AEP Comprehensive Dental Plan (DMO Option)

Transcription

1 AEP Comprehensive Dental Plan (DMO Option) Summary Plan Description for Active Employees, Retirees and Surviving Dependents Issued 2016

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3 ID Cards If you are an enrollee with Aetna Dental coverage, you don't need an ID card. When visiting a dentist, simply provide your name, date of birth and Member ID# (or social security number). The dental office can use that information to verify your eligibility and benefits. If you still would like an ID card for you and your dependents, you can print a customized ID card by going to the secure member website at You can also access your benefits information when you re on the go. To learn more, visit us at or call us at Remember, DMO members need to choose a primary care dentist in Aetna s network. Otherwise, you could end up paying more. You can use our provider search tool online or call us at to make your selection. CA /AZ DMO participants, if you have not selected a PCD, one may have been selected for you. View your digital ID card to determine if one was selected on your behalf. AEP 2016 Active and Retiree Dental DMO Plan SPD

4 AEP System Comprehensive Dental Plan The American Electric Power System Comprehensive Dental Plan is administered by Aetna. The Dental Plan is designed to provide you and your eligible dependents with high quality, cost-effective dental care. The plan offers a wide range of preventive care, basic and major restorative care, and orthodontic coverage for you and your covered dependents. What s Here: Your Dental Options at a Glance... 1 Dental Preferred Provider Organization (DPPO)... 1 Dental Maintenance Organization (DMO)... 1 DPPO/DMO Comparison Chart... 2 Participating AEP Companies... 3 Requirements for Coverage... 3 Eligibility... 4 Active Employees... 4 Retirees... 4 Surviving Spouse and Dependent Eligibility... 5 Dependent Eligibility... 5 Enrolling for Coverage... 7 How and When to Make Enrollment Elections and Changes... 7 As a New Employee... 7 Annual Enrollment for Employees... 8 As a New Retiree... 8 As a New Surviving Dependent... 8 Annual Enrollment for Retirees and Surviving Dependents... 9 Waiving Coverage... 9 Qualified Medical Child Support Order (QMCSO)... 9 Cost of Coverage Employees Retirees and Surviving Dependents When Coverage Begins The AEP Benefits Center When Coverage Ends Continuation of Coverage Continuing Coverage as an AEP Retiree Continuing Coverage as a Surviving Dependent Continuing Health Care Benefits Handicapped Continuing Dental Coverage under COBRA Qualified Beneficiaries COBRA Qualifying Events Obligation to Notify the Company of Certain Qualifying Events Continuation of Coverage During Military Leave (USERRA) Life Events and Your Coverage You Begin Working at AEP You Get Married Your Marriage Ends AEP 2016 Active and Retiree Dental DMO Plan SPD

5 Your Domestic Partnership Ends You Are Unable to Work Due to an Illness or Injury You Die A Covered Family Member Dies Your Child Loses Dependent Status Birth, Adoption, Placement for Adoption or Legal Guardianship Change in Your Spouse's/Domestic Partner s Employment You Begin a Family Medical Leave of Absence (FMLA) You Begin an Unpaid Leave of Absence (non-fmla) You Begin a Paid Military Leave of Absence You Terminate Employment Before Qualifying for AEP Retiree Benefits You Terminate Employment After Becoming Retiree Benefits Eligible You Are Rehired at AEP You Return from an Unpaid Leave of Absence You Return After Retirement Coverage or Employer Contributions Lost Under Another Dental Plan Newly Eligible Because of Change in AEP Employment Status How Your Aetna Dental Plan Works Understanding Your Aetna Dental Plan Accessing Network Providers Changing Your PCD Using Your Dental Plan In Case of a Dental Emergency What the Plan Covers Managed Dental Plan Schedule of Benefits General Managed Dental Expense Coverage Plan Rules and Limits That Apply to the Dental Plan What the Managed Dental Plan Does Not Cover Additional Items Not Covered by a Health Plan Coordination of Benefits What Happens When There Is More Than One Health Plan When Coordination of Benefits Applies Which Plan Pays First How Coordination of Benefits Works When You Have Medicare Coverage General Provisions Type of Coverage Physical Examinations Legal Action Confidentiality Additional Provisions Assignments Misstatements Incontestability Recovery of Overpayments Reporting of Claims Payment of Benefits AEP 2016 Active and Retiree Dental DMO Plan SPD

6 Contacting Aetna Appeals Procedure Your Legal Rights Receive Information about Your Plans and Benefits Continue Group Health Plan Coverage Prudent Actions by Plan Fiduciaries Plan Documents Transfer of Benefits Plan Amendment or Termination Administrative Information Glossary Aetna Coinsurance Copay or Copayment Cosmetic Covered Expenses Deductible Dental Provider Dental Emergency Dentist Directory Experimental or Investigational Hospital Illness Injury Jaw Joint Disorder Lifetime Maximum Medically Necessary or Medical Necessity Negotiated Charge Network Provider Network Service(s) or Supply(ies) Non-Occupational Illness Non-Occupational Injury Occupational Injury or Occupational Illness Occurrence Orthodontic Treatment Out-of-Network Service(s) and Supply(ies) Out-of-Network Provider Physician Precertification or Precertify Prescriber Prescription Prescription Drug Primary Care Dentist (PCD) Recognized Charge Referral Referral Care R.N AEP 2016 Active and Retiree Dental DMO Plan SPD

7 Skilled Nursing Facility Specialist Specialist Dentist Specialty Care Confidentiality Notice IMPORTANT NOTICE This is a summary of the American Electric Power Comprehensive Dental Plan as in effect on January 1, This description of the American Electric Power Comprehensive Dental Plan is not intended as an employment contract or a guarantee of current or future employment. The Company reserves the right to amend, modify, suspend, or terminate the Plan, in whole or in part, at any time, at its discretion, with or without advance notice to participants, for any reason, subject to applicable law. The Company further reserves the right to change the amount of required participant contributions for coverage at any time, with or without advance notice to participants. This Summary Plan Description ( SPD ) is an overview of the Plan documents as they apply to the benefits described herein. In the event of a conflict between this Summary and any Plan documents, the applicable Plan documents (excluding this Summary Plan Description) shall govern. For fully insured benefits, any discrepancy will be governed by the insurance certificates or policies. AEP 2016 Active and Retiree Dental DMO Plan SPD

8 Your Dental Options at a Glance Dental Preferred Provider Organization (DPPO) The DPPO option, administered by Aetna, lets you choose between receiving in-network and out-ofnetwork care each time you need dental work. You will generally pay less for your dental care when you use an Aetna in-network dental provider because in-network dentists have agreed to lower, negotiated fees for their services. Annual deductible (applies to basic and restorative expenses only) Preventive care Basic restorative care Major restorative care Orthodontia care (eligible children under age 19) Covered DPPO Expenses* $50/individual $150/family 100% (no deductible) 80% after deductible 50% after deductible 50% of eligible expenses (no deductible) Lifetime orthodontia maximum $1,500/lifetime per covered child under age 19 Annual maximum benefit $1,500/year per covered person (excludes orthodontia) *Up to Aetna s network discounted rates or Aetna s recognized charges if a non-network provider is used. Dental Maintenance Organization (DMO) The DMO option, administered by Aetna, offers you a broad range of dental services based on a Dental Benefits Summary described in this document that shows the patient copay that applies to each covered dental procedure. You are responsible for the applicable copay at the time the services are performed. You agree to receive care solely from a primary care dentist (PCD) associated with the DMO network, and in return, you will have: No deductibles or annual maximum. No copayment for covered preventive services. Low, fixed copayments on other dental services. No claim forms to file. AEP Active and Retiree Dental DMO Plan SPD

9 DPPO/DMO Comparison Chart Features DPPO DMO Cost Sharing Arrangement Coinsurance you pay a percentage of covered expenses Copay you pay a set dollar amount at the time of service. Primary Care Dentist Election Not required Yes, you must elect a PCD at the time you enroll, either online at or by calling Annual Deductible the amount you pay before your plan pays. Annual Maximum the maximum amount your plan will pay out in a Plan Year. Individual: $50 Family: $150 No Deductible $1,500 per covered person No Limit Orthodontics Eligibility Children under age 19 Adults and children Orthodontics Out-of-Pocket Maximum No Limit Orthodontics Lifetime Maximum $1,500 No Limit Out-of-Network Benefits Referrals the primary care dentist directs you to seek dental care from another dental professional. Procedures NOT covered by the plan Visit any licensed dentist to receive benefits. You will typically pay lower out-ofpocket costs if you choose a dentist who participates in the Aetna DPPO network. None required You are responsible for the cost of procedures not covered by your plan. Note: Participating DPPO dentists offer discounts on procedures not covered by the plan. $2,400 per covered person Out-of-network coverage is not available in Arizona, Texas, North Carolina, New Jersey, and California. Contact Aetna at for staterequired benefits Referrals are required, except when you visit an orthodontist in the DMO network. You are responsible for the cost of procedures not covered by the plan. Please refer to the separate AEP Comprehensive Dental Plan (DPPO Option) Summary Plan Description for Active Employees and Retirees for additional information about the DPPO option. You may also obtain more information about your eligibility for the DPPO, how the DPPO works, and what the DPPO covers if you would contact Aetna at AEP Active and Retiree Dental DMO Plan SPD

10 Participating AEP Companies Eligibility to participate in the plan depends, in part, on employment with a Participating AEP System Company. The list of Participating AEP System Companies includes the following as of January 1, 2016, but their inclusion may change for various reasons, including an amendment to the plan, or disposition of AEP s interest in the Company: American Electric Power Service Corporation AEP Energy Services, Inc. AEP Energy Partners, Inc. AEP Generating Company AEP Generation Resources Inc. AEP Onsite Partners, LLC AEP Pro Serv, Inc. AEP Texas Central Company AEP Texas North Company Appalachian Power Company CSW Energy, Inc. Dolet Hills Lignite Company, LLC Indiana Michigan Power Company Kentucky Power Company Kingsport Power Company Ohio Power Company Public Service Company of Oklahoma River Transportation Division I &MP Southwestern Electric Power Company Wheeling Power Company This list is not complete. If you want more information on whether and when a particular AEP System Company participated in the plan, please call the AEP Benefits Center toll-free at Requirements for Coverage To be covered by the plan, services and supplies must meet all of the following requirements: 1. The service or supply must be covered by the plan. For a service or supply to be covered, it must: Be included as a covered expense in this SPD; Not be an excluded expense under this SPD. Refer to the Exclusions sections of this SPD for a list of services and supplies that are excluded; Not exceed the maximums and limitations outlined in this SPD. Refer to the What the Plan Covers section and the Schedule of Benefits for information about certain expense limits; and Be obtained in accordance with all the terms, policies and procedures outlined in this SPD. 2. The service or supply must be provided while coverage is in effect. See the Who Can Be Covered, How and When to Enroll, When Your Coverage Begins, When Coverage Ends and Continuation of Coverage sections for details on when coverage begins and ends. 3. The service or supply must be medically necessary. To meet this requirement, the dental service or supply must be provided by a physician, or other health care provider or dental provider, exercising prudent clinical judgment, to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms. The provision of the service or supply must be: (a) In accordance with generally accepted standards of dental practice; (b) Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient s illness, injury or disease; and (c) Not primarily for the convenience of the patient, physician or dental provider or other health care provider; (d) And not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient s illness, injury, or disease. AEP Active and Retiree Dental DMO Plan SPD

11 For these purposes generally accepted standards of dental practice means standards that are based on credible scientific evidence published in peer-reviewed dental literature generally recognized by the relevant dental community, or otherwise consistent with physician or dental specialty society recommendations and the views of physicians or dentists practicing in relevant clinical areas and any other relevant factors. Important Note Not every service or supply that fits the definition for medical necessity is covered by the plan. Exclusions and limitations apply to certain dental services, supplies and expenses. For example some benefits are limited to a certain number of days, visits or a dollar maximum. Refer to the What the Plan Covers section and the Schedule of Benefits for the plan limits and maximums. Eligibility Important Reminder Keep in mind that you cannot receive coverage under this Plan as: Both an employee and a dependent; or A dependent of more than one employee. Active Employees You are eligible to enroll yourself and your eligible dependents in the AEP Comprehensive Dental Plan on your first day of work if you are classified by AEP as: A full-time active employee of a Participating AEP System Company scheduled to work an average of at least 40 hours per week; or A part-time active employee of a Participating AEP System Company scheduled to work an average of at least 20 hours per week. You are not eligible to participate if you are: Not an employee of a Participating AEP System Company; or Classified by AEP as a contractor, a temporary employee, a leased employee, or as an employee under a collective bargaining agreement not covered under the plan. Retirees You remain eligible to elect dental coverage for yourself and your eligible dependents if you were last hired or rehired by an AEP Participating System Company on or before December 31, 2013 and you are at least age 55 with 10 or more years of service with a Participating AEP Company and elected to enroll in retiree dental coverage at retirement. If you do not remain covered by retiree dental coverage at retirement, you will not be eligible to enroll in dental coverage at a later date. In addition, if you are rehired by a Participating AEP System Company on or after January 1, 2014, you may remain eligible to elect dental coverage for yourself and your eligible dependents upon your later retirement if you were eligible to elect such benefits in connection with your pre-2014 employment with AEP and maintained that coverage until your rehire date. In determining whether a Retiree has met the service requirement, any service provided as a temporary employee, independent contractor, leased employee or otherwise had services based upon a fee or contract, will not be taken into account. You also will be excluded from eligibility if your benefits were the subject of a collective bargaining agreement that does not provide for retiree coverage under this Plan. AEP Active and Retiree Dental DMO Plan SPD

12 Surviving Spouse and Dependent Eligibility Survivors of Active Employees (not retiree benefit eligible) Surviving spouses of active employees who were not retiree benefit eligible on the date of death can elect to continue dental coverage until the earlier of age 65 or remarriage, if the surviving spouse was enrolled in the dental plan at the time of the employee s death. Surviving dependent children of an active employee who was not retiree benefit eligible on the date of death can elect to continue dental coverage until they reach the limiting age (see the Dependent Eligibility section), if the surviving dependent was enrolled in the dental plan at the time of the employee s death. Survivors of Active Employees (retiree benefit eligible) Surviving spouses of active employees who were retiree benefit eligible on the date of death can elect dental coverage until remarriage, if the surviving spouse was enrolled in the dental plan at the time of the employee s death. Surviving dependents of active employees who were retiree benefit eligible on the date of death can elect dental coverage until the limiting age (see the Dependent Eligibility section), if the surviving dependent was enrolled in dental coverage at the time of the employee s death. Survivors of Retirees Surviving spouses of retirees can elect dental coverage until remarriage, if the surviving spouse was enrolled in the dental plan at the time of the retiree s death. Surviving dependents of retirees can elect dental coverage until the limiting age (see the Dependent Eligibility section), if the surviving dependent was enrolled in dental coverage at the time of the retiree s death. Once a survivor waives or terminates participation in the dental plan, he or she cannot re-elect it. Domestic Partners are not eligible for survivor dental benefits. However, AEP will offer COBRA-like coverage to eligible Alternative Family Members. Refer to the Continuing Dental Coverage through COBRA section for additional information. Dependent Eligibility The AEP Comprehensive Dental Plan allows Employees and Retirees covered by the Plan to purchase coverage for their eligible dependents. Survivors of active employees or Retirees generally cannot enroll any of their own dependents who were not covered by the dental plan at the time of the Employee s or Retiree s death. Eligible dependents include the Employee s or Retiree s: Spouse: As defined by state law where you live, including common law marriages. However, a same-sex spouse relationship created under applicable law will be respected regardless of whether the state in which you live recognizes it. Domestic Partner: AEP no longer allows the addition of domestic partners to coverage under the Plan. Only those same-sex domestic partners enrolled prior to October 28, 2015, are permitted to remain covered, but only through December 31, Coverage after December 31, 2016 will be limited to those who are legally married. AEP Active and Retiree Dental DMO Plan SPD

13 To qualify one for coverage as a domestic partner, you and your domestic partner must have certified and declared that you met the criteria below. You and your domestic partner: Must be the same gender. Must not be related by blood. Must be at least 18 years of age or older. Must be jointly financially responsible for basic living expenses defined as the cost of food, shelter, and any other expenses of maintaining a household. Your partner need not contribute equally or jointly to the cost of these expenses as long as you both agree that you both are responsible for the cost. Must have been living with you in the same residence for at least six consecutive months with the intent to continue doing so indefinitely. Must be in a serious and committed relationship. Must not be legally married to you or anyone else, in a partnership with another individual, or have had another partner within the prior six months. The determination of whether you are legally married will be determined based upon the law of the state in which you reside or where the marriage takes place. Must be legally competent that is, legally and mentally capable of entering into a legally enforceable contract. Must have Affidavit of Domestic Partnership on file at the AEP Benefits Center. Note: If you terminate your domestic partner relationship, or your domestic partner ceases to satisfy the criteria above for an eligible domestic partner, you must notify the AEP Benefits Center to discontinue your domestic partner from coverage. Failure to do so in a timely manner will not prevent their loss of coverage retroactively but will result in their loss of eligibility to elect COBRA-like continuation coverage. You may cover your domestic partner whether or not he or she qualifies as your tax dependent. If your domestic partner is not your tax dependent, you will incur imputed income on that benefit coverage. Children: To qualify for coverage, your dependent child(ren) must be under age 26 and fall into one of the following categories: Your natural child or the natural child of your spouse or eligible domestic partner; A child legally adopted by you, your spouse or eligible domestic partner or placed with you, your spouse or covered domestic partner for adoption. Placement for adoption means the assumption and retention by the Employee of the legal obligation for the total or partial support of a child to be adopted. Placement ends whenever the legal support obligation ends. Your foster child; A child who resides in your household and for whom you, your spouse or your eligible domestic partner are the court-appointed guardian; A child for whom you are required to provide coverage as a result of a Qualified Medical Child Support Order (QMSCO); or Any other child you claim as a dependent on your federal income tax return, provided that neither natural parent of the child lives with the child and you are acting as the child s guardian. Note: The FirstCare HMO medical plan option also allows you to cover your grandchildren whom you claim as a dependent on your federal income tax return at the time of his or her initial enrollment, regardless of whether the child s natural parent resides with you or you are acting as the grandchild s guardian. AEP Active and Retiree Dental DMO Plan SPD

14 Disabled Dependents: To qualify for coverage beyond age 26, your disabled child(ren) must meet the criteria listed under the Children section above, plus: Disability must have occurred prior to attaining age 26. The child must remain continuously covered under any of the options available under this Plan. You must submit proof that the child reaching age 26 is disabled and incapable of self-support within 31 days after he or she reaches age 26. If you are enrolling the child for the first time after the child has already reached age 26, you must submit proof that the child has been disabled and incapable of selfsupport since age 26 within 31 days after enrolling the child. The Medical Claims Administrator has the right to require, at reasonable intervals, proof that the child continues to be disabled and incapable of selfsupport. If you fail to submit any required proof or if you refuse to permit a medical examination of the child, he or she will not be considered disabled and therefore not eligible for coverage. If Both You and Your Eligible Dependent have AEP Benefits If both you and your spouse/domestic partner or eligible dependent are eligible for the dental plan as an AEP employee or retiree: You may each enroll in the plan as an employee or retiree, as appropriate; or One of you may enroll as an employee or retiree and the other as a dependent spouse, domestic partner or child. Neither of you may be covered as both an employee or retiree and as a dependent. Neither of you or your spouse or domestic partner can cover the same eligible dependent children. Tax Considerations When Covering Your Dependents A number of benefits that AEP offers to its employees receive special tax treatment. For the most part, the special tax provisions allow employees to pay their share of the cost of certain benefits on a before-tax basis and AEP to pay its share of the cost without having to include those payments in the employees' taxable wages. AEP makes dental coverage available to dependents that may not satisfy the requirements to be treated as dependents for tax purposes, and the employee s contributions for covering those dependents would be paid on an after-tax basis and AEP s share of the cost of covering them would be taxable wages for the employee. If you want more information on the requirements to be treated as a dependent for tax purposes, please call the AEP Benefits Center toll-free at When you enroll one or more dependents, you will be required to declare whether or not they are considered your federal income tax dependent under Sections 152 and 106 of the Internal Revenue Code for group health coverage purposes. Enrolling for Coverage How and When to Make Enrollment Elections and Changes You can enroll for coverage after you meet the eligibility requirements. As a New Employee As a newly eligible employee of a Participating AEP System Company, you will receive information and instructions about how to enroll for your benefits. You must indicate your dental election either online or by phone to the AEP Benefits Center within 31 days of your date of hire. If you do not enroll within 31 days, you will not be covered by the Plan. AEP Active and Retiree Dental DMO Plan SPD

15 Social Security Numbers Generally Required for Enrollment Under Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 ( MMSEA ), the Centers for Medicare & Medicaid Services ( CMS ) generally require Social Security numbers (or Tax Identification number for non-usa citizens) for employees and dependents to assist with reporting under the Medicare Secondary Payer requirements. For a newborn child, the newborn may be enrolled under your coverage without a Social Security number (provided you do so within 90 days of the birth). However, you should apply for the child s Social Security number as soon as possible and provide it to the AEP Benefits Center. Annual Enrollment for Employees Each year, during a designated Annual Enrollment period, you will be given the opportunity to enroll in or drop coverage, change your coverage elections, or change the dependents you cover. Your Annual Enrollment materials will provide the options available to you and your share of the premium cost, if any, for the coverages you elect. Your materials will also include what actions you must take to continue certain coverages and will explain any applicable default coverage that you will be deemed to have elected if you do not make the required elections by the specified deadline. The elections you make will take effect on January 1 and stay in effect through December 31, unless you have a qualifying change in status that permits you to make a mid-year election change. See the Making Changes During the Year section. As a New Retiree Your coverage in effect as an active employee will automatically continue into retirement. You will continue being enrolled in the same option under the plan, covering the same eligible dependents. If you wish to change plan options, drop coverage or add/remove dependents at the time of your retirement, you must do so by contacting the AEP Benefits Center within 31 days of your retirement. You may NOT change options under the AEP Dental Plan due to your retirement event. If you are not enrolled in an AEP dental plan option at the time of your retirement, you will continue to not be enrolled until you contact the AEP Benefits Center within 31 days of your retirement. This is a one-time election. If you choose not to enroll in dental benefits or waive coverage as a new retiree, you cannot enroll in dental coverage at any time in the future. As a New Surviving Dependent As a new AEP surviving spouse or dependent, if all contributions are paid up to date at the time of the Employee s or Retiree s death, you will automatically be enrolled in the same dental plan option you had as of the date of death. You may NOT change dental plan options. If you do not wish to continue coverage as a surviving spouse or dependent, you must contact the AEP Benefits Center within 31 days of the Employee s or Retiree s death. If you choose not to enroll in dental coverage as a surviving spouse or dependent, you will not be able to enroll at a later date, regardless of any changes in employment or family status. This is a one-time election. If you waive coverage as a new surviving spouse or surviving dependent, you cannot enroll in dental coverage at any time in the future. AEP Active and Retiree Dental DMO Plan SPD

16 Annual Enrollment for Retirees and Surviving Dependents Each year, during a designated Annual Enrollment period, Retirees and then participating Surviving Dependents will be given the opportunity to drop coverage or change coverage elections. Retirees may change the dependents they cover, Surviving Dependents only would have the opportunity to drop any eligible dependents that they cover. Your Annual Enrollment materials will provide the options available to you and your share of the premium cost, if any, for the coverages you elect. Your materials will also include what actions you must take to continue certain coverages and will explain any applicable default coverage that you will be deemed to have elected if you do not make the required elections by the specified deadline. The elections you make will take effect on January 1 and stay in effect through December 31, unless you have a qualifying change in status that permits you to make a mid-year election change. See the Making Changes During the Year section. Making Changes During the Year In general, after you enroll in benefits, you may not change or cancel your election choices during the year. However, certain qualifying changes in status may warrant benefit changes if they are due to and consistent with the qualifying change in status that affects your eligibility for the coverage. If you experience a qualifying change in status, you can make certain mid-year changes to your dental coverage elections. Examples of these qualifying life events and what you need to do relative to your dental coverage are listed in the "Life Events and Your Coverage" section. Covering Your Family When you enroll yourself in dental coverage, you decide if you want to enroll your eligible dependents. Refer to the Eligibility section for a definition of eligible dependents. You can choose one of the following coverage levels: Participant only; Participant + Spouse or Domestic Partner (not applicable to surviving dependents); Participant + Child(ren) and/or Domestic Partner s Child(ren) (A surviving spouse or dependent child may enroll the other surviving dependent children); or Participant + Family (not applicable to surviving dependents). You must be enrolled in dental coverage to enroll your eligible dependents. Coverage is provided only for those eligible dependents the Employee, Retiree or Surviving Dependent has actually enrolled. You should contact the AEP Benefits Center to confirm those enrolled or to add or remove dependents from your coverage at permissible times. Waiving Coverage You may also waive coverage under the AEP Comprehensive Dental Plan. If you elect to waive coverage for yourself, you automatically waive coverage for your eligible dependents. If you are a Retiree or Surviving Dependent, if you waive coverage, you cannot enroll at a later date. Qualified Medical Child Support Order (QMCSO) In some cases, you may be required by a court or administrative order to cover a dependent under the AEP Comprehensive Dental Plan. Federal law requires group health plans to comply with orders from state courts and administrative agencies that meet the requirements to be considered Qualified Medical Child Support Orders (QMCSOs). A QMCSO may require you to add your child as a dependent for dental benefits in some situations, typically a divorce. AEP Active and Retiree Dental DMO Plan SPD

17 You must be enrolled in dental coverage to add a dependent pursuant to a QMCSO. When you receive a QMCSO, you should contact the AEP Benefits Center toll-free at to request a change in coverage. You will also need to forward a copy of the court or administrative order to the AEP Benefits Center. Once you or your dependent furnishes a court or administrative order to the AEP Benefit Center, you and each affected child will be informed of receipt of the order and will be provided a copy of the procedures for determining if the order is a QMCSO. Subsequently, the interested parties will be notified of the determination. You may also obtain a copy of the QMCSO administrative procedures, free of charge, by contacting the AEP Benefits Center. Cost of Coverage Each year, AEP evaluates plan costs and may adjust your cost of coverage for the next year. Your cost may be affected by factors that AEP considers appropriate, such as the availability of other coverage to covered dependents, the time and circumstances applicable to an Employee or Retiree at the time of disability, retirement or death and wellness incentive programs that AEP may implement from time to time. The applicable cost for the upcoming year is made available by the time the Annual Enrollment period for that year begins. Employees As an active employee, you and AEP share the cost of your dental coverage. Your monthly cost for dental coverage is automatically deducted from 24 paychecks per year. For any period that your paycheck is not sufficient to cover your cost, you will have to make payment as directed at that time. The amount you contribute toward the cost of your benefits generally is determined by: The options you choose. The number of dependents you cover. Your contributions generally will be paid through before-tax payroll deductions; however, some benefits or other circumstances may require contributions to be paid with after-tax dollars. Retirees and Surviving Dependents If you are covered as a Retiree or Surviving Dependent, you pay the full cost of your dental coverage on an after-tax basis. If you are covered as a Retiree, you may be able to elect payment of your contribution from a monthly annuity being paid to you by the AEP System Retirement Plan (including the portion consisting of the former Central and South West Corporation Retirement Plan). Otherwise, you will receive a monthly billing statement for your dental contributions. Failure to remit payments in a timely manner will result in loss of coverage. When Coverage Begins For New Hires If you timely enroll as an eligible employee, your coverage begins on your date of hire. Coverage for your dependents begins the same day that your coverage begins. For New Retirees If you timely enroll as a Retiree (or, if your coverage automatically continued, failed to waive coverage), your retiree coverage begins the first of the month following your retirement date. For Newly Surviving Dependents If you fail to waive coverage as a surviving dependent, your coverage continues the first of the month following the date of the Employee s or Retiree s death. AEP Active and Retiree Dental DMO Plan SPD

18 During Annual Enrollment If you make changes to your AEP Comprehensive Dental Plan election during the Annual Enrollment period, coverage for you and your enrolled dependents begins on January 1 of the following year and continues through December 31. If You Make Changes During the Year You must notify the AEP Benefits Center, toll-free, at within 31 days of a qualifying change in status event (or within 90 days of a birth or adoption),except as otherwise specified. To be qualified, the change that you make to your coverage must be due to and consistent with the event and affect your eligibility for coverage. You also may be required to provide proof of the qualifying status changes. If you make changes to your coverage because of a qualifying status change, the change in your coverage generally will become effective as of the date of your qualifying event. Refer to the Life Events and Your Coverage section for a list of some possible qualifying events and actions you must take if any of these events in your life occur. The AEP Benefits Center You may contact the AEP Benefits Center in order to provide any notice required under these procedures as follows: AEP Benefits Center P.O. Box 622 Des Moines, IA Phone number: When Coverage Ends Under most circumstances, your AEP coverage ends on the last day of the month in which: You stop paying required contributions; You terminate employment; You are no longer eligible; The plan ends; or You die. Coverage for your eligible dependents ends on the last of the month in which your coverage ends, or in which they are no longer eligible. Continuation of Coverage Continuing Coverage as an AEP Retiree If you are age 55 or older with at least 10 years of service when your employment with AEP ends, you alternatively may be able to continue coverage for yourself as an AEP "retiree" and for your eligible dependents. Please refer to the Eligibility section for more information. Continuing Coverage as a Surviving Dependent If you are covered as a dependent spouse or child of an Employee or Retiree at the time of the Employee s or Retiree s death, your coverage may be continued as a Surviving Dependent. Please refer to the Eligibility section for more information about the availability and additional circumstances that may cause that coverage to terminate. AEP Active and Retiree Dental DMO Plan SPD

19 Continuing Health Care Benefits Handicapped Dependent Children Health Expense Coverage for your fully handicapped dependent child may be continued past the maximum age for a dependent child. Your child is fully handicapped if: he or she is not able to earn his or her own living because of mental retardation or a physical handicap which started prior to the date he or she reaches the maximum age for dependent children under your plan; and he or she depends chiefly on you for support and maintenance. Proof that your child is fully handicapped must be submitted to Aetna no later than 31 days after the date your child reaches the maximum age under your plan. Coverage will cease on the first to occur of: Cessation of the handicap. Failure to give proof that the handicap continues. Failure to have any required exam. Termination of Dependent Coverage as to your child for any reason other than reaching the maximum age under your plan. Aetna will have the right to require proof of the continuation of the handicap. Aetna also has the right to examine your child as often as needed while the handicap continues at its own expense. An exam will not be required more often than once each year after 2 years from the date your child reached the maximum age under your plan. Continuing Dental Coverage under COBRA Under the Consolidated Omnibus Budget Reconciliation Act, a federal law known as COBRA, employers with 20 or more employees that sponsor group health plans generally are required to offer employees and their families the opportunity for a temporary extension of health coverage (called continuation coverage ) at group rates in certain instances where coverage under the plan would otherwise end. This section is intended to inform you, in a summary fashion, of your rights and obligations under the continuation coverage provisions of COBRA in connection with the group health benefits maintained by the Participating AEP Companies (generally referred to in this notice as the Company ). The group health benefits maintained by the Company include the American Electric Power System Comprehensive Dental Plan (referred to as the Plan ). You and your spouse should take the time to read this notice carefully. Qualified Beneficiaries Status as a qualified COBRA beneficiary gives an individual special rights under COBRA. Persons covered by the plan will be considered COBRA qualified beneficiaries only if they fit into one of the following categories: Retiree; Employee or former employee; Spouse or former spouse of the retiree, employee, or former employee; or Dependent child(ren) of the retiree, employee, or former employee. AEP Active and Retiree Dental DMO Plan SPD

20 Therefore, you, your spouse and dependent children who are covered by the Plan at the time of the qualifying event generally will be considered qualified COBRA beneficiaries with respect to the Plan. Any child born or placed for adoption during the COBRA continuation period will also be treated as a qualified beneficiary if you have dependent coverage under the Plan at the time. Please remember that to enroll a newborn infant or a child placed with you for adoption (or even any other child or other dependents acquired through marriage) in the Plan, you must follow the enrollment procedures that are described in the Plan. A child is considered placed for adoption when the adoptive parent assumes and retains the legally enforceable obligation for the partial or total support of the child. This obligation generally arises when the proper court or proper agency issues an order to that effect. Although COBRA laws do not establish health benefit continuation rights for other categories of eligible dependent children or Alternative Family Members (such as domestic partners), AEP offers COBRA-like coverage to them under the AEP Comprehensive Dental Plan. COBRA Qualifying Events Employee. You have a right to choose this continuation coverage if you lose your coverage because of a reduction in your hours of employment or the termination of your employment (for reasons other than gross misconduct on your part) or, if you are a retiree, because of a filing under Title 11 of the Federal Bankruptcy Code with respect to your employer (with regard to this qualifying event, the loss of coverage may include the substantial elimination of your coverage within one year before or after the filing). Spouse or Domestic Partner. The spouse or domestic partner of an employee (or a retiree for reason 6) covered by the Plan, has the right to choose continuation coverage for himself or herself if he or she lost coverage under that plan for ANY of the following six (6) reasons: 1. Your death; 2. A surviving spouse s remarriage within 36 months of your death; 3. The termination of your employment (for reasons other than gross misconduct) or reduction in your hours; 4. Your divorce, legal separation or termination of domestic partnership; 5. You become eligible for benefits under Medicare Part A, Part B, or both; or 6. A filing under Title 11 of the Federal Bankruptcy Code with respect to the employer. With regard to this qualifying event, the loss of coverage may include the substantial elimination of coverage within one year before or after the filing. Dependent Child. Your dependent child, if covered by the Plan, has the right to continuation coverage under the Plan if coverage is lost for any of the following six (6) reasons: 1. Your death; 2. The termination of your employment (for reasons other than gross misconduct) or reduction in your hours; 3. Your divorce, legal separation or termination of domestic partnership; 4. You become eligible for benefits under Medicare Part A, Part B, or both; 5. Your dependent ceases to be a dependent child under the Plan; or 6. A filing under Title 11 of the Federal Bankruptcy Code with respect to the employer. With regard to this qualifying event, the loss of coverage may include the substantial elimination of coverage within one year before or after the filing. AEP Active and Retiree Dental DMO Plan SPD

21 For qualifying event purposes, coverage will be considered lost if a person ceases to be covered under the same terms and conditions as in effect immediately before the applicable qualifying event. Any increase in the premium or contribution that you must pay (or that your spouse or dependent child must pay) for coverage under a plan that results from the occurrence of a qualifying event is considered a loss of coverage. The loss of coverage need not occur immediately after the qualifying event, so long as the event occurs before the end of the maximum coverage period (discussed under the heading Duration of Continuation Coverage ). The taking of leave under the Family and Medical Leave Act (FMLA) is not considered a qualifying event under COBRA. A qualifying event may occur under COBRA, however, on the last day of your FMLA leave. Obligation to Notify the Company of Certain Qualifying Events Under COBRA, you or your family member has the responsibility to inform the Company of a divorce or legal separation, or of a child losing dependent status under the Plan. This notice must be provided to the AEP Benefits Center within 60 days of the qualifying event. If the AEP Benefits Center is not provided such notice within that time, there will be no continuation coverage available with respect to that qualifying event. You or your covered family member also has the responsibility to inform the Company of a Social Security determination that you or your covered family member was disabled either at the time of your termination or reduction in hours, or within 60 days thereafter. This notice must be provided to the AEP Benefits Center in writing during the initial 18 months of continuation coverage and within 60 days of the Social Security determination. If the AEP Benefits Center is not provided such notice within that time, the 11-month extension of the maximum continuation coverage period will not be available. Also, if a child is born to you or placed for adoption with you during the period that you have elected continuation coverage, that child may also be added to your coverage assuming that you timely notify the AEP Benefits Center of the addition of the child and timely pay any additional premium that becomes payable as a result of the addition. Please refer to the section entitled Dependent Eligibility to determine how and when you may add a child to your coverage. The Company has the responsibility to notify the Plan of your death, termination of employment or reduction in hours, or if you become eligible for Medicare. Therefore, you should immediately notify the AEP Benefits Center if you or another covered individual becomes eligible for Medicare. The Company also relies on you to notify the Plan of the death of a covered individual or if a covered individual becomes eligible for Medicare. Therefore, please immediately notify the AEP Benefits Center if any of these persons dies or becomes eligible for Medicare and of the death of a covered individual. Notice of Election. When the AEP Benefits Center is notified that one of the applicable qualifying events has occurred, the AEP Benefits Center will in turn notify the qualified beneficiary of the right to choose continuation coverage. This COBRA Notification letter will be mailed to you and/or the other qualified beneficiaries at the last known address; therefore, it is imperative that you and your dependents keep the AEP Benefits Center informed of any address change. AEP Active and Retiree Dental DMO Plan SPD

22 Under COBRA, you and each qualified beneficiary have 60 days from the latter of the date you would lose coverage because of one of the qualifying events previously described, or the date you are notified of your rights to continue coverage, to inform the Company that you want continuation coverage. As mentioned, to inform the Company of your decision, please contact the AEP Benefits Center toll-free at If you do not choose continuation coverage with respect to the Plan, your coverage under the Plan will end. If you choose continuation of coverage under the Plan, the Company is required to give you coverage which is identical to the coverage provided under the Plan to similarly situated employees or family members, as such coverage may change from time to time. You and each of your other qualified beneficiaries are eligible to continue only those Plan coverages that were in effect immediately before the qualifying event. No evidence of insurability is required for election of COBRA continuation coverage. Of course, you must pay the required contributions for the continuation coverage in a timely manner. (See the section on Conditions on Continuation Coverage. ) Duration of Continuation Coverage. COBRA requires that you be afforded the opportunity to maintain continuation coverage for 36 months unless you lost coverage because of a termination of employment or reduction in hours. In that case, the required continuation coverage period is 18-months, unless the Social Security Administration determines that you or a member of your family were disabled at the time of the termination or reduction of hours (or within 60 days thereafter), and you inform the AEP Benefits Center in writing within 60 days of that determination and before the end of the 18-month period, in which case your coverage and the coverage of your family members may be extended to as many as 29 months. You may be requested to provide additional documentation in order to qualify for this 11-month extension. If, during the initial 18 months of continuation coverage, another qualifying event takes place that also entitles you to coverage, coverage may be extended. In no case may the total amount of continued coverage be more than 36 months. If a second event occurs, it is the qualified beneficiary s obligation to notify the AEP Benefits Center of the second qualifying even within 60 days of that event and within the original 18-month period. There is a special rule that applies if you become eligible for Medicare within the 18 months prior to termination of employment or reduction in hours. Under that circumstance, although your spouse and/or dependent children effectively lose coverage because of your termination of employment or reduction in hours, they will be entitled to maintain continuation coverage for a period that does not expire before 36 months have passed since you became entitled to Medicare. If you are a retiree or a spouse or dependent child of a retiree, special rules apply to determine your maximum period of COBRA continuation coverage. COBRA generally requires that a plan offer conversion health plan coverage to a qualified beneficiary who uses continuation coverage for the maximum coverage period, but only if conversion coverage is otherwise generally available under the Plan. Because the DPPO option offers no such conversion coverage, none will be made available following the expiration of continuation coverage for any qualified beneficiary. DMO option participants may be eligible to convert to an individual health plan without providing proof of good health. AEP Active and Retiree Dental DMO Plan SPD

23 COBRA also provides that continuation coverage may be cut short for ANY of the following reasons: 1. The Company no longer provides group health coverage to any of its employees; 2. The contribution for continuation coverage is not paid in a timely fashion; 3. You, your spouse or dependent will lose COBRA continuation coverage upon becoming covered under another group health plan that does not include a preexisting conditions clause that applies (note that the Health Insurance Portability and Accountability Act of 1996 limits the circumstances in which plans can apply preexisting conditions clauses); 4. You, your spouse or dependent will lose COBRA continuation coverage upon becoming entitled to benefits under Medicare (Part A, Part B or both); or 5. For cause, such as fraudulent claim submission, on the same basis that coverage could terminate for other similarly situated participants in the Plan. Therefore, you must immediately notify the AEP Benefits Center if you, your spouse or any of your covered dependents become eligible for benefits under Medicare. Furthermore, if continuation coverage is extended beyond 18 months because of disability, continuation coverage will be cut short after the latter of the expiration of the initial 18-month continuation period or the date that the qualifying beneficiary is determined to be no longer disabled. You are required to notify the AEP Benefits Center within 60 days of the date of any final determination by the Social Security Administration that the qualified beneficiary is no longer disabled. If you fail to timely notify the AEP Benefits Center, the Plan reserves the right to recover from you its costs associated with recovering the excess benefits provided to you. Conditions on Continuation Coverage. You do not have to show that you are insurable to choose continuation coverage. However, under COBRA, you will have to timely pay all of the contributions for your continuation coverage as outlined under the law. The contribution for your continuation coverage generally is equal to no more than the full cost of the coverage plus a 2% charge to cover the cost of plan administration. If you or your dependents are entitled to up to 29 months of continuation coverage due to disability, the premium increases to as much as 150% of the full cost beginning with the 19th month of continuation coverage. The AEP Benefits Center can provide you with current cost information. You must pay for the coverage in monthly installments. Your first payment must be in full and received no later than 45 days after the date you elect continuation coverage. For payment after that first payment, you will have a grace period of at least 30 days to pay the premiums. As a general matter, coverage will be suspended for any period that premiums have not been paid. However, coverage will be reinstated upon the receipt of timely payment (taking into account the grace period for that payment). Continuation of Coverage During Military Leave (USERRA) Under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), you may have a right to continuation of benefits subject to the conditions described below. AEP Active and Retiree Dental DMO Plan SPD

24 Under USERRA, if the Employee (or his or her Dependents) is covered under this Plan, and if the Employee becomes absent from employment by reason of military leave, the Employee (or his or her Dependents) may have the right to elect to continue health coverage under the Plan. In order to be eligible for coverage during the period that the Employee is gone on military leave, the Employee must give reasonable notice to the Employer of his or her military leave and the Employee will be entitled to COBRA-like rights with respect to his or her group health benefits in that the Employee and his or her Dependents can elect to continue coverage under the plan for a period of 24 months from the date the military leave commences or, if sooner, the period ending on the day after the deadline for the Employee to apply for or return to work with the Employer. During military leave the Employee is required to pay the Employer for the entire cost of such coverage, including any elected Dependents coverage. However, if the Employee s absence is less than 31 days, the Employer must continue to pay its portion of the contributions and the Employee is only required to pay his or her share of the contributions without the COBRA-type 2% administrative surcharge. Also, when the Employee returns to work, if the Employee meets the requirements specified below, USERRA states that the Employer must waive any exclusions and waiting periods, even if the Employee did not elect COBRA continuation. These requirements are (i) the Employee gave reasonable notice to his or her Employer of military leave, (ii) the military leave cannot exceed a prescribed period (which is generally five (5) years, except in unusual or extraordinary circumstances) and the Employee must have received no less than an honorable discharge (or, in the case of an officer, not been sentenced to a correctional institution), and (iii) the Employee must apply for reemployment or return to work in a timely manner upon expiration of the military leave (ranging from a single day up to 90 days, depending upon the period that he or she was gone). The Employee may also have to provide documentation to the Employer upon reemployment that would confirm eligibility. This protection applies to the Employee upon reemployment, as well as to any Dependent who has become covered under the Plan by reason of the Employee s reinstatement of coverage. Life Events and Your Coverage In general, once you enroll in dental plan benefits, you cannot make changes to your elections until the next Annual Enrollment period. However, certain events in your life such as a marriage, divorce or birth of a child may warrant mid-year changes that are due to and consistent with the event. Remember if you do not make your change within 31 days of the event (or as otherwise specified below in certain circumstances), you may not change your elections until the next Annual Enrollment period. You Begin Working at AEP As a new employee of a Participating Company, you must indicate your dental plan election within 31 days of your hire date. If you do not enroll within 31 days, you will not have coverage. Unless you experience a qualifying change in family or employment status, you will not be able to make changes to your benefit elections until the next Annual Enrollment period. Coverage begins on your first day of work, if you enroll within 31 days of your date of hire. You Get Married Your marriage is considered a qualifying change in family status which allows you to adjust your participation in the dental plan. You must contact the AEP Benefits Center in order to make benefit changes when you marry. All changes must be made within 31 days of the date of your marriage. A copy of the certified marriage certificate will be requested by the AEP Benefits Center in order to enroll your new spouse. A marriage event does NOT allow you to change your dental plan option. AEP Active and Retiree Dental DMO Plan SPD

25 Coverage is effective on the date of your marriage if you enroll yourself, your spouse and/or your eligible dependents within 31 days of the date of your marriage. Your Marriage Ends It s important to keep the AEP Benefits Center informed of loss of dependent eligibility due to the end of your marriage. The AEP Benefits Center can help you make appropriate benefits changes. If you have spouse or family dental coverage, coverage for your former spouse (and any stepchildren) ends on the last day of the month in which your marriage ends. You are required to notify the AEP Benefits Center to remove the names of former dependents from your dental plan. Your former spouse and any stepchildren may continue the group coverage for 36 months through COBRA. If you have eligible children, you may wish to retain Participant + Child(ren) dental coverage even if you do not have custody of your child(ren). If you drop dependent coverage, you may not resume coverage for these dependents until the next Annual Enrollment period. If you were covered under your spouse s dental plan, you have 31 days from the date your marriage ends to apply for AEP dental coverage in your own name. An event ending your marriage event does NOT allow you to change your dental plan option. Your Domestic Partnership Ends You must notify the AEP Benefits Center of the loss of dependent eligibility due to termination of a domestic partnership. The AEP Benefits Center can help you make changes to your dental coverage. You will need to supply a Declaration of Termination of Domestic Partnership form to the AEP Benefits Center in order to change your dental coverage. If you have domestic partner or family dental coverage, coverage for your former domestic partner (and any children of your domestic partner) ends on the last day of the month of the end of your partnership. You are required to notify the AEP Benefits Center to remove the names of former dependents from your dental coverage. Your former domestic partner (and any children of your domestic partner) may continue the group coverage for up to 36 months, based on the manner the Company is currently offering COBRA continuation coverage. If you were covered under your domestic partner s dental coverage, you have 31 days from the date of the end of the partnership to apply for AEP dental coverage. The termination of your domestic partnership does NOT allow you to change your dental plan option. You Are Unable to Work Due to an Illness or Injury If you are unable to work due to illness or injury while covered under the AEP Comprehensive Dental Plan, your coverage and obligation to make contributions continue while you are receiving sick pay and for as long thereafter as you are receiving benefits under AEP s Long-term Disability (LTD) plan. You Die In the event you die, your survivors must contact the AEP Benefits Center to: Make decisions about whether to continue dental coverage for themselves if they were enrolled in dental coverage at the time of your death. AEP Active and Retiree Dental DMO Plan SPD

26 If you die while employed at AEP, your eligible surviving dependents can continue dental plan coverage if all required contributions are paid up to date. Please refer to the Eligibility section for additional information about who is eligible to be covered as a surviving dependent and for how long. If a surviving dependent enrolls in the AEP Comprehensive Dental Plan but later disenrolls from the plan, he or she may not elect to re-enroll later. Your survivors will need to submit a copy of your Death Certificate to the AEP Benefits Center prior to enrollment in coverage. Your survivors must enroll within 31 days of your death, or such longer period as may be required by COBRA. Your survivors will need to submit a copy of your Death Certificate to the AEP Benefits Center prior to enrollment in coverage. Your death does NOT allow your surviving dependents to change the dental plan option in which they were enrolled A Covered Family Member Dies The death of a family member who is eligible for AEP benefits is considered a qualifying change in family status which allows you to adjust your participation in the dental plan. Remember that any changes must be made within 31 days of the death. Review your dental coverage, and contact the AEP Benefits Center to adjust your coverage level, as appropriate, for the surviving family members The death of a covered dependent does NOT allow you to change your dental plan option.. Your Child Loses Dependent Status Your child loses eligibility to be covered as your dependent at the end of the month in which he or she turns age 26. If your child is disabled when coverage would otherwise end, you may be able to keep him or her covered under your plan. Consult the AEP Benefits Center for requirements to continue coverage during the child s disability. Dental coverage also ends for your dependent on the last day of the month in which he or she no longer meets any other requirement to be considered an eligible dependent. The child may continue coverage through COBRA. Birth, Adoption, Placement for Adoption or Legal Guardianship Your newborn child will be eligible for coverage on the date of birth. If a child is placed with you for adoption, he or she will be eligible for coverage on the date of the placement for adoption as long as the child satisfies the eligibility requirements of this plan. To enroll a newborn or other dependent child in dental coverage, you must notify the AEP Benefits Center within 90 days of the birth, adoption, or the date the child was legally placed in your care in anticipation of adoption. You must provide the dependent s Social Security number or tax-identification number for non-usa citizens, within six months of adding a dependent. The AEP Benefits Center will request a copy of the birth certificate to validate their eligibility. AEP Active and Retiree Dental DMO Plan SPD

27 Change in Your Spouse's/Domestic Partner s Employment If your spouse s/domestic partner s coverage is affected by a change in his or her employment or benefits eligibility with his or her current employer, you may be eligible to begin, change, or discontinue coverage under the AEP Comprehensive Dental Plan to the extent that would be consistent with the events affecting your spouse/domestic partner. You may not change your dental plan option if you are already enrolled in the AEP Dental Plan. You must contact the AEP Benefits Center within 31 days of your spouse s/domestic partner s loss/gain of coverage. You Begin a Family Medical Leave of Absence (FMLA) If you are on an approved Family Medical Leave of Absence (FMLA), your benefits may be affected. You may be on a paid or unpaid leave of absence under FMLA. Under a paid FMLA absence, your dental coverage continues as normal and your dental plan contributions continue to be taken from your first and second paychecks of the month. If your FMLA is unpaid, you have the following options: Revoke Coverages during the Leave. In order to take advantage of this option, then within 31 days after your leave begins, you must notify the AEP Benefits Center of the specific coverages that you want to discontinue during the period of your unpaid FMLA leave. You will be entitled to reinstate the discontinued coverages upon your return to work following your leave. Continue Your Coverages by Making Payments. Unless you notify the AEP Benefits Center otherwise, it will be assumed that this is the option that you select. Under this option, you would pay for your coverage by the first of each month during the leave. When the leave ends, your salary reduction election that had been in effect at the beginning of your leave will be given effect for the duration of the calendar year unless you would make an election change upon returning from the leave, as permitted under the terms of our plan (e.g., for changes in status). If you would stop making contributions for your coverage during the leave, AEP will continue your coverage, and AEP will recoup your missed payments upon your return. COBRA eligibility does not begin until your FMLA leave ends. You Begin an Unpaid Leave of Absence (non-fmla) In certain situations, you may need to take more time off from work than your available vacation time allows. In such cases, you may be eligible for an unpaid leave of absence. Your dental contributions from your paycheck stop when your unpaid leave begins. Coverage ends at the end of the month in which your unpaid Leave of Absence begins. You will be offered the option to continue dental coverage through COBRA. You Begin a Paid Military Leave of Absence Serving on active duty in the Armed Forces of our country can have an effect on your AEP benefits. Generally, all benefit coverage levels will continue for up to 24 months at the level in effect immediately before your paid military leave begins. You have the option to maintain some or all of your benefits during your paid military leave. AEP Active and Retiree Dental DMO Plan SPD

28 If you elect to continue your dental coverage, your contribution continues at the active employee rate for as long as you receive pay differential, for up to 24 months and your contributions will be withheld from your paycheck. If you don t have enough net pay to take all of your deductions, you will be billed on a monthly basis. If you elect to discontinue dental coverage during your paid military leave of absence, your coverage will end at the end of the month in which your paid military leave began. If you go onto an unpaid Military Leave of Absence, see Continuation of Coverage During Military Leave (USERRA), and You Begin an Unpaid Leave of Absence (non-fmla) for information regarding your dental coverage. You Terminate Employment Before Qualifying for AEP Retiree Benefits If your employment with a Participating Company terminates for any reason prior to both reaching age 55 and at least 10 years of service, your dental coverage ends on the last day of the month in which your employment ends. You and your dependents may be eligible to continue dental coverage through COBRA. Under COBRA you pay the full cost of that coverage, plus an administrative charge. You Terminate Employment After Becoming Retiree Benefits Eligible If you are age 55 or older with at least 10 years of service when your employment with a Participating AEP system company ends, you may be considered an AEP retiree. See the Enrolling for Coverage section. If you elect retiree dental coverage, premiums will either be deducted from your monthly pension check or you will be billed monthly for your premiums. You Are Rehired at AEP As a rehired employee of a Participating Company, you must indicate your dental care election within 31 days of your rehire date. If you do not enroll within 31 days, you will not have dental coverage. Unless you experience a qualifying change in family or employment status, you will not be able to make changes to your benefit elections until the next Annual Enrollment period. You and your eligible dependents are covered from your first day of work, if you enroll within 31 days of your rehire date. You Return from an Unpaid Leave of Absence After returning from an approved leave of absence, you may resume participation in benefits that you may have stopped during your leave or benefits that you may have elected under COBRA. You may continue, add, or discontinue dental coverage for yourself and your eligible dependents, within 31 days of your return from leave. If you resume participation in the dental plan when you return from your unpaid leave, your contributions will begin coming out of your paycheck again. AEP Active and Retiree Dental DMO Plan SPD

29 You Return After Retirement If you return to work with a Participating AEP Company after retirement and are only returning for a temporary length of time (less than 1 year), you may be eligible to be considered a rehired retiree or you can also return to work for AEP as a regular full-time or part-time employee. If you return as a rehired retiree, you retain your retiree dental coverage at the applicable retiree contribution rate while you work. Your dental contributions will be deducted from your paycheck. Coverage or Employer Contributions Lost Under Another Dental Plan A Special Enrollment Period is available to you (if you are an eligible Employee or Retiree) and your eligible Dependents who: lost eligibility under a prior dental plan for reasons other than non-payment of premium or due to fraud or intentional misrepresentation of a material fact; exhausted COBRA benefits or stopped receiving group contributions toward the cost of the prior dental plan; or lost Employer contributions towards the cost of the other coverage. Notice of a requested change must be made to the AEP Benefits Center within 31 days of the event (or within 90 days of a birth or adoption). You also may be required to provide proof of the qualifying status change(s). Newly Eligible Because of Change in AEP Employment Status If your AEP employment status would change from one not eligible to participate (such as if you had been classified as a contractor, temporary employee, or leased employee) to one that is, you may be able to enroll in the dental plan within 31 days of the change in employment status. Notice of a requested change must be made to the AEP Benefits Center within 31 days of the change in your status. How Your Aetna Dental Plan Works Understanding Your Aetna Dental Plan It is important that you have the information and useful resources to help you get the most out of your Aetna dental plan. This Summary Plan Description ( SPD ) explains: Definitions you need to know; How to access care, including procedures you need to follow; What services and supplies are covered and what limits may apply; What services and supplies are not covered by the plan; How you share the cost of your covered services and supplies; and Other important information such as eligibility, complaints and appeals, termination, continuation of coverage and general administration of the plan. Important Notes: Unless otherwise indicated, you refers to you and your covered dependents. You can refer to the Eligibility section for a complete definition of you. This SPD applies to coverage only and does not restrict your ability to receive covered expenses that are not or might not be covered expenses under this dental plan. Store this SPD in a safe place for future reference. AEP Active and Retiree Dental DMO Plan SPD

30 Getting Started: Common Terms Many terms throughout this SPD are defined in the Glossary Section at the back of this document. Defined terms appear in bolded print. Understanding these terms will also help you understand how your plan works and provide you with useful information regarding your coverage. About the Managed Dental Plan Under the Managed Dental Plan, you access care through the primary care dentists (PCD) you select when you enroll. Each covered family member may select a different PCD. Your PCD provides basic and routine dental services and supplies, and will refer you to other dental providers in the network. You may select a PCD from the Aetna network provider directory or by logging on to Aetna s website at You can search Aetna s online directory, DocFind, for names and locations of network providers. Out-of-network services and supplies are not covered, except in the event of a dental emergency. Important Reminder You must have a referral from your PCD in order to receive coverage for any services a specialist dentist provides. Please refer to the Referral Process section. Accessing Network Providers The plan pays a higher level of benefits when your PCD provides your care or refers you to a specialist dentist. You must pay a copay for certain types of services and supplies. You have no further out-of-pocket expenses after you pay all applicable copays, as shown in the Schedule of Benefits. You will not have to submit dental claims for treatment received from network providers. Your network provider will take care of claim submission. Aetna will directly pay the network providers less any cost sharing required by you. You will be responsible for coinsurance and copayments, if any. If you need a service that is not available from a network provider, your PCD may refer you to an outof-network provider. You will receive the network level of coverage if your PCD gets approval from Aetna for this referral. Changing Your PCD You may change your PCD at any time on Aetna s website, or by writing to Aetna or calling the Member Services toll-free number on your identification card. The change will be effective as follows: If Aetna receives a request on or before the 15th day of the month, the change will be effective on the first day of the next month. If Aetna receives a request after the 15th day of the month, the change will be effective on the first day of the month following the next month. Availability of Providers Aetna cannot guarantee the availability or continued participation of a particular provider. Either Aetna or any network provider may terminate the provider contract or limit the number of patients accepted in a practice. If the PCD initially selected cannot accept additional patients, you will be notified and given an opportunity to make another selection. If the agreement between Aetna and your selected PCD is terminated, Aetna will notify you of the termination and request you to select another PCD. AEP Active and Retiree Dental DMO Plan SPD

31 Important Reminder Refer to the Schedule of Benefits for details about any applicable deductibles, copayments, coinsurance and maximums. There is a separate deductible and maximum that applies to orthodontic treatment. Using Your Dental Plan The Referral Process There may be times when you need services and supplies that only a dental specialist can provide. In these cases, your PCD will make a referral to a specialist dentist. A PCD referral is not required for any orthodontic services. Having a referral from your PCD keeps your out-of-pocket expenses lower for services of a specialist dentist and any necessary follow-up treatment. The referral is important because it is how your PCD arranges for you to receive care and follow-up treatment. Important Reminder You must have a referral from your PCD in order to receive the network level of coverage for any services received from a specialist dentist. How Referrals Work Here are some important points to remember: When your PCD determines that your treatment should be provided by a specialist dentist, you'll receive a written or electronic referral. The referral will be good for 90 days, as long as you remain covered under the plan. Go over the referral with your PCD. Make sure you understand what types of services have been recommended and why. When you visit the specialist dentist, bring the referral (or check in advance to verify that they have received the electronic referral). Without it, you'll receive out-of-network benefits even if you receive your treatment from a network provider. You cannot request a referral from your PCD after you have received services from a specialist dentist. If a service you need isn't available from a network provider, your PCD may refer you to an out-ofnetwork provider. Your PCD must get precertification from Aetna and issue a special out-of-network referral for services from out-of-network providers to be covered at the network level of coverage. When You Do Not Need a PCD Referral You do not need a PCD referral for: Emergency care. Please refer to the In the case of a Dental Emergency section. Direct Access Services. Orthodontic services and supplies do not require a referral. AEP Active and Retiree Dental DMO Plan SPD

32 In Case of a Dental Emergency If you need dental care for the palliative treatment (pain relieving, stabilizing) of a dental emergency, you are covered 24 hours a day, 7 days a week. A dental emergency is any dental condition which: Occurs unexpectedly; Requires immediate diagnosis and treatment in order to stabilize the condition; and Is characterized by symptoms such as severe pain and bleeding. Follow the guidelines below when you believe you have a dental emergency. If you have a dental emergency, call your PCD. If you cannot reach your PCD or are away from home, you may get treatment from any dentist. You may also call Member Services for help in finding a dentist. The care must be for the temporary relief of the dental emergency until you can be seen by your PCD. The care provided must be a covered service or supply. You must submit a claim to Aetna describing the care given. The plan pays a benefit up to the dental emergency maximum. All follow-up care should be provided by your PCD. If you seek care from an out-of-network provider for a non-emergency dental condition (that is, one that does not meet the definition above), no benefit will be payable. What the Plan Covers Managed Dental Plan Managed Dental Plan is merely a name of the benefits in this section. The plan does not pay a benefit for all dental expenses you incur. Important Reminder Your dental services and supplies must meet the following rules to be covered by the plan: The services and supplies must be medically necessary. The service and supplies must be listed in the dental care schedule. You must be covered by the plan when you incur the expense. Covered expenses include charges made by a dental provider only for the services and supplies that are listed in the dental care schedule that applies. See Schedule of Benefits. The next sentence applies if: A charge is made for an unlisted service given for the dental care of a specific condition; and The list includes one or more services that; under standard practices; are separately suitable for the dental care of that condition. In that case, the charge will be considered to have been made for a service in the list that Aetna determines would have produced a professionally acceptable result. Coverage is also provided for a dental emergency. For additional information, please refer to In Case of a Dental Emergency. AEP Active and Retiree Dental DMO Plan SPD

33 Important Reminder The copays that apply to each type of dental care are shown in the Schedule of Benefits. Schedule of Benefits This Schedule Applies To Covered Expenses Provided By Network Providers. Dental Emergency Maximum: $100 Dental Care Schedule The following dental care schedule shows services that require a copay; and the copay amount. Dental services that are considered covered expenses as shown in the dental care schedule must be given by network providers, at the dental office location. The exceptions to this rule are when Aetna approves referral care, or for out-of-area emergency dental care. If: A charge is made for an unlisted service given for the dental care of a specific condition; and The list includes one or more services that, under standard practices, are separately suitable for the dental care of that condition, then the charge will be considered to have been made for a service that would have produced professionally acceptable result, as determined by Aetna. This Schedule Applies to Services Provided by Network Providers Primary Care Dentist Services Visits and Exams Oral examination (limited to total of 4 visits per calendar year) Copayment Amount $0 Emergency palliative treatment $10 Prophylaxis (cleaning), (limited to 2 treatments per calendar year) Adult $0 Child $0 Topical application of fluoride (limited to 1 treatment per calendar year and to covered persons under age 16) $0 Oral hygiene instruction $0 Sealants, per tooth (limited to 1 application every 3 rolling years for permanent molars only and covered persons to age 16) $5 Pulp vitality test $0 Consultation $0 Diagnostic casts $0 X-Rays and Pathology Bitewing x-rays (limited to 1 set per calendar year) $0 Entire series, including bitewings, or panoramic film, (limited to 1 set every 3 rolling years) $0 Vertical bitewing X-rays (limited to 1 set every 3 rolling years) $0 Periapical x-ray $0 Intra-oral, occlusal view, maxillary or mandibular $0 Extra-oral upper or lower jaw $0 Biopsy and histopathologic examination of oral tissue $75 AEP Active and Retiree Dental DMO Plan SPD

34 Space Maintainers - (only when needed to preserve space resulting from premature loss of primary teeth) Includes all adjustments within six months after installation Fixed $75 Removable $70 Recement space maintainer $12 Remove fixed space maintainer (by dentist who did not place appliance) $12 Endodontics Pulp cap $0 Pulpotomy $22 Root canal therapy, including necessary x-rays Anterior $70 Bicuspid $109 Restorations and Repairs (Copayments for crowns and pontics are per unit.) There will be an additional patient charge for the actual cost of high noble metal ( gold ) when used for services shown with an asterisk. Amalgam restoration 1 surface $0 2 surfaces $0 3 surfaces $0 4 or more surfaces $0 Resin-based composite restoration (anterior) 1 surface $0 2 surfaces $0 3 surfaces $0 4 or more surfaces or incisal angle $45 Resin-based composite crown, anterior $50 Resin-based composite restoration (posterior) 1 surface $35 2 surfaces $45 3 surfaces $55 4 or more surfaces $75 Retention pins $10 Stainless steel crowns, prefabricated, primary tooth $40 Stainless steel crowns, prefabricated, permanent tooth $50 Recementing inlays or crowns $10 Recementing bridges $15 Sedative filling $3 Inlays and Onlays, metallic* $195 Crowns Porcelain $255 Porcelain with metal (includes abutments)* $255 Metallic (full cast) (includes abutments)* $255 Metallic (3/4 cast)* $255 Cast post and core* $112 Prefabricated post and core $74 Core buildup including pins $80 AEP Active and Retiree Dental DMO Plan SPD

35 Pontics Metallic (full cast)* $255 Porcelain with metal* $255 Full mouth rehabilitation, per unit (This means 6 or more covered units of crowns and/or pontics under one treatment plan.) $125 Dentures and Partials - (Includes relines, rebases and adjustments within six months after installation. Adjustments within first six months are limited to four.) Complete, upper or lower $275 Partial, upper or lower Resin base $275 Cast metal base $350 Immediate, upper or lower (does not include charge for reline) $315 Adjust complete denture, upper or lower $10 Adjust partial denture, upper or lower $10 Repair broken acrylic, complete denture, upper or lower $30 Replace one tooth on complete denture $20 Repair acrylic, cast frame, broken clasp $35 Replace broken tooth, partial $35 Add tooth to existing partial denture $35 Add clasp to existing partial $40 Replace all teeth and acrylic on cast metal framework $100 Rebase, complete denture, upper or lower $100 Rebase, partial denture, upper or lower $100 Reline, complete denture, upper or lower (chairside) $45 Reline, partial denture, upper or lower (chairside) $45 Reline, complete denture, upper or lower (laboratory) $102 Reline, partial denture, upper or lower (laboratory) $102 Interim partial denture, upper or lower (stayplate), anterior only $90 Tissue conditioning for dentures $40 Periodontics Scaling and root planning, per quadrant (limited to 4 separate quadrants every 2 rolling years) $62 Scaling and root planning -1 to 3 teeth per quadrant (limited to once per site every 2 rolling years) $37 Periodontal maintenance procedures following surgical therapy (limited to 2 per calendar year) $45 Full mouth debridement (once per lifetime) $60 Occlusal guard (for bruxism only), limited to 1 every 3 rolling years $100 Oral Surgery - Includes local anesthetics and routine post-operative care Extraction - exposed root or erupted tooth $0 Extraction - coronal remnants $0 Surgical removal of erupted tooth $28 Surgical removal of impacted tooth (soft tissue) $46 Incision and drainage of intraoral abscess $20 Surgical exposure of impacted or unerupted tooth to aid eruption. $30 AEP Active and Retiree Dental DMO Plan SPD

36 Specialty Services Copayment Amount Endodontics - Includes local anesthetics where necessary Apicoectomy/periradicular surgery Anterior $92 Bicuspid, first root $92 Molar, first root $90 Each additional root $55 Retrograde filling, per root $40 Root amputation, per root $70 Molar root canal therapy $280 Retreatment of previous root canal therapy Anterior $170 Bicuspid $209 Molar $380 Oral Surgery - Includes local anesthetics where necessary and post-operative care Surgical removal of root tip, root recovery $25 Frenectomy $34 Alveoplasty in conjunction with extractions per quadrant $25 Alveoplasty not in conjunction with extractions per quadrant $40 Surgical removal of impacted tooth Partially bony $58 Completely bony $117 Completely bony with unusual surgical complications $117 Periodontics Gingivectomy or gingivoplasty - per quadrant, limited to 1 per quadrant, every $133 3 rolling years Gingivectomy or gingivoplasty 1 3 teeth, limited to 1 per site, every 3 rolling years $57 Gingival flap procedure per quadrant $134 Gingival flap procedure 1 3 teeth one per quadrant $80 Occlusal adjustment (other than with an appliance or restoration) Limited $20 Complete $80 Osseous surgery (including flap entry and closure) - per quadrant, limited to 1 per quadrant, every 3 rolling years $300 Osseous surgery (including flap entry and closure) 1 3 teeth, limited to once per site every 3 rolling years $180 Surgical revision procedure, per tooth $120 Pedicle soft tissue graft $230 Free soft tissue graft (including donor site surgery) $245 Subepithelial connective tissue graft $275 Soft tissue allograft $275 Combined connective tissue and double pedicle graft $303 Clinical crown lengthening hard tissue $180 Orthodontics Orthodontic screening exam (when no Orthodontic Procedure is performed) $30 Orthodontic diagnostic records $150 Comprehensive orthodontic treatment of adolescent and adult dentition $1,945 Orthodontic retention $275 AEP Active and Retiree Dental DMO Plan SPD

37 GENERAL ANESTHESIA AND INTRAVENOUS SEDATION (only when provided in conjunction with a covered surgical procedure) Deep sedation/general Anesthesia First 30 minutes $165 each additional 15 minutes $70 Intravenous conscious sedation/analgesia First 30 minutes $165 each additional 15 minutes $70 This Schedule Applies to Covered Expenses Provided by Out-of-Network Providers Dental Care Schedule Out-of-Network Deductible $100 Copayment The copayment is the amount of charges that exceeds the benefits payable under this coverage. This dental care schedule shows services that are covered and maximum charge eligible under the plan for each service. Dental services that are considered covered expenses as shown in the dental care schedule must be given by a licensed dentist, at the dental office location. You are responsible for any amount above the Amount Payable shown. The next sentence applies if: A charge is made for an unlisted service given for the dental care of a specific condition; and The list includes one or more services that, under standard practices, are separately suitable for the dental care of that condition, then the charge will be considered to have been made for a service that would have produced a professionally acceptable result, as determined by Aetna. Primary Care Services Schedule Type A Services Visits and Exams Office visit for oral examination (limited to 4 visits per year) $12 Emergency palliative treatment $12 Prophylaxis (cleaning) (limited to 2 treatments per year) Adult $26 Child $14 Topical application of fluoride (limited to 1 treatment per year and to covered persons under age 16) $16 Oral hygiene instruction $12 Sealants; per tooth (limited to 1 application every 3 years for permanent molars and to covered persons under age 16) $10 Pulp vitality test $8 Consultation $12 Diagnostic casts $20 Out-of-Network maximum Amount Payable by Aetna AEP Active and Retiree Dental DMO Plan SPD

38 X-Ray and Pathology Bitewing x-rays (limited to 1 set per year) $8 Entire series; including bitewings; or panoramic film (limited to 1 set every 3 years) $14 Vertical bitewing x-rays (limited to 1 set every 3 years) $12 Periapical x-rays $6 Intra-oral; occlusal view; maxillary or mandibular $8 Extra-oral upper or lower jaw $12 Biopsy and histopathologic examination of oral tissue $27 Space Maintainers - Includes all adjustments within six months after installation. Fixed; band type $40 Removable acrylic with round wire clasp $32 Recement space maintainer $10 Removal of fixed space maintainer (by dentist who did not place appliance) $10 Type B Services Endodontics Pulp cap $3 Pulpotomy $27 Root canal therapy; including necessary x-rays Anterior $80 Bicuspid $96 Restorations and Repairs Amalgam restoration 1 surface $12 2 surfaces $16 3 surfaces $24 4 or more surfaces $26 Resin restoration (other than for molars) 1 surface $12 2 surfaces $16 3 surfaces $26 4 or more surfaces or incisal angle $30 Retention pins $14 Sedative filling $12 Stainless steel crowns $26 Prefabricated resin crowns (excluding temporary crowns) $60 Recementing inlays or crowns $16 Recementing bridges $16 Tissue conditioning for dentures $26 Periodontics Emergency treatment (abscess; acute periodontitis; etc.) $26 Subgingival curettage (limited to 4 separate quadrants; every 2 years) $40 Scaling and root planning (limited to 4 separate quadrants every 2 years) $40 Periodontal maintenance procedures following surgical therapy (limited to 2 per year) $40 Oral Surgery - Includes local anesthetics and routine post-operative care. Extraction, coronal remnants $14 Extraction - exposed root or erupted tooth $27 Surgical removal of erupted tooth $32 AEP Active and Retiree Dental DMO Plan SPD

39 Surgical removal of impacted tooth (soft tissue) $40 Excision of hyperplastic tissue $32 Excision of pericoronal gingival $40 Incision and drainage of abscess $20 Crown exposure to aid eruption $26 Removal of foreign body from soft tissue $20 Suture of soft tissue injury $20 Type C Services Restorations Inlays 1 surface $60 2 or more surfaces $80 Onlays 2 surfaces $80 3 or more surfaces $80 Crowns (including build-ups when necessary) Resin $120 Resin with noble metal $120 Resin with base metal $120 Porcelain $120 Porcelain with noble metal $120 Porcelain with base metal $120 Base metal (full cast) $120 Noble metal (full cast) $120 Metallic (3/4 cast) $120 Post and core $27 Pontics Base metal (full cast) $20 Noble metal (full cast) $20 Porcelain with noble metal $20 Porcelain with base metal $20 Resin with noble metal $20 Resin with base metal $20 Dentures and Partials - (includes relines; rebases and adjustments within six months after installation) Full (Upper or Lower) $120 Partial $120 Stress breakers (per unit) $40 Interim partial denture; (stayplates); anterior only $40 Crown and bridge repairs $27 Adding teeth to an existing denture $40 Full and partial denture repairs $27 Relining/rebasing dentures (includes adjustments with six months after installation) $40 Occlusal guard (for bruxism only); (limited to 1 every 3 years) $40 AEP Active and Retiree Dental DMO Plan SPD

40 Specialty Care Dental Services Type B Services Endodontics - Includes local anesthetics where necessary. Apexification/recalcification - per visit $32 Apicoectomy First root $60 Each additional root $40 Retrograde Filling $14 Root Amputation $27 Hemisection $27 Oral Surgery - Includes local anesthetics where necessary and post-operative care. Removal of residual root $27 Removal of odontogenic cyst $40 Closure of oral fistula $48 Removal of foreign body from bone $20 Sequestrectomy $20 Frenectomy $40 Transplantation of tooth or tooth bud $48 Alveoplasty in conjunction with extractions - per quadrant $27 Alveoplasty not in conjunction with extractions - per quadrant $40 Removal of exostosis $60 Sialolithotomy; removal of salivary calculus $36 Closure of salivary fistula $36 Periodontics Gingivectomy or gingivoplasty - per quadrant (limited to 1 quadrant; every 3 years) $40 Gingivectomy or gingivoplasty - per tooth (limited to 1 per site; every 3 years) $20 Gingival flap procedure - per quadrant $60 Occlusal adjustment (other than with an appliance or by restoration) Limited $20 Entire Mouth $40 Type C Services Endodontics - Includes local anesthetics where necessary. Complex Molar Root Canal Therapy $120 Intravenous Sedation and General Anesthesia - per 15-minute segment. $20 Oral Surgery - Includes local anesthetics where necessary and post-operative care. Surgical removal of impacted tooth Partially bony $53 Completely bony $60 Completely bony with unusual surgical complications $64 Periodontics Osseous surgery (including flap entry and closure) per quadrant (limited to 1 per quadrant; every 3 years) $80 Osseous surgery (including flap entry and closure) 1 3 teeth per quadrant (limited to 1 per site every 3 years) $40 Clinical crown lengthening hard tissue $40 AEP Active and Retiree Dental DMO Plan SPD

41 Orthodontics Comprehensive orthodontic treatment of adolescent dentition Comprehensive orthodontic treatment of adult dentition Post Treatment Stabilization Lifetime Maximum: $400 Expense Provisions The following provisions apply to your health expense plan. This section describes cost sharing features, benefit maximums and other important provisions that apply to your Plan. The specific cost sharing features and the applicable dollar amounts or benefit percentages are contained in the attached health expense sections of this Schedule of Benefits. The insurance described in this Schedule of Benefits will be provided under Aetna Life Insurance Company's policy form GR-29N. Deductible Provisions Out-of-Network Calendar Year Deductible This is an amount of out-of-network covered expenses incurred each calendar year for which no benefits will be paid. The out-of-network calendar year deductible applies separately to you and each of your covered dependents. After covered expenses reach the out-of-network calendar year deductible, the plan will begin to pay benefits for covered expenses for the rest of the calendar year. Copayments and Benefit Deductible Provisions Copayment, Copay This is a specified dollar amount or percentage of the negotiated charge required to be paid by you at the time you receive a covered service from a network provider. It represents a portion of the applicable expense. Maximum Benefit Provisions Lifetime Maximum Benefit The most the plan will pay for covered expenses incurred by any one covered person during their lifetime is called the Lifetime Maximum Benefit. The Lifetime Maximum Benefit applies to network and out-of-network expenses combined. The Lifetime Maximum Benefit will not deny benefits for certain covered expenses. General This Schedule of Benefits replaces any similar Schedule of Benefits previously in effect under your plan of benefits. Requests for coverage other than that to which you are entitled in accordance with this Schedule of Benefits cannot be accepted. Coverage is underwritten by Aetna Life Insurance Company. Managed Dental Expense Coverage Plan The following additional dental expenses will be considered covered expenses for you and your covered dependent if you have medical coverage insured or administered by Aetna and have at least one of the following conditions: Pregnancy; Coronary artery disease/cardiovascular disease; Cerebrovascular disease; or Diabetes AEP Active and Retiree Dental DMO Plan SPD

42 Additional Covered Dental Expenses One additional prophylaxis (cleaning) per year. Scaling and root planing, (4 or more teeth); per quadrant; Scaling and root planing (limited to 1 3 teeth); per quadrant; Full mouth debridement; Periodontal maintenance (one additional treatment per year); and Localized delivery of antimicrobial agents. (Not covered for pregnancy) Payment of Benefits The additional prophylaxis, the benefit will be payable the same as other prophylaxis under the plan. The plan coinsurance applied to the other covered dental expenses above will be 100%. These additional benefits will not be subject to any frequency limits except as shown above. Aetna will reimburse the provider directly, or you may pay the provider directly and then submit a claim for reimbursement for covered expenses. Rules and Limits That Apply to the Dental Plan Several rules apply to the dental plan. Following these rules will help you use the plan to your advantage by avoiding expenses that are not covered by the plan. Orthodontic Treatment Rule The plan does not cover the following orthodontic services and supplies: Replacement of broken appliances; Re-treatment of orthodontic cases; Changes in treatment necessitated by an accident; Maxillofacial surgery; Myofunctional therapy; Treatment of micrognathia; Treatment of cleft palate; Treatment of macroglossia; Treatment of primary dentition; Treatment of transitional dentition; Lingually placed direct bonded appliances and arch wires (i.e. invisible braces ); or Removable acrylic aligners (i.e. invisible aligners ). The plan will not cover the charges for an orthodontic procedure if an active appliance for that procedure was installed before you were covered by the plan. Replacement Rule Crowns, inlays, onlays and veneers, complete dentures, removable partial dentures, fixed partial dentures (bridges) and other prosthetic services are subject to the plan's replacement rule. That means certain replacements of, or additions to, existing crowns, inlays, onlays, veneers, dentures or bridges are covered only when you give proof to Aetna that: While you were covered by the plan, you had a tooth (or teeth) extracted after the existing denture or bridge was installed. As a result, you need to replace or add teeth to your denture or bridge. The present crown, inlay and onlay, veneer, complete denture, removable partial denture, fixed partial denture (bridge), or other prosthetic service was installed at least 5 years before its replacement and cannot be made serviceable. AEP Active and Retiree Dental DMO Plan SPD

43 You had a tooth (or teeth) extracted while you were covered by the plan. Your present denture is an immediate temporary one that replaces that tooth (or teeth). A permanent denture is needed, and the temporary denture cannot be used as a permanent denture. Replacement must occur within 12 months from the date that the temporary denture was installed. Tooth Missing but Not Replaced Rule The first installation of complete dentures, removable partial dentures, fixed partial dentures (bridges), and other prosthetic services will be covered if: The dentures, bridges or other prosthetic services are needed to replace one or more natural teeth that were removed while you were covered by the plan; and The tooth that was removed was not an abutment to a removable or fixed partial denture installed during the prior 5 years. The extraction of a third molar does not qualify. Any such appliance or fixed bridge must include the replacement of an extracted tooth or teeth. Alternate Treatment Rule Sometimes there are several ways to treat a dental problem, all of which provide acceptable results. When alternate services or supplies can be used, the plan's coverage will be limited to the cost of the least expensive service or supply that is: Customarily used nationwide for treatment, and Deemed by the dental profession to be appropriate for treatment of the condition in question. The service or supply must meet broadly accepted standards of dental practice, taking into account your current oral condition. You should review the differences in the cost of alternate treatment with your dental provider. Of course, you and your dental provider can still choose the more costly treatment method. You are responsible for any charges in excess of what the plan will cover. Coverage for Dental Work Begun Before You Are Covered by the Plan The plan does not cover dental work that began before you were covered by the plan. This means that the following dental work is not covered: An appliance, or modification of an appliance, if an impression for it was made before you were covered by the plan; A crown, bridge, or cast or processed restoration, if a tooth was prepared for it before you were covered by the plan; or Root canal therapy, if the pulp chamber for it was opened before you were covered by the plan. Coverage for Dental Work Completed After Termination of Coverage Your dental coverage may end while you or your covered dependent is in the middle of treatment. The plan does not cover dental services that are given after your coverage terminates. There is an exception. The plan will cover the following services if they are ordered while you were covered by the plan, and installed within 30 days after your coverage ends. Inlays; Onlays; Crowns; Removable bridges; Cast or processed restorations; Dentures; Fixed partial dentures (bridges); and Root canals. AEP Active and Retiree Dental DMO Plan SPD

44 Ordered means: For a denture: the impressions from which the denture will be made were taken. For a root canal: the pulp chamber was opened. For any other item: the teeth which will serve as retainers or supports, or the teeth which are being restored: Must have been fully prepared to receive the item; and Impressions have been taken from which the item will be prepared. What the Managed Dental Plan Does Not Cover Not every dental care service or supply is covered by the plan, even if prescribed, recommended, or approved by your physician or dentist. The plan covers only those services and supplies that are medically necessary and included in the What the Plan Covers section. Charges made for the following are not covered except to the extent listed under the What the Plan Covers section or by amendment attached to this SPD. In addition, some services are specifically limited or excluded. This section describes expenses that are not covered or subject to special limitations. These dental exclusions are in addition to the exclusions that apply to health coverage. Any instruction for diet, plaque control and oral hygiene. Cosmetic services and supplies including plastic surgery, reconstructive surgery, cosmetic surgery, personalization or characterization of dentures or other services and supplies which improve alter or enhance appearance, augmentation and vestibuloplasty, and other substances to protect, clean, whiten bleach or alter the appearance of teeth; whether or not for psychological or emotional reasons; except to the extent coverage is specifically provided in the What the Plan Covers section. Facings on molar crowns and pontics will always be considered cosmetic. Crown, inlays and onlays, and veneers unless: It is treatment for decay or traumatic injury and teeth cannot be restored with a filling material; or The tooth is an abutment to a covered partial denture or fixed bridge. Dental implants, braces, mouth guards, and other devices to protect, replace or reposition teeth and removal of implants. Dental services and supplies that are covered in whole or in part: Under any other part of this plan; or Under any other plan of group benefits provided by the policyholder. Dentures, crowns, inlays, onlays, bridges, or other appliances or services used for the purpose of splinting, to alter vertical dimension, to restore occlusion, or correcting attrition, abrasion, or erosion. Except as covered in the What the Plan Covers section, treatment of any jaw joint disorder and treatments to alter bite or the alignment or operation of the jaw, including temporomandibular joint disorder (TMJ) treatment, orthognathic surgery, and treatment of malocclusion or devices to alter bite or alignment. First installation of a denture or fixed bridge, and any inlay and crown that serves as an abutment to replace congenitally missing teeth or to replace teeth all of which were lost while the person was not covered. General anesthesia and intravenous sedation. AEP Active and Retiree Dental DMO Plan SPD

45 Orthodontic treatment except as covered in the What the Plan Covers section. Pontics, crowns, cast or processed restorations made with high noble metals (gold or titanium). Prescribed drugs; pre-medication; or analgesia. Replacement of a device or appliance that is lost, missing or stolen, and for the replacement of appliances that have been damaged due to abuse, misuse or neglect and for an extra set of dentures. Services and supplies done where there is no evidence of pathology, dysfunction, or disease other than covered preventive services. Services and supplies provided for your personal comfort or convenience, or the convenience of any other person, including a provider. Services and supplies provided in connection with treatment or care that is not covered under the plan. Space maintainers except when needed to preserve space resulting from the premature loss of deciduous teeth. Surgical removal of impacted wisdom teeth only for orthodontic reasons. Treatment by other than a dentist. However, the plan will cover some services provided by a licensed dental hygienist under the supervision and guidance of a dentist. These are: Scaling of teeth; and Cleaning of teeth. Additional Items Not Covered by a Health Plan Not every health service or supply is covered by the plan, even if prescribed, recommended, or approved by your physician or dentist. The plan covers only those services and supplies that are medically necessary and included in the What the Plan Covers section. Charges made for the following are not covered except to the extent listed under the What the Plan Covers section or by amendment attached to this SPD. Acupuncture, acupressure and acupuncture therapy, except as provided in the What the Plan Covers section. Any charges in excess of the benefit, dollar, day, visit or supply limits stated in this SPD. Charges submitted for services by an unlicensed hospital, physician or other provider or not within the scope of the provider s license. Charges submitted for services that are not rendered, or rendered to a person not eligible for coverage under the plan. Court ordered services, including those required as a condition of parole or release. AEP Active and Retiree Dental DMO Plan SPD

46 Examinations: Any dental examinations: required by a third party, including examinations and treatments required to obtain or maintain employment, or which an employer is required to provide under a labor agreement; required by any law of a government, securing insurance or school admissions, or professional or other licenses; required to travel, attend a school, camp, or sporting event or participate in a sport or other recreational activity; and any special medical reports not directly related to treatment except when provided as part of a covered service. Experimental or investigational drugs, devices, treatments or procedures, except as described in the What the Plan Covers section. Medicare: Payment for that portion of the charge for which Medicare or another party is the primary payer. Miscellaneous charges for services or supplies including: Cancelled or missed appointment charges or charges to complete claim forms; Charges the recipient has no legal obligation to pay; or the charges would not be made if the recipient did not have coverage (to the extent exclusion is permitted by law) including: Care in charitable institutions; Care for conditions related to current or previous military service; or Care while in the custody of a governmental authority. Non-medically necessary services, including but not limited to, those treatments, services, prescription drugs and supplies which are not medically necessary, as determined by Aetna, for the diagnosis and treatment of illness, injury, restoration of physiological functions, or covered preventive services. This applies even if they are prescribed, recommended or approved by your physician or dentist. Routine dental exams and other preventive services and supplies, except as specifically provided in the What the Plan Covers section. Services rendered before the effective date or after the termination of coverage, unless coverage is continued under the Continuation of Coverage section of this SPD. Work related: Any illness or injury related to employment or self-employment including any injuries that arise out of (or in the course of) any work for pay or profit, unless no other source of coverage or reimbursement is available to you for the services or supplies. Sources of coverage or reimbursement may include your employer, workers compensation, or an occupational illness or similar program under local, state or federal law. A source of coverage or reimbursement will be considered available to you even if you waived your right to payment from that source. If you are also covered under a workers compensation law or similar law, and submit proof that you are not covered for a particular illness or injury under such law, that illness or injury will be considered non-occupational regardless of cause. AEP Active and Retiree Dental DMO Plan SPD

47 Coordination of Benefits What Happens When There Is More Than One Health Plan When Coordination of Benefits Applies General A. This coordination of benefits ( COB ) provision applies to This Plan when an employee or the employee's covered dependent has health care coverage under more than one plan. Plan and This Plan are defined below. B. If this COB provision applies, you should look first at the order of benefit determination rules. Those rules determine whether the benefits of This Plan are determined before or after those of another plan. The benefits of This Plan: Shall not be reduced when, under the order of benefit determination rules, This Plan determines its benefits before another plan; but May be reduced when, under the order of benefits determination rules, another plan determines its benefits first. Getting Started Important Terms A. Plan means any of the following which provides benefits or services for, or because of, medical or dental care or treatment: Group insurance or group-type coverage, whether insured or uninsured. This includes prepayment, group practice or individual practice coverage. It also includes coverage other than school accident-type coverage. Coverage under a governmental plan, or coverage required or provided by law. This does not include a state plan under Medicaid (Title XIX, Grants to States for Medical Assistance Programs, of the United States Social Security Act, as amended from time to time). Plan does not include school accident-type coverage, individual contracts of coverage, or some supplemental sickness and accident policies. Each contract or other arrangement for coverage under (1) or (2) is a separate plan. If an arrangement has two parts and COB rules apply only to one of the two, each part is a separate plan. B. This Plan is the part of this group contract that provides benefits for health care expenses. C. Primary Plan/Secondary Plan : the order of benefit determination rules state whether This Plan is a Primary Plan or Secondary Plan as to another plan covering the person. When This Plan is a Primary Plan, its benefits are determined before those of the other plan and without considering the other plan s benefits. When This Plan is a Secondary Plan, its benefits are determined after those of the other plan and may be reduced because of the other plan s benefits. When there are more than two plans covering the person, This Plan may be a Primary Plan as to one or more other plans and may be a Secondary Plan as to a different plan or plans. D. Allowable Expense means a necessary, reasonable and customary item of expense for health care when the item of expense is covered by this plan. However, This Plan is not required to pay for an item, service, or benefit which is not a part of this Plan s contract. When a plan provides benefits in the form of services, the reasonable cash value of each service rendered will be considered both an allowable expense and a benefit paid. Which Plan Pays First A. When there is a basis for a claim under This Plan and another plan, This Plan is a Secondary Plan whose benefits are determined after those of the other plan, unless: 1) The other plan has rules coordinating its benefits with those of This Plan; and AEP Active and Retiree Dental DMO Plan SPD

48 2) Both those rules and this plan's rules, in subsection below, require that this plan's benefits be determined before those of the other plan. B. This Plan determines its order of benefits using the first of the following rules which applies: 1) The benefits of the plan which covers the person as an employee, member, insured, or subscriber (that is, other than as a dependent) are determined before those of the plan which covers the person as a dependent; except that: if the person is also a Medicare beneficiary, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, 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 (e.g. a retired employee). 2) Benefits for a dependent child whose parents are not separated or divorced shall be determined as follows: 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 If both parents have the same birthday, the benefits of the plan which covered one parent longer are determined before those of the plan which has covered the other parent for a shorter period of time. However, if the other plan does not have the rules described in (A) above, but instead has a rule based upon the gender of the parent, 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) Benefits for a dependent child whose parents are divorced or separated shall be determined as follows. To the extent the plan has been notified by receiving a copy of the court decree: If the specific terms of the court decree state that one of the parents is responsible for the health care expenses of the child, the benefits of the plan of that parent are determined first. The plan of the other parent shall be the Secondary Plan. If the specific terms of the court decree state that the parents shall share joint custody, without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child shall be subject to the order of benefit determination contained in subdivision (B)(2) of this section. If neither subdivision (A) nor (B) applies, the order of benefits shall be determined in the following order: 1) The plan of the parent with custody of the child; 2) The plan of the spouse of the parent with the custody of the child; 3) The plan of the parent not having custody of the child; and 4) The plan of the spouse of the parent not having custody of the child. 5) The benefits of a plan which covers a person as an employee who is neither laid off not retired (or as that employee's dependent) are determined before the benefits of a plan which covers that person as a laid off or retired employee (or as that 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 paragraph shall be ignored. 6) Continuation Coverage. If a person whose coverage is provided under a right of continuation pursuant to federal law (i.e., COBRA) or state law also is covered under another plan, the benefits of the plan covering the person as employee, member or subscriber (or that person s dependent) shall be determined before the benefits under the continuation coverage. 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 paragraph shall be ignored. 7) Longer/shorter length of coverage. If none of the above rules determines the order of benefits, the benefits of the plan which covered an employee, member or subscriber longer are determined before those of the plan which covered that person for the shorter term. AEP Active and Retiree Dental DMO Plan SPD

49 How Coordination of Benefits Works A. This section applies when, in accordance with the Order of Benefit Determination Rules, This Plan is a Secondary Plan as to one or more other plans. In that event, the benefits of This Plan may be reduced under this section. Such other plan or plans are referred to as the other plans in (B) below. B. Reduction in This Plan s benefits. The benefits of This Plan will be reduced to the extent that the sum of: The benefits that would be payable for the allowable expense under This Plan in the absence of this COB provision; and The benefits that would be payable for the allowable expenses under the other plans, in the absence of provisions with a purpose like that of this COB provision, whether or not claim is made, exceeds those allowable expenses. If the allowable expense under This Plan is lower than the primary plan s, Aetna will use the primary plan s allowable expense. That may be lower than the actual bill. Right to Receive and Release Needed Information Certain facts are needed to apply these COB rules. Aetna has the right to decide which facts it needs. It may get needed facts from or give them to any other organization or person. Aetna need not tell, or get the consent of, any person to do this. Each person claiming benefits under This Plan must give Aetna any facts it needs to pay the claim. Facility of Payment A payment made under another plan may include an amount which should have been paid under This Plan. If it does, Aetna may pay that amount to the organization which made that payment. That amount will then be treated as though it were a benefit paid under This Plan. Aetna will not have to pay that amount again. The term payment made includes providing benefits in the form of services, in which case payment made means reasonable cash value of the benefits provided in the form of services. Right of Recovery If the amount of the payments made by Aetna is more than it should have paid under this COB provision, it may recover the excess from one or more of: The persons it has paid or for whom it has paid; Another plan; or The provider of service. The amount of the payments made includes the reasonable cash value of any benefits provided in the form of services. Coordination Disputes If you believe that we have not paid a claim properly, you should first attempt to resolve the problem by contacting us. If you are still not satisfied, you may call the Ohio Department of Insurance for instructions on filing a consumer complaint. Call (614) or When You Have Medicare Coverage This section explains how the benefits under This Plan interact with benefits available under Medicare. Medicare, when used in this SPD, means the health insurance provided by Title XVIII of the Social Security Act, as amended. It includes Health Maintenance Organization (HMO) or similar coverage that is an authorized alternative to Parts A and B of Medicare. AEP Active and Retiree Dental DMO Plan SPD

50 You are eligible for Medicare if you are: Covered under it by reason of age, disability, or End Stage Renal Disease; or Not covered under it because you: 1. Refused it; 2. Dropped it; or 3. Failed to make a proper request for it. If you are eligible for Medicare, the plan coordinates the benefits it pays with the benefits that Medicare pays. Sometimes, the plan is the primary payor, which means that the plan pays benefits before Medicare pays benefits. Under other circumstances, the plan is the secondary payor, and pays benefits after Medicare. Which Plan Pays First The plan is the primary payor when your coverage for the plan s benefits is based on current employment with your employer. The plan will act as the primary payor for the Medicare beneficiary who is eligible for Medicare: Solely due to age if the plan is subject to the Social Security Act requirements for Medicare with respect to working aged (i.e., generally a plan of an employer with 20 or more employees); Due to diagnosis of end stage renal disease, but only during the first 30 months of such eligibility for Medicare benefits. This provision does not apply if, at the start of eligibility, you were already eligible for Medicare benefits, and the plan s benefits were payable on a secondary basis; Solely due to any disability other than end stage renal disease; but only if the plan meets the definition of a large group health plan as outlined in the Internal Revenue Code (i.e., generally a plan of an employer with 100 or more employees). The plan is the secondary payor in all other circumstances. How Coordination With Medicare Works When the Plan is Primary The plan pays benefits first when it is the primary payor. You may then submit your claim to Medicare for consideration. When Medicare is Primary Your health care expense must be considered for payment by Medicare first. You may then submit the expense to Aetna for consideration. Aetna will calculate the benefits the plan would pay in the absence of Medicare: The amount will be reduced so that when combined with the amount paid by Medicare, the total benefits paid or provided by all plans for the claim do not exceed 100 % of the total allowable expense. This review is done on a claim-by-claim basis. Charges used to satisfy your Part B deductible under Medicare will be applied under the plan in the order received by Aetna. Aetna will apply the largest charge first when two or more charges are received at the same time. Aetna will apply any rule for coordinating health care benefits after determining the benefits payable. AEP Active and Retiree Dental DMO Plan SPD

51 Right to Receive and Release Required Information Certain facts about health care coverage and services are required to apply coordination of benefits (COB) rules to determine benefits under This Plan and other plans. Aetna has the right to obtain or release any information, and make or recover any payments it considers necessary, in order to administer this provision. General Provisions Type of Coverage Coverage under this plan is non-occupational. Only non-occupational accidental injuries and nonoccupational illnesses are covered. This plan covers charges made for services and supplies only while the person is covered under this plan. Physical Examinations Aetna will have the right and opportunity to examine and evaluate any person who is the basis of any claim at all reasonable times while a claim is pending or under review. This will be done at no cost to you. Legal Action No legal action can be brought to recover payment under any benefit after 3 years from the deadline for filing claims. Aetna will not try to reduce or deny a benefit payment on the grounds that a condition existed before your coverage went into effect, if the loss occurs more than 2 years from the date coverage commenced. This will not apply to conditions excluded from coverage on the date of the loss. Confidentiality Information contained in your medical records and information received from any provider incident to the provider- patient relationship shall be kept confidential in accordance with applicable law. Information may be used or disclosed by Aetna when necessary for your care or treatment, the operation of the plan and administration of this Booklet- Certificate, or other activities, as permitted by applicable law. You can obtain a copy of Aetna s Notice of Information Practices by calling Aetna s toll-free Member Service telephone. Additional Provisions The following additional provisions apply to your coverage. This SPD applies to coverage only, and does not restrict your ability to receive health care services that are not, or might not be, covered. You cannot receive multiple coverage under the plan because you are connected with more than one employer. In the event of a misstatement of any fact affecting your coverage under the plan, the true facts will be used to determine the coverage in force. This document describes the main features of the plan. Additional provisions are described elsewhere in the group policy. If you have any questions about the terms of the plan or about the proper payment of benefits, contact your employer or Aetna. Your employer hopes to continue the plan indefinitely but, as with all group plans, the plan may be changed or discontinued with respect to your coverage. AEP Active and Retiree Dental DMO Plan SPD

52 Assignments Coverage may be assigned only with the written consent of Aetna. To the extent allowed by law, Aetna will not accept an assignment to an out-of-network provider, including but not limited to, an assignment of: The benefits due under this group insurance policy; The right to receive payments due under this group insurance policy; or Any claim you make for damages resulting from a breach or alleged breach, of the terms of this group insurance policy. Misstatements If any fact as to the Policyholder or you is found to have been misstated, a fair change in premiums may be made. If the misstatement affects the existence or amount of coverage, the true facts will be used in determining whether coverage is or remains in force and its amount. All statements made by the Policyholder or you shall be deemed representations and not warranties. No written statement made by you shall be used by Aetna in a contest unless a copy of the statement is or has been furnished to you or your beneficiary, or the person making the claim. Aetna s failure to implement or insist upon compliance with any provision of this policy at any given time or times, shall not constitute a waiver of Aetna s right to implement or insist upon compliance with that provision at any other time or times. This includes, but is not limited to, the payment of premiums. This applies whether or not the circumstances are the same. Incontestability As to Accident and Health Benefits: Except as to a fraudulent misstatement, or issues concerning Premiums due: No statement made by the Policyholder or you or your dependent shall be the basis for voiding coverage or denying coverage or be used in defense of a claim unless it is in writing after it has been in force for 2 years from its effective date. No statement made by the Policyholder shall be the basis for voiding this Policy after it has been in force for 2 years from its effective date. No statement made by you, an eligible employee or your dependent shall be used in defense of a claim for loss incurred or starting after coverage as to which claim is made has been in effect for 2 years. Recovery of Overpayments Health Coverage If a benefit payment is made by Aetna, to or on your behalf, which exceeds the benefit amount that you are entitled to receive, Aetna has the right: To require the return of the overpayment; or To reduce by the amount of the overpayment, any future benefit payment made to or on behalf of that person or another person in his or her family. Such right does not affect any other right of recovery Aetna may have with respect to such overpayment. AEP Active and Retiree Dental DMO Plan SPD

53 Reporting of Claims A claim must be submitted to Aetna in writing. It must give proof of the nature and extent of the loss. Your employer has claim forms. All claims should be reported promptly. The deadline for filing a claim is 90 days after the date of the loss. If, through no fault of your own, you are not able to meet the deadline for filing claim, your claim will still be accepted if you file as soon as possible. Unless you are legally incapacitated, late claims for health benefits will not be covered if they are filed more than 2 years after the deadline. Payment of Benefits Benefits will be paid as soon as the necessary proof to support the claim is received. Written proof must be provided for all benefits. All covered health benefits are payable to you. However, Aetna has the right to pay any health benefits to the service provider. This will be done unless you have told Aetna otherwise by the time you file the claim. Aetna will notify you in writing, at the time it receives a claim, when an assignment of benefits to a health care provider or facility will not be accepted. Any unpaid balance will be paid within 30 days of receipt by Aetna of the due written proof. Aetna may pay up to $1,000 of any other benefit to any of your relatives whom it believes are fairly entitled to it. This can be done if the benefit is payable to you and you are a minor or not able to give a valid release. It can also be done if a benefit is payable to your estate. Records of Expenses Keep complete records of the expenses of each person. They will be required when a claim is made. Very important are: Names of dentists who furnish services. Dates expenses are incurred. Copies of all bills and receipts. Contacting Aetna If you have questions, comments or concerns about your benefits or coverage, or if you are required to submit information to Aetna, you may contact Aetna s Home Office at: Aetna Life Insurance Company 151 Farmington Avenue Hartford, CT You may also use Aetna s toll free Member Services phone number on your ID card or visit Aetna s web site at AEP Active and Retiree Dental DMO Plan SPD

54 Effect of Benefits Under Other Plans Effect of a Health Maintenance Organization Plan (HMO Plan) on Coverage If you are in an eligible class and have chosen dental coverage under an HMO Plan offered by your employer, you will be excluded from dental expense coverage on the date of your coverage under such HMO Plan. If you are in an eligible class and are covered under an HMO Plan providing dental coverage, you can choose to change to coverage for yourself and your covered dependents under this plan. If you: Live in an HMO Plan enrollment area and choose to change dental coverage during an open enrollment period, coverage will take effect on the group policy anniversary date after the open enrollment period. There will be no rules for waiting periods or preexisting conditions. Live in an HMO Plan enrollment area and choose to change dental coverage when there is not an open enrollment period, coverage will take effect only if and when Aetna gives its written consent. Move from an HMO Plan enrollment area or if the HMO discontinues and you choose to change dental coverage within 31 days of the move or the discontinuance, coverage will take effect on the date you elect such coverage. There will be no restrictions for waiting periods or preexisting conditions. If you choose to change coverage after 31 days, coverage will take effect only if and when Aetna gives its written consent. Any extension of dental benefits under this plan will not apply on or after the date of a change to an HMO Plan. No benefits will be paid for any charges for services rendered or supplies furnished under an HMO Plan. Incentives In order to encourage you to access certain medical services when deemed appropriate by you in consultation with your physician or other service providers, we may, from time to time, offer to waive or reduce a member s copayment, coinsurance, and/or a deductible otherwise required under the plan or offer coupons or other financial incentives. We have the right to determine the amount and duration of any waiver, reduction, coupon, or financial incentive and to limit the covered persons to whom these arrangements are available. Appeals Procedure Definitions Adverse Benefit Determination (Decision) means: A decision by Aetna: To deny, reduce, terminate or fail to provide or make payment in whole or in part, for a service, supply or Benefit. Such adverse benefit determination may include all of the following: Your eligibility for coverage. A determination that the health care services does not meet the plan's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, including experimental or investigational treatments. A determination of your eligibility for individual health insurance coverage, including coverage offered through a non-employer group, to participate in a plan or health insurance coverage. The results of any Utilization Review activities. A determination that a health care service is not a covered benefit. The imposition of an exclusion, including exclusions for pre-existing conditions, source of injury, network, or any other limitation on benefits that would otherwise be covered. AEP Active and Retiree Dental DMO Plan SPD

55 Not to issue individual health insurance coverage to you, including coverage offered through a nonemployer group. As to medical and prescription drug claims only, an adverse benefit determination also means the termination of your coverage back to the original effective date (rescission) as it applies under any rescission of coverage provision of the Policy or the SPD. Appeal: An oral or written request to Aetna to reconsider an adverse benefit determination. Authorized Representative: An individual who represents you in an internal appeal or external review process of an adverse benefit determination who is any of the following: A person to whom you have given express, written consent to represent you in an internal appeals process or external review process of an adverse benefit determination; A person authorized by law to provide substituted consent for you; A family member or a treating health care professional, but only when you are unable to provide consent. Complaint: Any oral or written expression of dissatisfaction about quality of care or the operation of the Plan. Concurrent Care Claim Extension: A request to extend a course of treatment that was previously approved. Concurrent Care Claim Reduction or Termination: A decision to reduce or terminate a course of treatment that was previously approved. Covered Benefits or Benefits: Those health care services to which a covered person is entitled under the terms of a health benefit plan. Covered Person: Policyholder, subscriber, enrollee, member, or individual covered by a health benefit plan. Covered person does include the covered person s authorized representative with regard to an internal appeal or external review. Emergency Services: A medical screening examination, as required by federal law, that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department, to evaluate an emergency medical condition; Such further medical examination and treatment that are required by federal law to stabilize an emergency medical condition and are within the capabilities of the staff and facilities available at the hospital, including any trauma and burn center of the hospital. External Review: A review of an adverse benefit determination or a final adverse benefit determination by an Independent Review Organization/External Review Organization (ERO) assigned by the State Insurance Commissioner and made up of physicians or other appropriate health care providers. The ERO must have expertise in the problem or question involved. Final Adverse Benefit Determination: An adverse benefit determination that has been upheld by Aetna at the exhaustion of the appeals process. Health Benefit Plan: A policy, contract, certificate, or agreement offered by a health plan issuer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. AEP Active and Retiree Dental DMO Plan SPD

56 Health Care Services: Services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. Health Plan Issuer: An entity subject to the insurance laws and rules of this state, or subject to the jurisdiction of the superintendent of insurance, that contracts, or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services under a health benefit plan, including a sickness and accident insurance company, a health insuring corporation, a fraternal benefit society, a self-funded multiple employer welfare arrangement, or a nonfederal, government health plan. Health Plan Issuer includes a third party administrator to the extent that the benefits that such an entity is contracted to administer under a health benefit plan are subject to the insurance laws and rules of this state or subject to the jurisdiction of the superintendent. Independent Review Organization: An entity that is accredited to conduct independent external reviews of adverse benefit determinations. Pre-service Claim: Any claim for medical care or treatment that requires approval before the medical care or treatment is received. Post-Service Claim: Any claim that is not a Pre-Service Claim. Rescission or to rescind: A cancellation or discontinuance of coverage that has a retroactive effect. Rescission does not include a cancellation or discontinuance of coverage that has only a prospective effect or a cancellation or discontinuance of coverage that is effective retroactively to the extent it is attributable to a failure to timely pay required premiums or contributions towards the cost of coverage. Stabilize: The provision of such medical treatment as may be necessary to assure, within reasonable medical probability that no material deterioration of a covered person s medical condition is likely to result from or occur during a transfer, if the medical condition could result in any of the following: Placing the health of the covered person or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; Serious impairment to bodily functions; Serious dysfunction of any bodily organ or part. In the case of a woman having contractions, stabilize means such medical treatment as may be necessary to deliver, including the placenta. Superintendent: The Superintendent of Insurance. Urgent Care Claim: Any claim for medical care or treatment in which a delay in treatment could: Seriously jeopardize your life or health; Jeopardize your ability to regain maximum function; Cause you to suffer severe pain that cannot be adequately managed without the requested medical care or treatment; or In the case of a pregnant woman, cause serious jeopardy to the health of the fetus. Full and Fair Review of Claim Determinations and Appeals As to medical and prescription drug claims and appeals only, Aetna will provide you with any new or additional evidence considered and rationale, relied upon, or generated by us in connection with the claim at issue. This will be provided to you in advance of the date on which the notice of the final adverse benefit determination is required to be provided so that you may respond prior to that date. AEP Active and Retiree Dental DMO Plan SPD

57 Prior to issuing a final adverse benefit determination based on a new or additional rationale, you must be provided, free of charge, with the rationale; the rationale must be provided as soon as possible and sufficiently in advance of the date on which notice of final adverse determination is required. Claim Determinations Notice of a claim benefit decision will be provided to you in accordance with the guidelines and timelines provided below. As to medical and prescription drug claims only, if Aetna makes an adverse benefit determination, written notice will be provided to you, or in the case of a concurrent care claim, to your provider. Urgent Care Claims Aetna will notify you of an urgent care claim decision as soon as possible, but not later than 72 hours after the claim is made. If more information is needed to make an urgent claim decision, Aetna will notify the claimant within 72 hours of receipt of the claim. The claimant has 48 hours after receiving such notice to provide Aetna with the additional information. Aetna will notify the claimant within 48 hours of the earlier to occur: The receipt of the additional information; or The end of the 48 hour period given the physician to provide Aetna with the information. If the claimant fails to follow the procedures for filing a claim, the plan will notify the claimant within 24 hours following the failure to comply. Pre-Service Claims Aetna will notify you of a pre-service claim decision as soon as possible, but not later than 15 calendar days after the claim is made. Aetna may determine that due to matters beyond its control an extension of this 15 calendar day claim decision period is required. Such an extension, of not longer than 15 additional calendar days, will be allowed if Aetna notifies you within the first 15 calendar day period. If this extension is needed because Aetna needs more information to make a claim decision, the notice of the extension shall specifically describe the required information. You will have 45 calendar days, from the date of the notice, to provide Aetna with the required information. Post-Service Claims Aetna will notify you of a post-service claim decision as soon as possible, but not later than 30 calendar days after the claim is made. Aetna may determine that due to matters beyond its control an extension of this 30 calendar day claim decision period is required. Such an extension, of not longer than 15 additional calendar days, will be allowed if Aetna notifies you within the first 30 calendar day period. If this extension is needed because Aetna needs more information to make a claim decision, the notice of the extension shall specifically describe the required information. The patient will have 45 calendar days, from the date of the notice, to provide Aetna with the required information. Concurrent Care Claim Extension Following a request for a concurrent care claim extension, Aetna will notify you of a claim determination for emergency or urgent care as soon as possible, but not later than 24 hours with respect to emergency care or urgent care, provided the request is received at least 24 hours prior to the expiration of the approved course of treatment and 15 calendar days with respect to all other care, following a request for a concurrent care claim extension. Concurrent Care Claim Reduction or Termination Aetna will notify you of a claim determination to reduce or terminate a previously approved course of treatment with enough time for you to file an appeal. AEP Active and Retiree Dental DMO Plan SPD

58 If you file an appeal, coverage under the plan will continue for the previously approved ongoing course of treatment until a final appeal decision is rendered. During this continuation period, you are responsible for any copayments; coinsurance; and deductibles; that apply to the services; supplies; and treatment; that are rendered in connection with the claim that is under appeal. If Aetna's initial claim decision is upheld in the final appeal decision, you will be responsible for all charges incurred for services; supplies; and treatment; received during this continuation period. Complaints If you are dissatisfied with the service you receive from the Plan or want to complain about a provider you must call or write Member Services within 30 calendar days of the incident. The complaint must include a detailed description of the matter and include copies of any records or documents that you think are relevant to the matter. Aetna will review the information and provide you with a written response within 30 calendar days of the receipt of the complaint, unless more information is needed and it cannot be obtained within this period. The notice of the decision will tell you what you need to do to seek an additional review. Notice of an Adverse Determination When Aetna notifies you of an adverse benefit determination in writing, you will also be notified of your right to an external review. As part of the written notice, the Plan will include the following: Sufficient information to identify the claim or health care service involved, including the health care provider, and the date of service and claim amount, if applicable; A description of the reason or reasons for the adverse benefit determination, including the denial code, such as the claim adjustment reason code and the remittance advice remark code, and each code's corresponding meaning; A description of the available internal appeals and external review processes, including information regarding how to initiate an appeal and an external review; and Disclosure of the availability of assistance from the superintendent with the internal appeals and external review processes, including the web site, telephone number, and mailing address of the superintendent's Office of Consumer Services. Appeals of Adverse Benefit Determinations You may submit an appeal if Aetna gives notice of an adverse benefit determination. This Plan provides for two levels of appeal. A final adverse benefit determination notice will also provide an option to request an External Review if the services are eligible for external review. You have 180 calendar days with respect to Group Health Claims following the receipt of notice of an adverse benefit determination to request your Level One Appeal. Your appeal may be submitted orally or in writing and must include: Your name. The employer's name. A copy of Aetna s notice of an adverse benefit determination. Your reasons for making the appeal. Any other information you would like to have considered. Send your written appeal to Member Services at the address shown on your ID Card. You may also choose to have another person (an authorized representative) make the appeal on your behalf. You must provide written consent to Aetna if you decide to choose an authorized representative. You may also supply additional information that you would like us to consider regarding your appeal. In addition, you may request copies of documents relevant to your claim (free of charge) by contacting us at the number on your member identification card. AEP Active and Retiree Dental DMO Plan SPD

59 You may be allowed to provide evidence or testimony during the appeal process in accordance with the guidelines established by the Federal Department of Health and Human Services. Level One Appeal A review of a Level One Appeal of an adverse benefit determination shall be provided by Aetna personnel. They shall not have been involved in making the adverse benefit determination. Urgent Care Claims (May Include Concurrent Care Claim Reduction or Termination) Aetna shall issue a decision within 36 hours of receipt of the request for an appeal. Pre-Service Claims (May Include Concurrent Care Claim Reduction or Termination) Aetna shall issue a decision within 15 calendar days of receipt of the request for an appeal. Post-Service Claims Aetna shall issue a decision within 30 calendar days of receipt of the request for an appeal. Level Two Health Appeal If Aetna upholds an adverse benefit determination at the first level of appeal, and the reason for the decision was based on medical necessity or experimental or investigational reasons, you or your authorized representative have the right to file a Level Two Appeal. The appeal must be submitted within 60 calendar days following the receipt of a decision of a Level One Appeal. Review of a Level Two Appeal of an adverse benefit determination of an urgent care claim, a Pre- Service Claim, or a Post-Service Claim shall be provided by Aetna personnel. They shall not have been involved in making the adverse benefit determination. Urgent Care Claims (May Include Concurrent Care Claim Reduction or Termination). Aetna shall issue a decision within 36 hours of receipt of the request for a Level Two Appeal. Pre-Service Claims (May Include Concurrent Care Claim Reduction or Termination). Aetna shall issue a decision within 15 calendar days of receipt of the request for a Level Two Appeal. Post-Service Claims. Aetna shall issue a decision within 30 calendar days of receipt of the request for a Level Two Appeal. Exhaustion of Process You must exhaust the applicable Level One and Level Two processes of the Appeal Procedure before you: Contact the Ohio Department of Insurance to request an investigation of a complaint or appeal; or File a complaint or appeal with the Ohio Department of Insurance; or Establish any: Litigation; Arbitration; or Administrative proceeding; regarding an alleged breach of the policy terms by Aetna or any matter within the scope of the Appeals Procedure. AEP Active and Retiree Dental DMO Plan SPD

60 Exceptions to the exhaustion of the Level One and Level Two processes of the Appeals procedure may occur in the following instances: a) Aetna agrees to waive the Exhaustion requirement; b) You did not receive a written decision of Aetna s internal appeal within the required timeframe; c) Aetna fails to meet all requirements of the internal appeals process unless the failure: was de minimis; does not cause or is not likely to cause prejudice or harm to you; was for good cause and beyond the control of the Plan; or is not reflective of a pattern or practice of non-compliance. d) An expedited external review is sought simultaneously with an expedited internal review. An internal appeal process shall be considered exhausted if you have requested an internal appeal and have not received a written decision from Aetna at each level of appeal within the timeframes listed above and Aetna fails to adhere to all requirements of the internal appeals process. You may not request an external review of an adverse benefit determination involving a retrospective utilization review decision until Aetna s internal appeal process has been exhausted unless the Aetna agrees to waive the exhaustion requirement Under certain circumstances, you may seek simultaneous review through the internal Appeals Procedure and External Review processes these include Urgent Care Claims and situations where you are receiving an ongoing course of treatment. Exhaustion of the applicable process of the Appeal Procedure is not required under these circumstances. Important Note: If Aetna does not adhere to all claim determination and appeal requirements of the Federal Department of Health and Human Services, you are considered to have exhausted the appeal requirements and may proceed with External Review or any of the actions mentioned above. There are limits, though, on what sends a claim or appeal straight to an External Review. Your claim or internal appeal will not go straight to External Review if: a rule violation was minor and isn t likely to influence a decision or harm you; it was for a good cause or was beyond Aetna s control; and it was part of an ongoing, good faith exchange between you and Aetna. Opportunity for External Review An external review may be conducted by an Independent Review Organization (IRO) or by the Ohio Department of Insurance. You do not pay for the external review. There is no minimum cost of health care services denied in order to qualify for an external review. However, you must generally exhaust the health Plan issuer s internal appeal process before seeking an external review. Exceptions to this requirement will be included in the notice of the adverse benefit determination. AEP Active and Retiree Dental DMO Plan SPD

61 External Review by an IRO You are entitled to an external review by an IRO in the following instances: The adverse benefit determination involves a medical judgment or is based on any medical information The adverse benefit determination indicates the requested service is experimental or investigational, the requested health care service is not explicitly excluded in your health benefit Plan, and the treating physician certifies at least one of the following: Standard health care services have not been effective in improving your condition. Standard health care services are not medically appropriate for you. No available standard health care service covered by the Plan is more beneficial than the requested health care service. There are two types of IRO reviews, standard and expedited. A standard review is normally completed within 30 days. An expedited review for urgent medical situations is normally completed within 72 hours and can be requested if any of the following applies: Your treating physician certifies that the adverse benefit determination involves a medical condition that could seriously jeopardize your life or health or would jeopardize your ability to regain maximum function if treatment is delayed until after the time frame of an expedited internal appeal. Your treating physician certifies that the final adverse benefit determination involves a medical condition that could seriously jeopardize your life or health or would jeopardize your ability to regain maximum function if treatment is delayed until after the time frame of a standard external review. The final adverse benefit determination concerns an admission, availability of care, continued stay, or health care service for which you received emergency services, but has not yet been discharged from a facility. An expedited internal appeal is already in progress for an adverse benefit determination of experimental or investigational treatment and your treating physician certifies in writing that the recommended health care service or treatment would be significantly less effective if not promptly initiated. Note: An expedited external review is not available for retrospective final adverse benefit determinations (meaning the health care service has already been provided to you.) External Review by the Ohio Department of Insurance You are entitled to an external review by the Department in the either of the following instances: The adverse benefit determination is based on a contractual issue that does not involve a medical judgment or medical information. The adverse benefit determination for an emergency medical condition indicates that medical condition did not meet the definition of emergency AND the Plan s decision has already been upheld through an external review by an IRO. Request for External Review Regardless of whether the external review case is to be reviewed by an IRO or the Department of Insurance, you or an authorized representative, must request an external review through Aetna within 180 days of the date of the notice of final adverse benefit determination issued by their Plan. All requests must be in writing, except for a request for an expedited external review. Expedited external reviews may be requested electronically or orally; however written confirmation of the request must be submitted to Aetna no later than five (5) days after the initial request. You will be required to consent to the release of applicable medical records and sign a medical records release authorization. AEP Active and Retiree Dental DMO Plan SPD

62 If the request is complete Aetna will initiate the external review and notify you in writing, or immediately in the case of an expedited review, that the request is complete and eligible for external review. The notice will include the name and contact information for the assigned IRO or the Ohio Department of Insurance (as applicable) for the purpose of submitting additional information. When a standard review is requested, the notice will inform you that, within 10 business days after receipt of the notice, you may submit additional information in writing to the IRO or the Ohio Department of Insurance (as applicable) for consideration in the review. Aetna will also forward all documents and information used to make the adverse benefit determination to the assigned IRO or the Ohio Department of Insurance (as applicable). If the request is not complete Aetna will inform you in writing and specify what information is needed to make the request complete. Aetna determines that the adverse benefit determination is not eligible for external review, Aetna must notify you in writing and provide you with the reason for the denial and inform you that the denial may be appealed to the Ohio Department of Insurance. The Ohio Department of Insurance may determine the request is eligible for external review regardless of the decision by Aetna and require that the request be referred for external review. The Department s decision will be made in accordance with the terms of the health benefit Plan and all applicable provisions of the law. IRO Assignment When the Plan initiates an external review by an IRO, the Ohio Department of Insurance web based system randomly assigns the review to an accredited IRO that is qualified to conduct the review based on the type of health care service. An IRO that has a conflict of interest with Aetna, you, the health care provider or the health care facility will not be selected to conduct the review. IRO Review and Decision The IRO must consider all documents and information considered by Aetna in making the adverse benefit determination, any information submitted by you and other information such as; your medical records, the attending health care professional s recommendation, consulting reports from appropriate health care professionals, the terms of coverage under the health benefit Plan, the most appropriate practice guidelines, clinical review criteria used by the health Plan issuer or its utilization review organization, and the opinions of the IRO s clinical reviewers. The IRO will provide a written notice of its decision within 30 days of receipt by the plan of a request for a standard review or within 72 hours of receipt by the Plan of a request for an expedited review. This notice will be sent to you, Aetna and the Ohio Department of Insurance and must include the following information: A general description of the reason for the request for external review. The date the independent review organization was assigned by the Ohio Department of Insurance to conduct the external review. The dates over which the external review was conducted. The date on which the independent review organization's decision was made. The rationale for its decision. References to the evidence or documentation, including any evidence-based standards, which was used or considered in reaching its decision. Note: Written decisions of an IRO concerning an adverse benefit determination that involves a health care treatment or service that is stated to be experimental or investigational also includes the principle reason(s) for the IRO s decision and the written opinion of each clinical reviewer including their recommendation and their rationale for the recommendation. AEP Active and Retiree Dental DMO Plan SPD

63 Binding Nature of External Review Decision An external review decision is binding on Aetna except to the extent that Aetna has other remedies available under state law. The decision is also binding on you except to the extent that you have other remedies available under applicable state or federal law. You may not file a subsequent request for an external review involving the same adverse benefit determination that was previously reviewed unless new medical or scientific evidence is submitted to the Plan. If You Have Questions About Your Rights or Need Assistance You may contact the Plan: Aetna National External Review Unit Great Oaks Way Alpharetta, GA Toll Free # (877) Fax #: (860) You may also contact the Ohio Department of Insurance: Ohio Department of Insurance ATTN: Consumer Affairs 50 West Town Street, Suite 300, Columbus, OH / (fax) (TDD) Contact ODI Consumer Affairs: File a Consumer Complaint: Your Legal Rights Participants in the AEP Comprehensive Dental Plan are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to. Receive Information about Your Plans and Benefits Examine, without charge, at the plan administrator s office and other specified locations, such as worksites and union halls, all documents governing the plan, including insurance contracts, and a copy of the latest annual report (Form 5500 series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. Obtain, upon written request to the plan administrator, copies of documents governing the operation of the plan, including insurance contracts, and copies of the latest annual report (Form 5500 Series), and updated Summary Plan Description. The plan administrator may charge a reasonable fee for the copies. Receive a summary of the plan s annual financial report. The plan administrator is required by law to furnish each participant a copy of this summary annual report. AEP Active and Retiree Dental DMO Plan SPD

64 Continue Group Health Plan Coverage Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this Summary Plan Description and the documents governing the plan on the rules governing your COBRA continuation coverage rights. Prudent Actions by Plan Fiduciaries In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called fiduciaries of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer or any other person may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights under ERISA. Enforce Your Rights If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy plan documents or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the plan administrator to provide the materials and pay up to $110 a day until you receive the materials, unless the materials were not sent due to reasons beyond the control of the plan administrator. If you have a claim for benefits which is ignored or denied, in whole or in part, you may file suit in Federal or state court. In addition, if you disagree with the plan s decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in a Federal court. If it should happen that plan fiduciaries misuse the plan s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. Assistance with Your Questions If you have any questions about your plans, you should contact the plan administrator. If you have any questions about this statement or about your rights under ERISA or if you need assistance in obtaining documents from the plan administrator, you should contact the nearest Office of the Employee Benefits Security Administration, U.S. Department of Labor listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration. AEP Active and Retiree Dental DMO Plan SPD

65 Plan Documents This AEP Comprehensive Dental Plan Summary Plan Description (SPD) provides a summary of the dental benefits available to eligible employees. In some instances, full details of the plan are contained in the official plan documents and/or insurance contracts. If a provision described in this SPD differs from the provision of the applicable plan document and/or insurance contract, the plan document and/or insurance contract prevails. Transfer of Benefits Your dental plan benefits belong to you and, in certain cases, to members of your family. Your benefits may not be sold, assigned, transferred, pledged, or garnished. In addition, a Qualified Medical Child Support Order (QMCSO) may require you to provide coverage for a dependent under your dental plan. In the event that you or your beneficiary is unable to attend to legal or financial affairs, benefits may be paid to a guardian, relative or other third party appointed on your behalf. If benefits are paid to a third party in good faith, benefits will not be paid again. Plan Amendment or Termination The Company reserves the right to change or end the AEP Comprehensive Dental Plan, in whole or in part, at any time and for any reason, which could result in modification or termination of benefits to employees, retirees or other participants. The Company s decision to amend, replace, or terminate a plan may be due to changes in federal law or state laws governing welfare benefits, the requirements of the Internal Revenue Service, ERISA or any other reason. If the Company does make a change or decides to end the plan, it may decide to set up a different plan providing similar or identical benefits. The Company has the right to change the amount of participant contributions to these plans. If the AEP Comprehensive Dental Plan is terminated, you will not receive any further benefits under the plan other than payment for losses or expenses incurred before the plan was terminated. Administrative Information This section provides details about the way the AEP Comprehensive Dental Plan is administered, the way claims are processed and related topics. If you have questions about your dental benefits that are not answered below, please contact the AEP Benefits Center toll-free at Plan Name: American Electric Power System Comprehensive Dental Plan Type of Plan: Welfare benefit group health plan that provides dental benefits Type of Administration: The Dental Maintenance Organization (DMO) option is insured through a contract with Aetna. Aetna sets the premiums, administers claims and is solely responsible for providing benefits. The Dental Preferred Provider Organization (DPPO) option is self-insured by AEP through contributions made solely by the Company and Plan participants. Benefits are paid either directly by the Company or through trusts administered by the Company. AEP contracts with Aetna to administer claims under the plan DPPO option (i.e., process claims, pay providers), but AEP bears the risk associated with offering DPPO benefits. AEP Active and Retiree Dental DMO Plan SPD

66 Plan Sponsor and Administrator: The Plan sponsored by American Electric Power Service Corporation (AEP) and AEP is also the plan administrator. AEP s address is: American Electric Power Service Corporation (AEP) 1 Riverside Plaza Columbus, OH (614) The plan administrator has the authority to control, administer and manage the operation of all plans. The rights to carry out responsibilities and use maximum discretionary authority permitted by law are assigned to the plan administrator and any representative it chooses for self-insured options, and to the claims administrator appointed by insurer for insured options. These rights and responsibilities include the following: Interpret, construe and administer the plans, Make determinations regarding plan participation, enrollment and eligibility for benefits, Evaluate and determine the validity of benefit claims, and Resolve any and all claims and disputes regarding the rights and entitlements of individuals to participate in the plans and to receive benefits and payments pursuant to the plans. The decisions of these parties are final and binding. Plan Numbers: Plans are identified by the United States Department of Labor by reference to two numbers: the Plan Sponsor s Employer Identification Number (EIN) and the Plan Number. The EIN for AEP is Three-Digit Plan Identification Number: 503. Plan Type: Fully Insured Plan Year: January 1 through December 31. Agent for Service of Legal Process: Legal process may be served on the plan administrator at the address listed under section titled Plan Sponsor and Administrator. Glossary In this section, you will find definitions for the words and phrases that appear in bold type throughout the text of this SPD. Aetna Aetna Life Insurance Company, an affiliate, or a third party vendor under contract with Aetna. Coinsurance Coinsurance is both the percentage of covered expenses that the plan pays, and the percentage of covered expenses that you pay. The percentage that the plan pays is referred to as plan coinsurance and varies by the type of expense. Please refer to the Schedule of Benefits for specific information on coinsurance amounts. Copay or Copayment The specific dollar amount or percentage required to be paid by you or on your behalf. The plan includes various copayments, and these copayment amounts or percentages are specified in the Schedule of Benefits. AEP Active and Retiree Dental DMO Plan SPD

67 Cosmetic Services or supplies that alter, improve or enhance appearance. Covered Expenses Medical, dental, vision or hearing services and supplies shown as covered under this SPD. Deductible The part of your covered expenses you pay before the plan starts to pay benefits. Additional information regarding deductibles and deductible amounts can be found in the Schedule of Benefits. Dental Provider This is: Any dentist; Group; Organization; Dental facility; or Other institution or person. legally qualified to furnish dental services or supplies. Dental Emergency Any dental condition that: Occurs unexpectedly; Requires immediate diagnosis and treatment in order to stabilize the condition; and Is characterized by symptoms such as severe pain and bleeding. Dentist A legally qualified dentist, or a physician licensed to do the dental work he or she performs. Directory A listing of all network providers serving the class of employees to which you belong. The policyholder will give you a copy of this directory. Network provider information is available through Aetna's online provider directory, DocFind. You can also call the Member Services phone number listed on your ID card to request a copy of this directory. Experimental or Investigational A drug, a device, a procedure, or treatment will be determined to be experimental or investigational if: There are insufficient outcomes data available from controlled clinical trials published in the peerreviewed literature to substantiate its safety and effectiveness for the illness or injury involved; or Approval required by the U. S. Food and Drug Administration (FDA) has not been granted for marketing; or A recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental or investigational, or for research purposes; or It is a type of drug, device, procedure or treatment that is the subject of a Phase I or Phase II clinical trial or the experimental or research arm of a Phase III clinical trial, using the definition of phases indicated in regulations and other official actions and publications of the FDA and Department of Health and Human Services; or AEP Active and Retiree Dental DMO Plan SPD

68 The written protocol or protocols used by the treating facility, or the protocol or protocols of any other facility studying substantially the same: drug; device; procedure; or treatment, or the written informed consent used by the treating facility or by another facility studying the same drug, device, procedure, or treatment states that it is experimental or investigational, or for research purposes. Hospital An institution that: Is primarily engaged in providing, on its premises, inpatient medical, surgical and diagnostic services; Is supervised by a staff of physicians; Provides twenty-four (24) hour-a-day R.N. service, Charges patients for its services; Is operating in accordance with the laws of the jurisdiction in which it is located; and Does not meet all of the requirements above, but does meet the requirements of the jurisdiction in which it operates for licensing as a hospital and is accredited as a hospital by the Joint Commission on the Accreditation of Healthcare Organizations. In no event does hospital include a convalescent nursing home or any institution or part of one which is used principally as a convalescent facility, rest facility, nursing facility, facility for the aged, extended care facility, intermediate care facility, skilled nursing facility, hospice, rehabilitative hospital or facility primarily for rehabilitative or custodial services. Illness A pathological condition of the body that presents a group of clinical signs and symptoms and laboratory findings peculiar to the findings set the condition apart as an abnormal entity differing from other normal or pathological body states. Injury An accidental bodily injury that is the sole and direct result of: An unexpected or reasonably unforeseen occurrence or event; or The reasonable unforeseeable consequences of a voluntary act by the person. An act or event must be definite as to time and place. Jaw Joint Disorder This is: A Temporomandibular Joint (TMJ) dysfunction or any alike disorder of the jaw joint; or A Myofacial Pain Dysfunction (MPD); or Any alike disorder in the relationship of the jaw joint and the related muscles and nerves. Lifetime Maximum This is the most the plan will pay for covered expenses incurred by any one covered person in their lifetime. AEP Active and Retiree Dental DMO Plan SPD

69 Medically Necessary or Medical Necessity These are health care or dental services, and supplies or prescription drugs that a physician, other health care provider or dental provider, exercising prudent clinical judgment, would give to a patient for the purpose of: preventing; evaluating; diagnosing; or treating: an illness; an injury; a disease; or its symptoms. The provision of the service, supply or prescription drug must be: a) In accordance with generally accepted standards of medical or dental practice; b) Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury or disease; and c) Not mostly for the convenience of the patient, physician, other health care or dental provider; and d) And do not cost more than an alternative service or sequence of services at least as likely to produce the same therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or disease. For these purposes generally accepted standards of medical or dental practice means standards that are based on credible scientific evidence published in peer-reviewed literature. They must be generally recognized by the relevant medical or dental community. Otherwise, the standards are consistent with physician or dental specialty society recommendations. They must be consistent with the views of physicians or dentists practicing in relevant clinical areas and any other relevant factors. Negotiated Charge The maximum charge a network provider has agreed to make as to any service or supply for the purpose of the benefits under this plan. Network Provider A dental provider who has contracted to furnish services or supplies for this plan; but only if the provider is, with Aetna's consent, included in the directory as a network provider for: The service or supply involved; and The class of employees to which you belong. Network Service(s) or Supply(ies) Health care service or supply that is: Furnished by a network provider; or Furnished or arranged by your PCD. Non-Occupational Illness A non-occupational illness is an illness that does not: Arise out of (or in the course of) any work for pay or profit; or Result in any way from an illness that does. AEP Active and Retiree Dental DMO Plan SPD

70 An illness will be deemed to be non-occupational regardless of cause if proof is furnished that the person: Is covered under any type of workers' compensation law; and Is not covered for that illness under such law. Non-Occupational Injury A non-occupational injury is an accidental bodily injury that does not: Arise out of (or in the course of) any work for pay or profit; or Result in any way from an injury which does. Occupational Injury or Occupational Illness An injury or illness that: Arises out of (or in the course of) any activity in connection with employment or self-employment whether or not on a full time basis; or Results in any way from an injury or illness that does. Occurrence This means a period of disease or injury. An occurrence ends when 60 consecutive days have passed during which the covered person: Receives no medical treatment; services; or supplies; for a disease or injury; and Neither takes any medication, nor has any medication prescribed, for a disease or injury. Orthodontic Treatment This is any: Medical service or supply; or Dental service or supply; furnished to prevent or to diagnose or to correct a misalignment: Of the teeth; or Of the bite; or Of the jaws or jaw joint relationship; whether or not for the purpose of relieving pain. Out-of-Network Service(s) and Supply(ies) Health care service or supply that is: Furnished by an out-of network provider; or Not furnished or arranged by your PCD. Out-of-Network Provider A dental provider who has not contracted with Aetna, an affiliate, or a third party vendor, to furnish services or supplies for this plan. Physician A duly licensed member of a medical profession who: Has an M.D. or D.O. degree; Is properly licensed or certified to provide medical care under the laws of the jurisdiction where the individual practices; and Provides medical services which are within the scope of his or her license or certificate. This also includes a health professional who: AEP Active and Retiree Dental DMO Plan SPD

71 Is properly licensed or certified to provide medical care under the laws of the jurisdiction where he or she practices; Provides medical services which are within the scope of his or her license or certificate; Under applicable insurance law is considered a physician for purposes of this coverage; Has the medical training and clinical expertise suitable to treat your condition; Specializes in psychiatry, if your illness or injury is caused, to any extent, by alcohol abuse, substance abuse or a mental disorder; and A physician is not you or related to you. For the purposes of Short Term Disability coverage, regular care of a physician means you are attended by a physician who: Is not you or related to you; Has the medical training and clinical expertise suitable to treat your disabling condition; Specializes in psychiatry, if your disability is caused, to any extent, by a mental health or psychiatric condition; and Whose treatment is: Consistent with the diagnosis of the disabling condition; According to guidelines established by medical, research and rehabilitative organizations; and Administered as often as needed. Precertification or Precertify A process where Aetna is contacted before certain services are provided, such as hospitalization or outpatient surgery, or prescription drugs are prescribed to determine whether the services being recommended or the drugs prescribed are considered covered expenses under the plan. It is not a guarantee that benefits will be payable. Prescriber Any physician or dentist, acting within the scope of his or her license, who has the legal authority to write an order for a prescription drug. Prescription An order for the dispensing of a prescription drug by a prescriber. If it is an oral order, it must be promptly put in writing by the pharmacy. Prescription Drug A drug, biological, or compounded prescription which, by State and Federal Law, may be dispensed only by prescription and which is required to be labeled Caution: Federal Law prohibits dispensing without prescription. This includes: An injectable drug prescribed to be self-administered or administered by any other person except one who is acting within his or her capacity as a paid healthcare professional. Covered injectable drugs include injectable insulin. Primary Care Dentist (PCD) This is the network provider who: Is selected by a person from the list of Primary Care Dentists in the directory; Supervises, coordinates and provides dental services to a person; Initiates referrals for specialist dentist care and maintains continuity of patient care; and Is shown on Aetna's records as the person's primary care dentist. AEP Active and Retiree Dental DMO Plan SPD

72 If you do not choose a PCD, Aetna will have the right to make a selection for you. You will be notified of the selection. Recognized Charge The amount of an out-of-network provider s charge that is eligible for coverage. You are responsible for all amounts above the recognized charge. The recognized charge may be less than the provider s full charge. Your plan s recognized charge applies to all out-of-network covered expenses. In all cases, the recognized charge is determined based on the Geographic Area where you receive the service or supply. For dental expenses: 80th percentile of the Prevailing Charge Rate We have the right to apply Aetna reimbursement policies. Those policies may further reduce the recognized charge. These policies take into account factors such as: The duration and complexity of a service; When multiple procedures are billed at the same time, whether additional overhead is required; Whether an assistant surgeon is necessary for the service; If follow up care is included; Whether other characteristics modify or make a particular service unique; When a charge includes more than one claim line, whether any services described by a claim line are part of or incidental to the primary service provided and The educational level, licensure or length of training of the provider. Aetna reimbursement policies are based on our review of: The Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI) and other external materials that say what billing and coding practices are and are not appropriate Generally accepted standards of medical and dental practice and The views of physicians and dentists practicing in the relevant clinical areas. We use commercial software to administer some of these policies. Some policies are different for professional services than for facility services. Special terms used Geographic Area and Prevailing Charge Rates are defined as follows: Geographic Area The Geographic Area is made up of the first three digits of the U.S. Postal Service zip code. If we determine we need more data for a particular service or supply, we may base rates on a wider Geographic Area such as an entire state. Prevailing Charge Rates The percentile value reported in a database prepared by FAIR Health, a nonprofit company. FAIR Health changes these rates periodically. Aetna updates its systems with these changes within 180 days after receiving them from FAIR Health. If the FAIR Health database becomes unavailable, Aetna has the right to substitute an alternative database that Aetna believes is comparable. AEP Active and Retiree Dental DMO Plan SPD

73 Additional Information: Get the most value out of your benefits. Use the Estimate the Cost of Care tool on Aetna Navigator to help decide whether to get care in network or out-of-network. Aetna s secure member website at may contain additional information which may help you determine the cost of a service or supply. Log on to Aetna Navigator to access the Estimate the Cost of Care feature. Within this feature, view our Cost of Care and Member Payment Estimator tools. Referral This is a written or electronic authorization made by your primary care physician (PCP) or primary care dentist (PCD) to direct you to a network provider, for medically necessary services or supplies covered under the plan. Referral Care Covered services given to you by a specialist dentist who is a network provider after referral by your primary care dentist and providing that Aetna approves coverage for the treatment. R.N. A registered nurse. Skilled Nursing Facility An institution that meets all of the following requirements: It is licensed to provide, and does provide, the following on an inpatient basis for persons convalescing from illness or injury: Professional nursing care by an R.N., or by a L.P.N. directed by a full-time R.N.; and Physical restoration services to help patients to meet a goal of self-care in daily living activities. Provides 24 hour a day nursing care by licensed nurses directed by a full-time R.N. Is supervised full-time by a physician or an R.N. Keeps a complete medical record on each patient. Has a utilization review plan. Is not mainly a place for rest, for the aged, for drug addicts, for alcoholics, for mental retardates, for custodial or educational care, or for care of mental disorders. Charges patients for its services. An institution or a distinct part of an institution that meets all of the following requirements: It is licensed or approved under state or local law. Is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons. Qualifies as a skilled nursing facility under Medicare or as an institution accredited by: The Joint Commission on Accreditation of Health Care Organizations; The Bureau of Hospitals of the American Osteopathic Association; or The Commission on the Accreditation of Rehabilitative Facilities Skilled nursing facilities also include rehabilitation hospitals (all levels of care, e.g. acute) and portions of a hospital designated for skilled or rehabilitation services. AEP Active and Retiree Dental DMO Plan SPD

74 Skilled nursing facility does not include: Institutions which provide only: Minimal care; Custodial care services; Ambulatory; or Part-time care services. Institutions which primarily provide for the care and treatment of alcoholism, substance abuse or mental disorders. Specialist A physician who practices in any generally accepted medical or surgical sub-specialty. Specialist Dentist Any dentist who, by virtue of advanced training is board eligible or certified by a Specialty Board as being qualified to practice in a special field of dentistry. Specialty Care Health care services or supplies that require the services of a specialist. AEP Active and Retiree Dental DMO Plan SPD

75 Confidentiality Notice Aetna considers personal information to be confidential and has policies and procedures in place to protect it against unlawful use and disclosure. By "personal information," we mean information that relates to a member's physical or mental health or condition, the provision of health care to the member, or payment for the provision of health care or disability or life benefits to the member. Personal information does not include publicly available information or information that is available or reported in a summarized or aggregate fashion but does not identify the member. When necessary or appropriate for your care or treatment, the operation of our health, disability or life insurance plans, or other related activities, we use personal information internally, share it with our affiliates, and disclose it to health care providers (doctors, dentists, pharmacies, hospitals and other caregivers), payors (health care provider organizations, employers who sponsor self-funded health plans or who share responsibility for the payment of benefits, and others who may be financially responsible for payment for the services or benefits you receive under your plan), other insurers, third party administrators, vendors, consultants, government authorities, and their respective agents. These parties are required to keep personal information confidential as provided by applicable law. In our health plans, participating network providers are also required to give you access to your medical records within a reasonable amount of time after you make a request. Some of the ways in which personal information is used include claim payment; utilization review and management; medical necessity reviews; coordination of care and benefits; preventive health, early detection, vocational rehabilitation and disease and case management; quality assessment and improvement activities; auditing and anti- fraud activities; performance measurement and outcomes assessment; health, disability and life claims analysis and reporting; health services, disability and life research; data and information systems management; compliance with legal and regulatory requirements; formulary management; litigation proceedings; transfer of policies or contracts to and from other insurers, HMOs and third party administrators; underwriting activities; and due diligence activities in connection with the purchase or sale of some or all of our business. We consider these activities key for the operation of our health, disability and life plans. To the extent permitted by law, we use and disclose personal information as provided above without member consent. However, we recognize that many members do not want to receive unsolicited marketing materials unrelated to their health, disability and life benefits. We do not disclose personal information for these marketing purposes unless the member consents. We also have policies addressing circumstances in which members are unable to give consent. To obtain a copy of our Notice of Privacy Practices, which describes in greater detail our practices concerning use and disclosure of personal information, please call the toll-free Member Services number on your ID card or visit our Internet site at AEP Active and Retiree Dental DMO Plan SPD

76 AEP Benefits Center