defraud or kowig that he/she is facilitatig a fraud agaist a isurer, submits a applicatio or files a claim cotaiig a false or deceptive statemet may be guilty of isurace fraud. SIGNATURE OF EMPLOYEE X DATE 2 DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER

21 Thak You If applicable, retur your completed form to your pla admiistrator. Please remember to: You chose... Detal: q PPO q q q q q q Check the coverage you wat Iclude your social security umber (ad those of your depedets, if applicable) Iclude dates of birth Idicate the best way to reach you Iclude your ame o each page of the form. Sig ad date form Date form submitted:

22 Make the most of your Guardia beefits at Erolled members ad their depedets ca access helpful, secure iformatio about their Guardia beefit(s) istatly at Review your beefits Look up amouts ad services covered i your pla Check the status of a claim Receive alerts whe a respose to your detal* claim is available olie Prit forms ad pla materials...ad much more To register, go to Hoffma Eterprises Detal Beefits Pla 2005 The Guardia Life Isurace Compay of America, 7 Haover Square, New York *Not available to members with Guardia pre-paid Detal/DHMO plas (icludig FirstCommowealth ad Maaged DetalGuard plas). 0001