Delta Dental of California Manual

Transcription

1 Delta Dental of California Manual

2 Table of Contents Welcome Letter 1 Contact Information 2 Quick Guide 3 Enrollment Guidelines 3 Choosing or Changing a Dentist 3 Eligibility 4 New Hires 4 Late Enrollees 5 Additions, Terminations and Other Changes 5 Employment Separation Guidelines 5 COBRA 5 Cal-COBRA 6 Administrative Guidelines 8 Appointments 8 Billing, Late Notices and Cancellations 8 Reinstatement Fee 8 This administration manual is subject to change without prior notification. Please contact CoPower for any updates.

3 Welcome! We would like to welcome your group to CoPower and Delta Dental of California. CoPower is a third party administrator that was created as a specialized purchasing pool for small employers to band together to provide large group-type benefits to their valued employees. One of the benefits offered to you by CoPower is dental coverage through Delta Dental of California. Delta Dental of California is the state s oldest and largest dental plan, covering millions of people statewide. Please read this manual carefully to be sure you fully understand your group s benefits, coverage and billing process. 1

4 Contact Information Delta Dental of California Benefit Information Claim Inquiries Eligibility Verification* Doctor Directories CoPower Enrollment Forms and Changes Billing Inquiries Benefit Supplies (summaries, enrollment forms, etc.) Phone: Fax: * If Delta Dental of California does not show the proper eligibility as reported by you to CoPower, please contact CoPower for verification. Your plan is administered by: CoPower 1600 W. Hillsdale Blvd. San Mateo, CA Tel: Fax: Monday Friday, 8:00 am to 5:00 pm Your plan is underwritten by: Delta Dental of California 100 1st Street San Francisco, CA Tel: Monday Friday, 8:00 am to 5:00 pm 2

5 Quick Guide 1. Checks* should be made payable to CoPower and sent to: CoPower Department P.O. Box San Francisco, CA *Please include the payment coupon and write your CoPower ID number on the check. 2. Monthly dues must be received no later than the first day of the month of coverage. 3. Additions and terminations must be received by CoPower no later than the 20th of the month prior to the coverage month. 4. Dentist directories (Delta Dental Premier and Delta Dental PPO) are accessible by calling Delta Dental of California toll free at AREA.DR ( ), or by visiting Delta Dental of California s web site at DO NOT SEND ENROLLMENT CHANGES TO THE P.O. BOX WITH YOUR PAYMENT. Enrollment Guidelines Choosing a Dentist Groups that are covered under the Delta Dental Premier program Under the Delta Dental Premier program, enrollees may visit any dentist, but it is to the enrollee s advantage to choose a Delta Dental of California dentist. There are more than 20,000 active Delta Dental of California offices in California (that is approximately 94% of the dentists in the state). There are several advantages to visiting a Delta dentist: 1. Delta Dental of California patients are charged fees that are no greater than the fees pre-negotiated by Delta Dental of California. 2. Delta Dental of California patients do not need to fill out or submit any claim forms. 3. Delta Dental of California dentists agree to follow Delta Dental of California s guidelines to assure professional standards of care. Under Delta Dental Premier, no referral is required to receive specialty care and there is no reduction in benefits when patients visit a dental specialist. Groups that are covered under Delta Dental PPO programs Under any Delta Dental PPO program, employees may visit any dentist, but it is to the 3

6 enrollee s advantage to choose a PPO dentist. PPO dentists are Delta Dental of California dentists who have agreed to charge PPO patients reduced PPO fees. There are over 139,000 PPO dental offices nationwide. When PPO enrollees visit a PPO dentist, they receive all the advantages of visiting a Delta Dental of California dentist. Also, under PPO, no referral is required to receive specialty care and there is no reduction in benefits when a patient visits a PPO specialist. Please refer to the Benefit Highlights for Delta Dental PPO document for further information regarding covered services, deductibles and claims. There are several ways enrollees can access a listing of Delta Dental of California and PPO dentists: Call Delta Dental of California toll free at AREA.DR ( ) or visit their Web site at Eligibility All primary enrollees and their dependents (Spouse and child/children ages 4 and up to but not including 26) are eligible while the primary enrollee is working on a permanent, full time basis. All eligible employees must enroll in this Delta Dental of California program following completion of their eligibility period unless they have coverage elsewhere (e.g. a spouse s program). For Classic plans, 20% of eligible enrollees may decline, but doing so forfeits their eligibility for the life of the Plan. Employees who do not enroll because they are covered through their spouse s program cannot enroll at a later time unless they show proof of a loss of coverage under the other dental program.* In addition, employees electing dependent coverage must enroll all eligible dependents. Enrollees declining dependent coverage cannot enroll their dependents at a later time unless the dependents show proof of loss of coverage under another dental program. Dependent children up to four years of age may be enrolled at the beginning of any contract year (the group s anniversary) including the contract year immediately following their 4th birthday. Category 1099 employees are NOT eligible for coverage under this Delta Dental of California program. New Hires Employees and their dependents are covered on the first day of the month following their eligibility period. Employees of groups with date of hire eligibility will be enrolled the first of the month following their hire date. * CoPower must be informed of this loss of coverage within 30 days of the event. The coverage will start the first of the month following the loss of coverage. 4

7 Late Enrollees A late enrollee is an employee that did not enroll with Delta Dental of California when the program was initially offered. These normally consist of those who waived coverage because they were covered by a spouse s program. These enrollees are only eligible to participate in the program the first of the month following the termination of their prior coverage. Proof of coverage termination will be requested by Delta Dental of California upon enrolling. Dependent children up to four years of age may be enrolled at the beginning of any contract year, including the contract year immediately following their fourth birthday. There is no open enrollment for late enrollees or dependents that did not enroll in the program when they first became eligible. Additions, Terminations and Other Changes Additions and terminations may be submitted to CoPower in one of two ways: 1. Fax the completed Dental Enrollment/Change or Termination form to CoPower at the completed Dental Enrollment/Change or Termination form to requests@copower.com. For timely processing, additions and terminations must be reported by the 20th of the month prior to the coverage month. Retroactive terminations are prohibited. Do not send premium for new enrollees and do not subtract premium for terminated employees. You will receive adjustments for all changes on the next invoice. Please pay as invoiced. A late fee will be assessed if you short pay. Monthly invoices should be reviewed each month to ensure changes requested are reflected accurately. Any discrepencies should be reported to CoPower within 30 days of the invoice date. Discrepencies reported after 30 days may jeopardize credits due to the group. Employment Separation Guidelines COBRA COBRA stands for Consolidated Omnibus Budget Reconciliation Act of 1985, federal law passed in April One purpose of the law is to prevent gaps in health care coverage. The continuation of coverage provisions require employers to provide a continuation of dental coverage for employees and their dependents under circumstances that would otherwise terminate coverage under the group s plan. Essentially all companies with 20 or more employees that provide dental coverage to their 5

8 employees are subject to the continuation of coverage requirements of COBRA. COBRA eligibility includes employment of full-time, seasonal and part-time employees. If you are uncertain of your COBRA classification, please seek legal counsel. There are a series of qualifying events that enable employees to be eligible for COBRA: Qualifying Event Death of a covered employee Termination of a covered employee (other than gross misconduct) or reduction in hours of employment Qualifying Beneficiary Any covered dependent(s) Covered employee and covered dependent(s) Continuation Period 18 months Divorce or legal separation of covered employee from spouse Dependent child ceases to be an eligible dependent under the terms of your group health and/or vision plan Covered employees eligibility for coverage under Medicare Covered dependent(s) losing coverage Covered dependent child Covered dependent(s) Employer s Responsibility When a qualifying event occurs, employers must provide written notification of COBRA rights to the employee and their dependents within 14 days of the event. Under COBRA, employers are required to administer continuation of coverage benefits and the employee is responsible for paying the employer the full cost of the continued coverage in addition to an administrative fee. The Employer must notify CoPower, Delta s designated administrator, as soon as possible when an employee loses coverage. The employee is terminated from the plan until the employer informs CoPower to reinstate the employee under COBRA. The employee will be reinstated retroactively to the first day of the month following the loss of coverage. Groups that contract with a COBRA administrator are still subject to CoPower s request for timely processing. Consequences for late requests will be charged to the group. Cal-COBRA The California Continuation Benefits Replacement Act (Cal-COBRA) became effective on January 1, This law requires that every small employer health care service plan contract must offer continuation coverage to enrollees under the plan who experience 6

9 a loss of coverage due to the occurrence of certain qualifying events. The cost of such continuation coverage will be charged entirely to those electing the coverage. There is no charge to the employer. The law requires that a small employer must notify the carrier, or in this case the third party administrator, of any employee who has experienced a qualifying event. A small employer is one that employs 2 to 19 employees on at least 50% of its working days during the preceding calendar year. If your group is uncertain of your COBRA classification, please seek legal counsel. There are a series of qualifying events that enable employees to be eligible for Cal-COBRA: Qualifying Event Death of a covered employee Termination of a covered employee (other than gross misconduct) or reduction in hours of employment Qualifying Beneficiary Any covered dependent(s) Covered employee and covered dependent(s) Continuation Period Divorce or legal separation of covered employee from spouse Dependent child ceases to be an eligible dependent under the terms of your group health and/or vision plan Dependents loss of coverage due to employee s eligibility for Medicare Covered dependent(s) losing coverage Covered dependent child Covered dependent(s) Employer s Responsibility If you are a small employer, either you or CoPower (Delta s designated administrator) can distribute a copy of the disclosure and election form to each employee enrolled in your dental plan within 14 days of an enrollee s qualifying event for Cal-COBRA. If you choose CoPower to send the Cal-COBRA notice to the qualified employee, please provide CoPower with the employee s and/or qualified dependent(s) name(s) and address(es) as soon as possible. The employee will be terminated from the plan until the application to enroll under Cal- COBRA is received by CoPower. The employee will be reinstated retroactively to the first day of the month following the loss of coverage. The Cal-COBRA enrollee will be responsible for paying the full cost of the coverage plus a 10% fee and will be billed directly by CoPower. 7

10 Administrative Guidelines The First Appointment During the first appointment, be sure to give the dentist the following information: 1. The Delta group number assigned to your company. 2. Primary enrollee s (the employee s) social security number. This number must also be used by dependents. 3. Relation to primary enrollee (if applicable). 4. Any other dental insurance with whom you have coverage. Billing, Late Notices and Cancellations PLEASE PAY AS BILLED. If full payment is not received by the first of the coverage month, a late notice will be issued and a late fee of $20.00 will be charged to your next bill. If payment is not received by the fifth of the month, a cancellation pending notice will appear on your next invoice and your group s eligibility to receive benefit services will be placed on hold. Once payment is received, the eligibility hold will be removed. Your dental coverage will be cancelled if no payment is received by the last business day of the month of coverage for which payment is due. For this plan to remain viable, there must be a minimum of five active enrolled employees. If the number of enrolled employees in your group falls below five, a letter will be sent to your group warning of a possible cancellation. Your group will be given three months from the first warning letter to bring the group number up to five or face cancellation. Reinstatement Fee Should any group decide to apply for reinstatement after termination of the policy, a fee of $15.00 for each employee, up to a maximum of $150.00, will apply. 8

11 1600 W. Hillsdale Blvd. San Mateo, CA Tel: Fax: CPM /11