Important Notice. BCD16P-C-IPED 1 Internal Control Number. Issued By CAPITAL ADVANTAGE ASSURANCE COMPANY Harrisburg, PA

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1 Issued By CAPITAL ADVANTAGE ASSURANCE COMPANY Harrisburg, PA A Capital BlueCross company and independent licensee of the BlueCross and BlueShield Association Individual Dental Policy BlueCross Dental SM Healthy Dental PPO Pediatric LIMITED BENEFIT POLICY- PLEASE READ CAREFULLY - THIS POLICY PROVIDES FOR CERTAIN PEDIATRIC DENTAL SERVICES. Important Notice This policy does not participate in any divisible surplus of premiums. This policy is non-assessable. This policy is guaranteed renewable subject to timely payment of premiums. Premiums are subject to change on a uniform basis for all members covered under this policy form. NOTICE OF MEMBER S PERSONAL REPRESENTATIVE S RIGHT TO EXAMINE POLICY FOR THIRTY DAYS: If for any reason member s personal representative is not satisfied with this policy, he/she may return the policy to the Plan within 30 days of receipt of policy, and the premiums paid will be promptly refunded to the member s personal representative BlueCross Dental is issued by Capital Advantage Assurance Company a subsidiary of Capital BlueCross and independent licensee of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. DESCRIPTION OF COVERAGE: This Limited Benefit Policy sets forth dental and oral health benefits coverage for eligible individuals who are under the age of 19. Benefits are subject to Copayments, coinsurance, Annual Deductible, and an annual (calendar year) Out-of-Pocket Maximum. Capital Advantage Assurance Company (hereinafter referred to as "Plan") certifies that the Member is covered under and subject to all the provisions, definitions, limitations and conditions of this Individual Dental Policy for the benefits approved herein, and is eligible for benefits stated in the attachments hereto (Coverage Schedule) as of the date indicated in the letter accompanying the Membership Identification Card or renewal notice. The address of the principal administrative office of Plan is: BlueCross Dental Processing Center, 115 S. Union Street, Suite 300, Alexandria, Virginia The telephone number is (800) Part I. DEFINITIONS A. Annual Deductible shall mean the amount set forth in the Coverage Schedule which Member s Personal Representative must pay each calendar year before Benefits will be paid by the Plan. B. Benefits shall mean the amount payable by the Plan, as set forth in the Coverage Schedule, for a Covered Service. C. Copayment shall mean the dollar amount listed in the attached Coverage Schedule that the Member s Personal Representative is required to pay when a service is rendered. D. Covered Service shall mean a procedure listed in the Coverage Schedule. E. Eligible Expenses shall mean covered dental services and procedures described in this policy and incurred while this Policy is in force. An Eligible Expense is considered incurred on the following dates: a) Dentures - on the date the final impression is taken. b) Fixed bridges, crowns, inlays and onlays - on the date the teeth are initially prepared. c) Root canal therapy - on the date the pulp chamber is opened. d) Periodontal surgery - on the date surgery is performed. e) All other services - on the date the service is performed. F. Health Care Exchange shall mean the Federal Health Benefits Exchange(s), operated within Pennsylvania, which allows individuals and small groups to compare and purchase affordable health and dental plans and determine if they are eligible for federal subsidies. G. Maximum Allowable Charge shall mean a limitation on the billed charge as determined by the Plan by geographic area where those expenses are incurred. H. Medically Necessary Orthodontia. an orthodontic procedure for Members with fully erupted set of teeth, that occurs as a part of an orthodontic treatment plan, as approved by the Plan, that is intended to treat a severe dentofacial abnormality that severely compromises the Member s physical health or is a serious handicapping malocclusion, and orthodontic treatment is determined to be the only method capable of: preventing irreversible damage to the Member s teeth or their supporting structures restoring the Member s oral structure to health and function BCD16P-C-IPED 1 Internal Control Number

2 Dentofacial abnormalities that severely compromise the Member s physical health may be manifested by: Markedly protruding upper jaw and teeth, protruding lower jaw and teeth, or the protrusion of upper and lower teeth so that the lips cannot be brought together. Under-developed lower jaw and receding chin. Marked asymmetry of lower face. Presence of a serious handicapping malocclusion is determined by the magnitude of the following variables: degree of malalignment, missing teeth, angle classification, overjet and overbite, open bite, and crossbite. A handicapping malocclusion is a condition that constitutes a hazard to the maintenance of oral health and interferes with the well-being of the recipient by causing: Obvious difficulty in eating because of the malocclusion, so as to require a liquid or semisoft diet, cause pain in jaw points during eating, or extreme grimacing or excessive motions of the orofacial muscles during eating because of necessary compensation for anatomic deviations. Obvious severe breathing difficulties related to the malocclusion, such as unusually long lower face with downward rotation of the mandible in which lips cannot be brought together, or chronic mouth breathing and postural abnormalities relating to breathing difficulties. Lisping or other speech articulation errors that are directly related to orofacial abnormalities and cannot be corrected by means other than orthodontic intervention. I. Member shall mean an individual who has been enrolled in the Plan by Member s Personal Representative and who is under the age of 19. J. Member s Personal Representative shall mean a parent, custodial parent, grandparent, legal guardian, or emergency guardian who has paid the Premiums on behalf of Member for Pediatric Services under the Plan. K. Non-Participating Dentist shall mean a licensed dentist that is not a member of the network of Participating Dentists. L. Out of Pocket Maximum shall mean the greatest amount Member s Personal Representative will be required to pay during the calendar year for medically necessary Pediatric Services. Premium does not contribute to the Out-of-Pocket Maximum. M. Participating Dentist shall mean an independent dentist who is properly licensed and has an agreement with the Plan, or its designee, to provide dental services for Members of the Plan. Participating Dentists are not employees of, nor supervised by the Plan. N. Pediatric Services shall mean services covered under this Individual Dental Policy for individuals under the age of 19. O. Plan Specialist shall mean an independent licensed specialist who is a Participating Dentist and who has an agreement with the Plan to provide dental services for members of the Plan that are of such a degree of complexity as to not be normally performed by a Participating Dentist who is not such a specialist. Plan Specialists are not employees of, nor supervised by the Plan. P. Policy Renewal Date shall mean January 1 st of each calendar year. Q. Premiums shall mean amounts payable on a regular prepayment basis for the Member to the Plan. R. Usual, Customary, and Reasonable Fees shall mean those fees that the Participating Dentist usually charges its patients for dental services when a person is not affiliated with any dental program. Part II. EFFECTIVE DATE OF BENEFITS A Member s Personal Representative has a 60 day special enrollment period to select a qualified health or dental plan for Member and/or change Member s enrollment from one qualified health or dental plan to another from the date of a triggering event, as defined under 45 CFR (d), in which a qualified individual gains a Dependent or becomes a Dependent through marriage, birth, adoption or placement for adoption. An Indian, as defined by section 4 of the Indian Health Care Improvement Act, in addition to the 60 day special enrollment period, may change from one qualified health or dental plan to another one time per month. All persons eligible to be a Member and who have enrolled in the Plan and paid the appropriate Premiums to the Plan shall be eligible for coverage on the date determined by the Health Care Exchange or, if purchased outside of the Health Care Exchange, on the date determined by Plan. Member becomes eligible for services on the effective date as shown in the letter accompanying the Membership Identification Card or renewal notice. Part III. TERMINATION OR CANCELLATION Benefits continue for one (1) month from the effective date of this contract and continue from month-to-month thereafter until discontinued, terminated, or voided as provided in this provision. Benefits shall cease upon the earliest of the following events: A. On the last day of the grace period. If payment is not made in full on or prior to the date due, as specified in Part IV, a grace period of 31 days from the due date shall be granted to the Member s Personal Representative for the payment of Premiums falling due after the first payment. For individuals who have purchased this Limited benefit Policy on a Health Care Exchange and who are receiving advance payments of the premium tax credit as determined under the Health Care Exchange, a 3-month grace period will be provided with the last date of coverage being on the last day of the first month of the 3-month grace period. During the grace period, Plan shall pay all appropriate claims for services rendered to the Member during the first month of the grace period and may pend claims for services rendered to the Member in the second and third months of the grace period until Premium due is paid in full in the amount(s) then overdue. The policy shall remain in full force and effect during the grace period. B. Upon the date of Member attaining the age of 19 years. The termination date will be the last day of the month following the month in which notice of ineligibility is sent to the Member s Personal Representative by the Health Care Exchange if this Policy was purchased on the Health Care Exchange, or by Plan if this Policy was not purchased on the Health Care Exchange. C. Upon Member or Member s Personal Representative performing an act, practice or omission that constitutes fraud, or intentional misrepresentation of material fact as defined in 45 CFR , coverage will be rescinded 30 days after written notice is provided to the Member s Personal Representative by the Plan. The rescission will only extend back to the date on which fraud or intentional misrepresentation of material fact occurred. D. Upon cancellation of contract by Member or Member s Personal Representative. The Member or Member s Personal Representative may cancel this contract on the last day of the calendar month by giving written notice to Capital at least thirtyone (31) days in advance. The Plan will provide 30 days written notice to the Member s Personal Representative in advance of termination. Upon termination of coverage, an extension of benefits shall be provided for any treatment in progress at the time of termination, provided the treatment requires two or more visits on separate days to the dentist's office. Extension of benefits will be limited to 90 days for all care other than orthodontics, and 60 days for orthodontics if the orthodontist has agreed to or is receiving monthly payments when coverage terminates, or to the end of the quarter in progress or 60 days, whichever is longer, if the orthodontist is receiving quarterly payments. An extension of benefits will not be provided if termination was due to a failure of the Member s Personal Representative to pay the Premium, or fraud or material misrepresentation by the Member s Personal Representative or Member. BCD16P-C-IPED 2

3 Part IV. PREMIUMS AND MEMBER COST SHARINGPAYMENTS A. Premiums are payable on a monthly or annual basis each month or year that this policy is in effect. Premiums must be received by the administrative office of the Plan no later than the first day on which the coverage period begins. Premiums may also be paid within the grace period for each coverage period after the first. B. Member cost sharing amounts such as Copayments, coinsurance and Annual Deductibles (as listed in the attached Coverage Schedule), are payable to the Participating or Non-Participating Dentist, as applicable, at the time services are rendered. Member cost sharing amounts contribute to the Out-of-Pocket Maximum. C. After the 30-day review period (see cover page), refunds are available only to Member s Personal Representative who has paid their Premiums in one annual installment. Annual Member s Personal Representatives who voluntarily terminate enrollment in the Plan may receive a prorated refund on a monthly basis if no services have been rendered during the current Plan year. Part V. BENEFITS AND COVERAGES ELIGIBLE EXPENSES: Plan will pay for Eligible Expenses incurred for Member. Eligible Expenses must be incurred while the policy is in force or under extension of benefits provision in Part III of this policy. The description of Eligible Expenses is shown in the Coverage Schedule. All Benefits will be paid to the Member s Personal Representative unless otherwise designated by the claimant. Benefits will be paid after the Member complies with any waiting periods, Deductibles and Annual Maximums as specified in the Coverage Schedule. All Benefits are subject to Plan Exclusions as set forth in the Coverage Schedule. Benefit amounts will vary depending on whether the Member obtains services from a Participating Dentist or a Non-Participating Dentist. To be considered an Eligible Expense, the service must be performed by a dentist, a physician, or a dental hygienist, and be deemed by the treating dentist to be necessary for the patient's dental health. IN-NETWORK BENEFITS: Plan will pay a percentage of the Participating Dentist's charge for each Covered Service up to the Participating Dentist's negotiated fee. The percentage of payment by Plan is determined by procedure classification as set forth in the Coverage Schedule. For example, if a procedure is covered at 80%, the Plan will pay 80% and the Member s Personal Representative will pay the remaining balance of 20%, up to the Participating Dentist's negotiated fee. The Member s Personal Representative may be required to remit payment for the remaining balance at the time of service. Billing arrangements are between the Member s Personal Representative and the Participating Dentist. Participating Dentists are listed in the dentist directory. Member s Personal Representative should confirm continued participation of a Participating Dentist prior to receiving treatment. OUT-OF-NETWORK BENEFITS: A Member may choose to receive treatment from a Non-Participating Dentist. Benefit percentages for outof-network Benefits, if applicable, are listed in the Coverage Schedule according to procedure classification. Benefits are calculated using a Maximum Allowable Charge. Member s Personal Representative is responsible for any amount charged which exceeds the Maximum Allowable Charge per procedure. Billing arrangements are between the Member s Personal Representative and the Non-Participating Dentist. If a Member receives treatment from a Non-Participating Dentist, the Member s Personal Representative may be required to make payment in full at the time of service. The Member s Personal Representative may then submit a claim to the Plan for Benefit payment. PRE-AUTHORIZATION OF BENEFITS (INCLUDING MEDICALLY NECESSARY ORTHODONTIA): The Plan requires the treating dentist (or orthodontist as applicable) to submit a treatment plan prior to initiating services: If the charge for treatment is expected to exceed $300 For medically necessary orthodontia The Plan may require treating dentist to submit a treatment plan prior to initiating services for Pediatric Services. The Plan may request x-rays or other dental records, prior to issuing the pre-authorization. The proposed services will be reviewed and a pre-authorization will be issued to the Member s Personal Representative or treating dentist (or orthodontist), specifying coverage. The pre-authorization is not a guarantee of coverage and is considered valid for 180 days. ALTERNATE BENEFIT: If: 1) Plan determines that a less expensive alternate treatment procedure, service, or course of treatment can be performed in place of the proposed treatment to correct a dental condition; and 2) the alternate treatment will produce a professionally satisfactory result; then the maximum the Plan will allow will be the charge for the less expensive treatment. COORDINATION OF BENEFITS: All Benefits covered under this policy are subject to coordination. The following definitions apply only to this Coordination of Benefits section: A. Plan shall mean coverage providing hospital, medical or dental benefits or services by: i) group or blanket insurance coverage except school accident coverage; ii) group Blue Cross and Blue Shield, group practice or other pre-payment coverage on a group basis; iii) labor-management trusteed plans, union welfare plans, employer organization plans or employee benefit plans; or iv) individual coverage. Plan will be construed separately for a policy, contract, or other arrangement for benefits or services that reserves the right to take the benefits or services of their Plans into consideration in determining its benefits, or separately for that portion which does not reserve the right. B. Eligible Expenses shall mean any necessary, reasonable and customary item of expense all or part of which is covered under one of the Plans. When a Plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service rendered will be considered to be both an Eligible Expense and a benefit paid. C. Claim Period shall mean a calendar year or portion of a calendar year for a claim on a Member covered under this Plan. If Member is also covered under one or more other Plans, the Benefits under this policy (also referred to as this Plan ) will be coordinated with benefits payable under all other Plans. In the event of coordination between medical insurance coverage and this Plan, medical will always be considered the primary insurance and this Plan secondary insurance. The coordination will apply in determining the benefits payable for any Claim Period if the sum of: i) the benefits that would be payable under this Plan in absence of the coordination; and ii) the benefits that would be payable under all other Plans without provisions for coordination in those Plans, would exceed Eligible Expenses. When this Plan pays second according to the rules of the following paragraph, Coordination of Benefits applied to the benefits payable for any Claim Period, the benefits that would be payable for Eligible Expenses under this Plan in the absence of Coordination of Benefits will be reduced to the extent necessary so that the sum of those reduced benefits and all the benefits payable for those Eligible Expenses under all other Plans will not exceed the total of those Eligible Expenses. Benefits payable under all other Plans include the benefits that would have been payable had a claim been properly made for them. BCD16P-C-IPED 3

4 The rules establishing the order of benefit determination are: 1. The benefits of a Plan covering a person for whom claim is made other than as a dependent will be determined before the benefits of a Plan covering such person as a dependent, except in the case of Medicare beneficiaries in which Medicare is secondary to the Plan covering the person as a dependent; and primary to the Plan covering the person as other than a dependent (retired employee). 2. Except as stated in (3) below, when this Plan and another Plan cover the same child as a dependent of different persons, called "parents": a. the benefits of the Plan of the parent whose birthday falls earlier in a year are determined before those of the Plan of the parent whose birthday falls later in that year; but b. if both parents have the same birthday, the benefits of the Plan covering the parent longer are determined before benefits of the Plan covering the other parent for the shorter period of time. However, if the other Plan does not have the rule described in (a) above, but instead uses a different method, and if, as a result, the Plans do not agree on the order of benefits, the rule in the other Plan will determine the order of benefits. 3. If two or more Plans cover a person as a dependent child of divorced or separated parents, or parents who are not living together, whether or not they have ever been married, benefits for such child are determined in this order: a. first, the Plan of the parent with custody of the child; b. then, the Plan of the spouse of the parent with custody of the child; c. then, the Plan of the parent not having custody of the child; and d. finally, the Plan of the spouse of the parent not having custody of the child. However, (i) if the specific terms of a court decree state that one of the parents is responsible for the health care expenses of the child, and the entity obligated to pay or provide the benefits of the Plan of such parent has actual knowledge of those terms, the benefits of that Plan are determined first. This does not apply with respect to any Claim Period or Plan Year during which any benefits are actually paid or provided before the entity has that actual knowledge; or (ii) if the court decree states that both parents are responsible for the child s health care expenses or health care coverage, the provisions of (i) above shall determine the order of benefits; or (ii.) if a court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the dependent child, the provisions of (i) above shall determine the order of benefits.. 4. The benefits of a Plan covering a person as an employee who is neither laid-off nor retired (or as that employee's dependent) are determined before those of a Plan which covers that person as a laid-off or retired employee (or as the employee's dependent). If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule (4) is ignored. 5. If a person whose coverage is provided pursuant to COBRA or under a right of continuation pursuant to state or other federal law is covered under another Plan, the Plan covering the person as an employee, member, subscriber or retiree or covering the person as a dependent of an employee, member, subscriber or retiree is the primary plan and the Plan covering that same person pursuant to COBRA or under a right of continuation pursuant to state or other federal law is the secondary plan. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule (5) is ignored. 6. If none of the above rules determines the order of benefits, the benefits of a Plan which has covered the person for whom claim is made for the longer period of time will be determined before the benefits of a Plan covering the person the shorter period of time. If this Plan is responsible for secondary coverage for Eligible Expenses, this Plan will not deny coverage or payment of the amount it owes as secondary payer solely on the basis of the failure of another contract, which is responsible as the primary payer, to pay for such Eligible Expenses. This Plan will not be required to pay the obligations of the primary payer. For the purposes of administering the above provisions of this policy or any similar provisions of other Plans, this Plan may, without consent or notice to any person, release to or obtain from any other insurance company, organizations or person, any information concerning any individual which is considered necessary. Any person claiming Benefit will furnish the Plan with any information necessary. Whenever payments which should have been made under this policy in accordance with the above provisions have been made under any other Plans, this Plan has the right, at its sole discretion, to pay any organizations making these payments any amount this Plan determines to be due. Amounts paid in this manner will be considered to be Benefits paid under this policy and, to the extent of these payments, Plan will be fully discharged from liability under this policy. Whenever payments have been made by this Plan, for Eligible Expenses in a total amount in excess of the maximum amount of payment necessary to satisfy the intent of the above provisions, this Plan will have the right to recover the excess from one or more of the following: (i) other insurance companies; (ii) other organizations; or (iii) persons to or for whom payments were made. Part VI. DENTAL RECORDS The dental records of all Members concerning services performed hereunder shall remain the property of the treating dentist. Information related to the number, cost and delivery of services provided under the Plan to Members may be made available to the Plan by dentists for purposes of review, investigation or evaluation of care. Part VII. CHANGE IN SERVICE Plan reserves the right to change the Premiums and/or Plan benefits on a uniform basis for all Members covered under this Plan after completion of the term of the policy. No change will be made without giving the Member s Personal Representative thirty (30) days prior written notice and without approval by the Pennsylvania Insurance Department. Part VIII. EMERGENCY SERVICES When a Member is more than 50 miles from their home, they may have emergency services rendered by any licensed dentist. Emergency services are defined as palliative care of injury, toothache, or accident requiring the immediate attention of a dentist or hospital/ambulatory surgical care center. For purposes of calculating any amount payable under the policy by the Member s Personal Representative, Plan will treat services received as if services were provided by a Participating Dentist. All policy provisions, limitations and exclusions will be applied. Part IX. CLAIMS PAYMENT OF CLAIMS: Benefits for losses are paid to the Member s Personal Representative. However, the Plan has the right to pay all or part of the benefits due to the treating dentist. This is true whether or not the Member is alive. If the Member has died and the Plan does not pay accrued benefits to the treating dentist, benefits will be paid to the Member's estate. CLAIM FORMS: If Plan receives a notice of claim, it will provide claim forms for filing proof of loss. If such forms are not sent by the Plan to the Member within 15 days after notice of claim is received, the claimant will be deemed to have complied with the requirements of this BCD16P-C-IPED 4

5 policy as to proof of loss. Notice of such a claim should be sent to BlueCross Dental, P.O. Box 1126, Elk Grove Village, IL NOTICE OF CLAIM/PROOF OF LOSS: Plan must receive written proof of loss within 180 days of treatment. Failure to provide proof of loss within the time required does not invalidate or reduce a claim if it was not reasonably possible to submit the proof within the required time, if the proof is furnished as soon as reasonably possible and, except in the absence of legal capacity of the claimant, not later than one year from the time proof is otherwise required. Proof of loss must be forwarded to BlueCross Dental, P.O. Box 1126, Elk Grove Village, IL These attachments contain other terms, including important exclusions and limitations. Member s Personal Representative may request additional copies by contacting Member Services at (800) TIME OF PAYMENT OF CLAIM: Benefits payable under this policy for any covered loss will be paid immediately or within the time required by state regulations. If Plan fails to pay claim within the time required by state regulations, it will pay interest from the date on which payment is required to the date the claim is paid. LEGAL ACTIONS: No action at law or in equity shall be brought to recover on this policy prior to the expiration of sixty (60) days after written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of three years after the time written proof of loss is required to be furnished. Part X. INCONTESTABILITY CLAUSE In the absence of fraud, all statements made by a Member s Personal Representative shall be considered representations and not warranties and no statement shall be the basis for voiding coverage or denying a claim after the policy has been in force for two years from its effective date. During the two year period, contests by the Plan are limited to material misstatements made in a written application. This policy does not exclude pre-existing conditions. Part XI. COMPLAINTS AND GRIEVANCES Complaints should be initially brought to the attention of the Member's Participating Dentist. If the issue is not resolved to the Member's Personal Representative s satisfaction, it may be sent in writing to Member Services, BlueCross Dental, 115 S. Union Street, Suite 300, Alexandria, Virginia Member Services will respond to the grievance within fifteen (15) working days. Most complaints can be resolved over the telephone. In such instances, Member s Personal Representative should phone (800) If the complaint cannot be satisfactorily resolved, the Member s Personal Representative may have the matter resolved pursuant to the Complaint and Quality Assurance Procedures established by the Plan. A copy of these procedures will be provided at the Member's Personal Representative s request. Part XII. ENTIRE CONTRACT The Enrollment Application, Coverage Schedule and this Individual Dental Policy (including any attachments hereto) constitute the entire policy between the parties. No portion of the charter, bylaws, or other corporate documents of Capital Advantage Assurance Company will constitute part of the policy. No change in this policy shall be valid until approved by an executive officer of the Plan and unless such approval is endorsed hereon or attached hereto. No agent has authority to change this policy or to waive any of its provisions. Part XIII. GUARANTEED RENEWABILITY This individual policy may be renewed at the discretion of the Member s Personal Representative subject to Part III and IV. ATTACHMENTS: Coverage Schedule Membership identification Card Outline of Coverage Notice of Privacy Practices/GLBA BCD16P-C-IPED 5