DSM USA Insurance Company, Inc. 465 Medford Street Boston, MA 02129

Transcription

1 DSM USA Insurance Company, Inc. 465 Medford Street Boston, MA DENTAQUEST PPO FOR GROUPS ACCOUNT DENTAL SERVICE AGREEMENT DSM USA Insurance Company, Inc., (the Plan), and the plan sponsor identified below (the Plan Sponsor), enter into this Agreement. In consideration of the benefits, subscription charges, and requirements of this Agreement, the parties agree as follows: Terms of Agreement 0.1 The initial term of this Agreement shall be for one year beginning at 12:00 AM Central Time on the Effective Date. 0.2 After the initial term, this Agreement shall extend year to year until this Agreement is terminated as provided for in this Agreement. 0.3 This Agreement, including the application and any amendments and riders, including the Schedule of Benefits, constitutes the entire contract of insurance and no change in this Agreement shall be valid until approved by an executive officer of the Plan and unless such approval be endorsed hereon or attached hereto. No agent has any authority to change this Agreement or to waive any of its provisions. This Agreement shall be interpreted and governed in accordance with the laws of the State of Illinois. DSM USA Insurance Company, Inc. Plan Sponsor: Name: Title: Dated: Steven J Pollock President DQ.IL.GRP.ACA.GA.PPO

2 Contents Article 1 - Responsibilities of the Plan......Page 3 Article 2 - Responsibilities of the Plan Sponsor......Page 4 Article 3 - Benefits......Page 5 Article 4 - Exclusions......Page 6 Article 5 - Other Contract Provisions......Page 7 Article 6 - Utilization Review/Right to Appeal Page 20 Article 7 - Filing a Claim......Page 21 Article 8 - Definitions......Page 24 2

3 Article 1 - Responsibilities of the Plan 1.1 The Plan agrees to provide a right to appeal decisions to deny coverage for dental services, as more fully described in Article The effective date of coverage for each Subscriber and his or her covered dependents shall be the date specified by the Plan Sponsor in a written notice to the Plan and incorporated into the enrollment form, or the date specified by the Exchange, as applicable. If the effective date is specified by the Plan Sponsor in a written notice, the effective date must not be more than seventy-two (72) days prior to the date of notice. Further, the Plan Sponsor must pay applicable subscription charges. There may exist some limitations or exclusions on membership. Please refer to Article 4 regarding limitations and exclusions. 1.3 The Plan will provide benefits to Covered Individuals and their covered dependents under this Agreement for so long as they meet the eligibility requirements of the Plan's underwriting guidelines, and for so long as applicable subscription charges are paid. Please see Section 2.3 for further details on eligibility. 1.4 The Plan will send a bill to the Plan Sponsor for the total subscription charges and will expect payment in full by the due date indicated on each monthly invoice. 1.5 The Plan will send the Plan Sponsor a notice at least sixty (60) days before any change in the subscription charge goes into effect. Rates will not change more than once every twelve (12) months. 1.6 A grace period of thirty-one (31) days will be granted for the payment of each premium falling due after the first premium, during which grace period the Agreement shall continue in force unless the Plan Sponsor shall have given the Plan notice of discontinuance thirty (30) days in advance of the date of discontinuance. The Plan Sponsor is liable to the Plan for the payment of a pro rata premium for the time the coverage was in force during the grace period. 1.7 The Plan will contract with dentists who desire to be a part of the Plan s network of Participating Dentists. Such Participating Dentists have agreed to file claims forms on behalf of Covered Individuals, and will receive payment for covered services directly from the Plan. If services are rendered to Covered Individuals by a Non-participating Dentist, claims forms may be requested from the Plan as further described in Article 7 of this Agreement. The Plan agrees to supply claims forms to Covered Individuals within fifteen (15) days of receipt of such request. 3

4 Article 2 - Responsibilities of the Plan Sponsor 2.1 The Plan Sponsor will pay the Plan the total subscription charges by the due date indicated on each monthly invoice. The total monthly subscription charges are identified in Attachment A. 2.2 The Plan Sponsor will maintain with the Plan a current and updated listing of covered subscribers, and will be responsible for all costs and expenses associated with failure to maintain with the Plan an accurate and current listing. 2.3 The Plan Sponsor will be responsible for the determination of newly eligible employees in accordance with the terms of this Agreement and the underwriting guidelines of the Plan. 2.4 The Plan Sponsor will be solely responsible for collecting any portion of the subscription charges, which it assesses, to its employees. 2.5 The Plan Sponsor will be solely responsible for complying with all applicable provisions of the Employee Retirement Income Security Act of 1974 (ERISA), as amended. In particular, the Plan Sponsor will be responsible for fulfilling the obligation of a plan sponsor under ERISA, including without limitation, providing its employees with copies of Subscriber s Certificates, Schedules of Benefits and any applicable riders and with copies of a summary brochure describing benefits, limitations and exclusions. 2.6 The Plan Sponsor will be solely responsible for complying with all applicable provisions of the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA). 2.7 The Plan Sponsor will be solely responsible for any dental services, which it must provide under any applicable employer s liability or indemnification law, or under any workers' compensation act. 4

5 Article 3 - Benefits Covered Individuals have the right to benefits on a non-discriminatory basis for the services listed in the Schedule of Benefits, except as limited or excluded elsewhere in this Agreement, including the Schedule of Benefits. The benefits may be limited to a maximum dollar payment for each Covered Individual for each Plan Year. The extent of these benefits is explained in the Schedule of Benefits the Plan Sponsor has purchased and which is incorporated as a part of this Agreement. Please refer to the Schedule of Benefits for the benefits covered under this Policy. 5

6 Article 4 - Exclusions 4.1 Benefits Are Provided Only For Necessary And Appropriate Services The Plan will not provide benefits for a dental service that is not covered under the terms of the Agreement. The Plan will not provide benefits for a covered dental service that is not necessary and appropriate to diagnose or to treat a dental condition. The Plan will not cover experimental care procedures that have not been sanctioned by the American Dental Association and for which no procedure codes have been established. A. To be necessary and appropriate, a service must be consistent with the prevention of oral disease or with the diagnosis and treatment on (1) those teeth that are decayed or fractured or (2) those teeth where supporting periodontium is weakened by disease. A service must be provided in accordance with standards of good dental practice not solely for the Covered Individual s convenience or the convenience of the dentist. B. The determination of what is necessary and appropriate under the terms of the Agreement is made based on a review of dental records describing the Covered Individual s condition and treatment. The Plan may decide a service is not necessary and appropriate under the terms of the Agreement even if the dentist has furnished, prescribed, ordered, recommended or approved the service. 4.2 Benefits Are Not Provided For: The Schedule of Benefits provides a summary of the dental services or items for which coverage is not provided under this Policy 6

7 Article 5 - Other Contract Provisions Part 1 - General 5.1 This Agreement may be modified or amended by written agreement of the parties. 5.2 Should the Plan be subject to federal or state laws or regulations mandating any change in the benefits specified in this Agreement or in the eligibility of subscribers and their covered dependents, the Plan shall implement such mandatory change. In this event, the Plan shall implement a premium increase commensurate with the change required by federal or state laws or regulations. The Plan will provide the Plan Sponsor with prior written notice of changes at least sixty (60) days before the effective date of the increase. Subscription charges may not be increased unless present rates under the contract have been in effect for at least twelve (12) months. 5.3 The Plan reserves the right to make any reasonable and necessary adjustment to the subscription rates if there is a +/- ten percent (10%) enrollment mix or total enrollment variance between provided information and actual enrollment. In this event, the Plan will provide the Plan Sponsor with written notice at least sixty (60) days before the effective date of the increase. Subscription charges may not be increased unless present rates under the contract have been in effect for at least twelve (12) months. Subscription charges may not be increased until the end of the Plan Year. 5.4 After two years from the date of issue of this Agreement, no misstatements, except fraudulent misstatements, made by the applicant in the application for such Agreement shall be used to void the Agreement or to deny a claim for loss incurred commencing after the expiration of such 2 year period. 5.5 A statement made by any Covered Individual under the Agreement relating to insurability may not be used in contesting the validity of the insurance with respect to which the statement was made after the insurance has been in force before the contest for a period of two (2) years during the person s lifetime. 5.6 Each statement made by an applicant, the Plan Sponsor or Subscriber, and the parent or guardian enrolling a minor child in the case of child-only coverage, is considered to be a representation and not a warranty. No written statement made by the Plan Sponsor to the Covered Individual shall be used in any contest unless a copy of the statement is furnished to him/her, his/her representative or beneficiary. 5.7 A statement made to effectuate insurance may not be used to avoid the insurance or reduce benefits under the Agreement unless (a) the statement is contained in a written instrument signed by the Plan Sponsor or Covered Individual, and (b) a copy of the statement is given to the Plan Sponsor, Covered Individual or Covered Beneficiary of the Covered Individual. This provision does not preclude the assertion at any time of defenses based upon the person s eligibility for coverage under the Agreement or upon other provisions in the 7

8 Agreement. 5.8 Notices under this Agreement shall be sent by first class mail, postage prepaid, or delivered by hand to the Plan. Letters should be sent to DSM USA Insurance Company, Inc., c/o DentaQuest Management, Inc., PO Box 9708, Boston, MA Choice of Law This Agreement shall be construed according to the laws of the State of Illinois. This Agreement will be automatically revised in order to conform to statutory requirements of the laws of the State of Illinois Legal Actions No action in law or equity will be brought to recover under this contract prior to sixty (60) days after a claim has been presented to the Plan. Nor will any such action be brought unless brought within three (3) years from the expiration of the time within such claim submission is required Misstatement of Age - If the age of the subscriber or any of the subscriber s covered dependents has been misstated, all amounts payable under this Agreement shall be such as the subscription charge paid would have purchased at the correct age The Plan will furnish to the Plan Sponsor, for delivery to each Subscriber, an individual certificate setting forth in summary form a statement of the essential features of the insurance coverage of the Subscriber and to whom benefits are payable From time to time, eligible new employees or Subscribers or dependents, in accordance with the terms of this Agreement, may be added to the group originally insured The Plan reserves the right to terminate any Covered Individual if he or she makes any fraudulent claim or intentional misrepresentation of material fact to the Plan or to any dentist. He or she may also be terminated if he or she commits any acts of physical or verbal abuse that pose a threat to a dentist or the Plan s employees. These actions of abuse must be unrelated to any mental or physical condition that the Covered Individual may have. Such termination for fraud or intentional misrepresentation will be as of the subscriber s effective date (i.e, a rescission), and the Plan will refund all subscription charges for the individual after the Plan has subtracted any payments for claims made under the Agreement. If the Plan has paid more for claims under the Agreement than the total subscription charges, the Plan reserves the right to collect the excess from the subscriber. The Plan shall provide at least 30 days advance written notice or electronic notice to any Covered Individual who would be affected by the rescission of coverage before coverage may be rescinded. Part 2 - Termination 5.15 In addition to the right to rescind coverage under Section 5.14, the Plan may also at its option terminate a Subscriber s Certificate for fraud or intentional misrepresentation of material fact by providing 30 days advance written notice or electronic notice to any 8

9 Covered Individual who would be affected by the termination The Plan may terminate this Agreement upon sixty (60) days prior written notice to the Plan Sponsor. Policies issued through the Exchange shall be terminated in accordance with requirements of the Exchange The Plan will terminate coverage under this Agreement to named subscribers and their covered dependents on the termination date specified by the Plan Sponsor in a written notice to the Plan, provided that: A. The termination date will not be more than seventy-two (72) days prior to the date of notice, and there are no paid claims past the date of termination; B. For certain treatments, benefits will continue beyond the termination date as specified in the Subscriber s Certificate(s), Schedule of Benefits and any applicable rider(s) identified in the Agreement. The claims experience will be charged to the Plan Sponsor; and C. The Plan Sponsor will be charged claims experience for the claims incurred after the effective date and prior to the date of the Plan's receipt of the Plan Sponsor's notice of termination The Plan will terminate coverage under this Agreement to named Subscribers and their covered dependents on the termination date specified by the Plan Sponsor in a written notice to the Plan, provided that the termination date will not be less than sixty (60) days after the date of notice and no claim payments have been made for services rendered after termination date. The Plan Sponsor will be solely responsible to continue to pay subscription charges for any Subscriber or dependent under this Agreement until the effective date of termination. Part 3 - Payments to Dentists 5.19 When a Participating Dentist provides covered services, he or she must accept the fee as payment in full. But in the following cases (in addition to any applicable coinsurance), the Covered Individual will be responsible for the difference between the Plan payment and the dentist s actual charge for covered services: A. If the Covered Individual has received the maximum benefit allowed for services. In essence, the maximum dollar amount for a Covered Individual in a Plan Year, including the service that caused him or her to reach the maximum. B. If the Covered Individual and his or her dentist decide to use services that are more expensive than those customarily furnished by most dentists, benefits will be provided towards the service with the lower fee. C. If the Covered Individual receives services from more than one dentist for the same dental procedure or receives services that are furnished in a series during a planned 9

10 course of treatment. In such a case, the total amount of benefits will not be more than the amount that would have been provided if only one dentist had furnished all the services If the treating dentist expects that dental treatment will involve a series of covered services (over $600), he or she should file a copy of the treatment plan with the Plan BEFORE these services are rendered to a Covered Individual. A treatment plan is a detailed description of the procedures that the dentist plans to perform and includes an estimate of the charges for each service. Upon receipt of the treatment plan, the Plan will notify the Covered Individual and the treating dentist about the maximum extent of the Covered Individual s benefits for the services reported. IMPORTANT NOTE: Pre-treatment estimates are calculated based on current available benefits and the patient s eligibility. Estimates are subject to modification and eligibility that applies at the time services are completed and a claim is submitted for payment. The pre-treatment estimate is NOT a guarantee of payment or a preauthorization WARNING, LIMITED BENEFITS WILL BE PAID WHEN NON-PARTICIPATING DENTISTS ARE USED. You should be aware that when you elect to utilize the services of a Non-participating Dentist in non-emergency situations, benefit payments to such Non-participating Dentist are not based upon the amount billed. The basis of your benefit payment will be based on the lesser of the dentist s fees, or the amounts indicated on the Fee Schedule for services that may be provided by Participating and Non-participating Dentists under this Policy. YOU CAN EXPECT TO PAY MORE THAN THE COINSURANCE AMOUNT DEFINED IN THE POLICY AFTER THE PLAN HAS PAID ITS REQUIRED PORTION. Non-participating Dentists may bill members for any amount up to the billed charge after the plan has paid its portion of the bill as provided in Section 356z.3a of the Illinois Insurance Code 215 ILCS 5/356z.3a. Participating Dentists have agreed to accept discounted payments for services with no additional billing to the member other than co-insurance and deductible amounts. You may obtain further information about the participating status of a dentist and information on out-of-pocket expenses by calling the toll free telephone number on your identification card or at the end of this Policy. The Plan s and any administrator s name and toll-free number will be included on the identification card. Only the Plan may assume any underwriting risk when that risk is part of the delivery of services. Benefits are payable in accordance with the terms and conditions of the applicable Schedule of Benefits attached to this Agreement and in effect at the time services are rendered In addition, the Covered Individual will be responsible for paying any difference between the Plan s payment to a Non-participating Dentist, after any deductible or coinsurance amounts selected by the Plan Sponsor are calculated, based on the Fee Schedule and the Non-participating Dentist s total charge, if the dentist s total charge 10

11 exceeds the Fee Schedule amount for that covered procedure(s) Whenever a Participating Dentist finds it medically necessary to refer a Covered Individual to a Non-participating Dentist, the Plan shall ensure that the Covered Individual so referred shall incur no greater out of pocket liability than had the Covered Individual received services from a Participating Dentist. This provision does not apply to a Covered Individual who willfully chooses to access a Non-participating Dentist for health care services available through Participating Dentists. In these circumstances, the contractual requirements for Non-participating Dentist reimbursements will apply Coordination of Benefits Part 4 - Coordination of Benefits The Plan will apply Coordination of Benefits (COB) to all the benefits described in this Agreement. Coordination of Benefits (COB) applies if you or any of your dependents have another plan that provides coverage for services that are benefits under your contract including: group insurance, closed panel or other forms of group or group-like coverage (whether insured or uninsured), medical care components of group long-term care policies, and Medicare or other governmental benefits as permitted by law. A plan may also include indemnity programs, PPO programs, discounted fee for service programs, point of service programs, and capitation programs. The following are not treated as plans for the purposes of COB: an individual or family insurance, or other individual coverage (except for group-type insurance), school accident type coverage, benefits for non-medical components of group longterm care policies, Medicaid policies and coverage under other governmental plans unless permitted by law, and an individual guaranteed renewable specified disease policy or intensive care policy that does not provide benefits on an expenseincurred basis. The Plan will administer the COB according to the applicable state Coordination of Benefits law and this Agreement. A. Definitions: 1. Claim determination period means a Plan Year. However, it does not include any part of a year during which a person has no coverage under the Plan, or before the date this COB provision or a similar provision takes effect. 2. Custodial parent means a parent awarded custody by a court decree. In the absence of a court decree, it is the parent with whom the child resides more than one half of the calendar year without regard to any temporary visitation. 3. The plan that provides benefits first under the COB rules is known as the primary plan. The primary plan is responsible for providing benefits in accordance with its terms and conditions of coverage without regard to coverage under any other plan. 4. The plan that provides benefits next is the secondary plan. It provides benefits toward any remaining balance for covered services in accordance with its terms and 11

12 conditions of coverage, including its COB provision. B. Secondary Plan s Benefits: The secondary plan s benefits are determined after those of another plan and may be reduced because of the primary plan s benefits. This Plan, as the secondary plan, will provide benefits toward any remaining patient balance for covered services in accordance with your contract, provided that the amount paid by this Plan as the secondary plan, when added to the amount paid by the primary plan, will not exceed the lesser of the provider s submitted charge or the amount allowed under your contract. C. Order of Benefit Determination Rules: 1. The coverage from both plans shall be coordinated so that the Covered Individual receives the maximum allowable benefit from each plan. 2. A plan that does not contain a COB provision is always primary. An exception to this rule is coverage that is obtained by virtue of membership in a group that is designed to supplement a part of a basic package of benefits provided by the Plan Sponsor. An example of this type of coverage is a point-of-service benefit written in connection to a closed panel (capitation) panel. 3. In determining which plan is the primary and which is the secondary, the following rules shall apply and in this order: a. The plan that covers the Covered Individual other than as a dependent is the primary plan. The secondary plan is the one that covers that Covered Individual as a dependent. However, if federal law requires Medicare to be a secondary plan, then this rule may be reversed. b. When both plans cover the Covered Individual as a dependent child, the plan of the parent whose birthday occurs first in a calendar year should be considered as primary. The parents should be married, not separated (whether or not they ever have been married), or a court decree awards joint custody without specifying that one party has the responsibility to provide health care coverage. c. If the parents are not married, or are separated (whether or not they ever have been married) or are divorced, the order of benefits shall be: 1) the plan of the custodial parent 2) the plan of the spouse of the custodial parent 3) the plan of the noncustodial parent 4) the plan of the noncustodial parent s spouse. d. If a determination cannot be made with the rules as set out above, the plan that has covered either of the parents for a longer time should be considered as primary. This rule shall apply if the parents have the same birthday. 12

13 e. If a court decree states that one of the parents is responsible for the child s health care expenses or health care coverage and the plan of that parent has actual knowledge of those terms, that plan is primary. This rule shall apply to claim determination periods or plan years commencing after the plan is given notice of the court decree. 4. A plan may consider the benefits paid or provided by another plan in determining its benefits only when it is secondary to that other plan. 5. If one of the plans is a medical plan and the other is a dental plan, the medical plan will always be the primary plan. 6. Whichever plan that covered the covered individual as an employee, member, subscriber or retiree longer is the primary. Part 5 - When Coverage Begins/Ends 5.25 Benefits will be provided ONLY for those covered services that are furnished on or after the effective date of this Agreement. No benefits will be provided for services that you receive after termination of this Agreement A Covered Individual may have the right to continue dental coverage for a period of time under federal legislation known as the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA). Subscribers and covered eligible dependent family members as defined by COBRA may be entitled to continue participating in this Plan for a period of time specified under law even under conditions (such as the subscriber s death or termination of employment) that would otherwise make him or her ineligible for coverage, so long as he or she pays the appropriate subscription in full. No change in benefits will occur as a result of coverage under COBRA. For more information about COBRA coverage, the Subscriber should consult with his or her Plan Sponsor Spousal Continuation - Existing insurance benefits for an employee's spouse and dependent children who are insured under this Agreement shall continue notwithstanding that the marriage is dissolved by judgment or terminated by the death of the employee or, notwithstanding the retirement of the employee provided that the employee's spouse is at least 55 years of age, in each case without any other eligibility requirements. Within 30 days of the entry of judgment or the death or retirement of the employee, the spouse of an employee insured under this Agreement who seeks a continuation of coverage shall give the Plan Sponsor or the Plan written notice of the dissolution of the marriage or the death or retirement of the employee. The Plan Sponsor, within 15 days of receipt of the notice shall give written notice of the dissolution of the employee's marriage or the death or retirement of the employee and that former spouse's or retired employee's spouse's residence to the Plan. Within 30 days after the date of receipt of a notice from the Plan Sponsor, retired 13

14 employee's spouse or former spouse or of the initiation of a new group policy, the Plan, by certified mail, return receipt requested, shall notify the retired employee's spouse or former spouse at his or her residence that the Agreement may be continued for that retired employee's spouse or former spouse and covered dependents, and the notice shall include: (i) a form for election to continue the insurance coverage; (ii) the amount of periodic premiums to be charged for continuation coverage and the method and place of payment; and (iii) instructions for returning the election form within 30 days after the date it is received from the Plan. Failure of the retired employee's spouse or former spouse to exercise the election to continue insurance coverage by notifying the Plan in writing within such 30-day period shall terminate the continuation of benefits and the right to continuation. The continuation coverage for former spouses who have not attained the age of 55 at the time coverage begins shall terminate upon the earliest to happen of the following: (i) the failure to pay premiums when due, including any grace period under this Agreement; or (ii) when coverage would terminate under the terms of this Agreement if the employee and former spouse were still married to each other; however, the existing coverage shall not be modified or terminated during the first 120 consecutive days subsequent to the employee spouse's death or to the entry of the judgment dissolving the marriage existing between the employee and the former spouse unless this Agreement terminated as to all employees; or (iii) the date on which the former spouse first becomes, after the date of election, an insured employee under any other group health plan; or (iv) the date on which the former spouse remarries; or (v) the expiration of 2 years from the date continuation coverage began. Upon the termination of continuation coverage, the former spouse shall be entitled to convert the coverage to an individual policy. The continuation rights granted to former spouses who have not attained age 55 shall also include eligible dependents insured prior to the dissolution of marriage or the death of the employee. The continuation coverage for retired employees' spouses and former spouses who have attained the age of 55 at the time coverage begins shall terminate upon the earliest to happen of the following: (i) the failure to pay premiums when due, including any grace period allowed by this Agreement; or (ii) when coverage would terminate, except due to the retirement of an employee, under the terms of this Agreement if the employee and former spouse were still married to each other; however, the existing coverage shall not be modified or terminated during the first 120 consecutive days subsequent to the employee spouse's death or retirement to the entry of the judgment dissolving the marriage existing between the employee and the former spouse unless this Agreement is modified or terminated as to all employees; or (iii) the date on which the retired employee's spouse or former spouse first becomes, after the date of election, an insured employee under any other group health plan; or (iv) the date on which the former spouse remarries; or (v) the date that person reaches the qualifying age or otherwise establishes eligibility under the Medicare Program pursuant to Title XVIII of the federal Social Security Act. Upon the termination of continuation coverage, the former spouse shall be entitled to convert the coverage to an individual policy. The continuation rights granted to former spouses who have 14

15 attained age 55 shall also include eligible dependents insured prior to the dissolution of marriage, the death of the employee, or the retirement of the employee. Premiums for continued coverage under this provision are determined in accordance with Illinois law Dependent Continuation - Existing benefits for an employee's dependent child who is insured under this Agreement shall continue in the event of the death of the employee and the child is not eligible for coverage as a dependent under Section 5.27 above or the dependent child has attained the limiting age under this Agreement. In the event of the death of the employee, if continuation coverage is desired, the dependent child or a responsible adult acting on behalf of the dependent child shall give the Plan Sponsor or the Plan written notice of the death of employee within 30 days of the date the coverage terminates. The Plan Sponsor, within 15 days of receipt of the notice, shall give written notice to the Plan of the death of the employee and the dependent child's residence. The Plan Sponsor shall send a copy of the notice within 10 days to the dependent child or responsible adult at the dependent child's residence. In the event of the dependent child attaining the limiting age under this Agreement, if continuation coverage is desired, the dependent child shall give the Plan Sponsor or the Plan written notice of the attainment of the limiting age within 30 days of the date the coverage terminates. The Plan Sponsor, within 15 days of receipt of the notice, shall give written notice to the Plan of the attainment of the limiting age by the dependent child and of the dependent child's residence. Within 30 days after the date of receipt of a notice from the Plan Sponsor, dependent child, or responsible adult acting on behalf of the dependent child, or of the initiation of a new group policy, the Plan, by certified mail, return receipt requested, shall notify the dependent child or responsible adult at the dependent child's residence that this Agreement may be continued for the dependent child. The notice shall include: (1) a form for election to continue the insurance coverage; (2) the amount of periodic premiums to be charged for continuation coverage and the method and place of payment; and (3) instructions for returning the election form within 30 days after the date it is received. Failure of the dependent child or the responsible adult acting on behalf of the dependent child to exercise the election to continue insurance coverage by notifying the Plan in writing within such 30 day period shall terminate the continuation of benefits and the right to continuation. The premium for the continued coverage shall be determined in accordance with Illinois law. Failure to pay the initial monthly premium within 30 days after the date of receipt of notice required by this provision terminates the continuation benefits and the right to continuation benefits. Continuation coverage under this provision shall terminate upon the earliest to happen of the following: (1) the failure to pay premiums when due, including any grace period allowed by this Agreement; (2) when coverage would terminate under this 15

16 Agreement if the dependent child was still an eligible dependent of the employee; (3) the date on which the dependent child first becomes, after the date of election, an insured employee under any other group health plan; or (4) the expiration of 2 years from the date continuation coverage began. Upon the termination of continuation coverage, the dependent child shall be entitled to convert the coverage to an individual policy. Part 6 - Enrollment and Agreement Changes 5.29 Any additions or changes to the enrollment form are allowed ONLY when they conform to the Plan s underwriting guidelines. Coverage for new spouses shall be effective from the date of marriage. Newly born children are covered from the moment of birth. Newly adopted dependent children or grandchildren shall be covered from the date of adoption or placement for adoption, whichever comes first. A child who is in the custody of an eligible employee or the eligible employee s spouse, pursuant to an interim court order of adoption or placement for adoption, vesting temporary care of the child in the insured, is covered as an adopted child, regardless of whether a final order granting adoption is ultimately issued. Coverage will not be excluded for a child solely because the child does not reside with the insured. The Plan requires that notification of the birth of a newly born child and payment of the required premium be submitted within thirty-one (31) days after the birth in order to have the coverage continue beyond the thirty-one (31) day period. A minor for whom guardianship is granted by court or testamentary appointment shall be covered from the date of appointment. A child, who the court orders to be covered under a Subscriber s dental coverage, shall be covered from the date of the order. Changes to the enrollment form may result in a change in the subscription charge. If additional payments of subscription charges are required to provide coverage for the newly dependent spouse, children or grandchildren, subscribers must notify the Plan Sponsor, and the Plan Sponsor then must notify the Plan, within thirty-one (31) days after a new marriage, birth, adoption or other court order or testamentary appointment. The Plan Sponsor may be required to submit proof of the court order or relationship. The Subscriber must notify the Plan of any new covered dependents within the thirty-one (31) days. Failure to notify the Plan of new dependents within thirty-one (31) days shall result in the Plan never recognizing coverage for the new dependent(s) during the thirtyone (31) days; provided that if a Subscriber already has family coverage and another family member is added, the Plan requests timely notification of the additional individual to facilitate claims payments but the thirty-one (31) day deadline shall not apply Enrolling Dependents Under certain situations, dependents may be added to the Subscriber s coverage at any time. Qualifying events could be a result of court order, involuntary employment termination, and the Subscriber s spouse s death. Under those circumstances, the Subscriber must notify the Plan Sponsor within seventy-two (72) days or six (6) months (only if specified below) of the qualifying event. A. Death of Spouse If a Subscriber s spouse dies, the Subscriber may add his or her 16

17 dependent child(ren) to the coverage provided under this Agreement at any time and without evidence of insurability if the dependent child(ren) previously were covered under the Subscriber s spouse s policy or contract. The Subscriber must notify the Plan Sponsor within six (6) months of this event. B. Court Order If a Subscriber is required under a court order (whether from this state or another state that recognizes the right of the child to receive benefits under the subscriber s health coverage) to provide health coverage for a child, the Plan shall allow the subscriber to enroll the child under the following circumstances: 1. The Subscriber shall be allowed to enroll in family members coverage and include the child in that coverage regardless of any enrollment period restrictions. 2. If the Subscriber is enrolled but does not include the child in the enrollment, the Plan shall allow the noninsuring parent of the child, child support enforcement agency, or any other agency with authority over the welfare of the child to apply for enrollment on behalf of the child. 3. The Subscriber may not terminate coverage for the child unless written evidence is provided to the Plan that the order is no longer in effect, that the child is or will be enrolled under other reasonable dental coverage that will take effect on or before the effective date of termination, the Plan Sponsor has eliminated family coverage for all of its employees or the Plan Sponsor no longer employs the subscriber. If the Plan Sponsor no longer employs the subscriber, COBRA benefits shall be available under the conditions specified in Section Entire Agreement Changes - The Agreement, including the Subscriber s Certificate, Schedule of Benefits, application, enrollment form and any applicable rider(s) or attachments, constitutes the entire Account Dental Service Agreement. A copy of any application of the Plan Sponsor shall be attached to the policy when issued. No change in this Agreement shall be valid until approved by an officer of the Plan and unless such approval be endorsed hereon or attached hereto. No agent has any authority to change this Agreement or to waive any of its provisions Notices: A. To S ubscribers: When the Plan sends a notice to the Plan Sponsor, it will send the notice by first class mail. Once the Plan mails the notice or bill, the Plan is not responsible for the notice s delivery. It will be the Plan Sponsor s responsibility to notify S ubscribers. This applies to the bill for subscription charges as well as to a notice of a change in the subscription charge or the Subscriber s Certificate. B. To the Plan: Send letters to DSM USA Insurance Company, Inc., c/o DentaQuest Management, Inc., PO Box 9708 Boston, MA Always include the Plan Sponsor s group number and subscriber s name In the absence of fraud or intentional misrepresentation of material fact in applying for 17

18 or procuring coverage under this Agreement, all statements made by the Plan Sponsor shall be deemed representations and not warranties, and no statement made for the purpose of effecting insurance shall avoid the insurance or reduce benefits unless contained in a written instrument signed by the Plan Sponsor, a copy of which has been furnished to the Plan Sponsor Enrollment Through the Exchange: A. Notwithstanding anything in Article 5, Part 5 to the contrary, if coverage is obtained through the Exchange, the Exchange will enroll Qualified Employers and enrollees and terminate coverage in accordance with the requirements of the ACA, the rules promulgated under the ACA, including Parts 155 and 156 of Title 45 of the Code of Federal Regulations, and the requirements of the Exchange. The annual open and special enrollment periods in 45 C.F.R and and effective dates of coverage in 45 C.F.R and will apply with respect to enrollment through the Exchange. Special enrollment periods include when a qualified individual gains a dependent or becomes a dependent through marriage, birth, adoption, placement for adoption or placement in foster care. B. For coverage obtained through the Exchange, premium payments will be required to be made directly to the Plan in accordance with the Plan s available methods for payment, unless provided otherwise by Exchange rules. The first premium payment will be due prior to the effective date of coverage, and premiums will be due monthly thereafter unless a different payment interval is permitted by the Plan Subrogation A Subscriber may have a legal right to recover some costs of dental care from someone else because another person has caused his sickness or injury. We are assigned the right to recover from the negligent third party, or his or her insurer, to the extent of the benefits we paid for that sickness or injury. You are required to furnish any information or assistance, or provide any documents that we may reasonably require in order to exercise our rights under this provision. This provision applies whether or not the third party admits liability Reimbursement - If a Covered Individual recovers expenses for sickness or injury that occurred due to the negligence of a third party, we have the right to first reimbursement for all benefits we paid from any and all damages collected from the negligent third party for those same expenses whether by action at law, settlement, or compromise, by the Covered Individual, the Covered Individual s parents if the Covered Individual is a minor, or the Covered Individual s legal representative as a result of that sickness or injury. You are required to furnish any information or assistance, or provide any documents that we may reasonably require in order to exercise our rights under this provision. This provision applies whether or not the third party admits liability. 18

19 Part 7 - Eligibility The Plan Sponsor shall notify the Plan of the newly eligible individuals. Newly eligible employees must meet the following requirements. For policies issued through the Exchange, the rules of the Exchange shall govern if such rules conflict with the requirements of this section. A. The Plan requires a subscriber to work a minimum of twenty (20) hours per week. B. A Covered Individual will not be eligible for coverage when any of the following occurs: 1. The subscriber is no longer enrolled in the group. The subscriber will be covered under this Agreement until the Plan Sponsor, or the Exchange, as applicable, notifies the Plan of the termination. 2. A dependent child under family coverage attains the limiting age for coverage (please see Article 8 for the definition of Family Coverage and eligibility requirements for dependents). 19

20 Article 6 Utilization Review/Right to Appeal This is the formal process designed to monitor the use of, or evaluate the medical appropriateness or efficiency of health care services. A utilization review program has been established to ensure that any guidelines and criteria used to evaluate the medical appropriateness of a health care service are clearly documented and include procedures for applying such criteria based on the needs of the individual patients and characteristics of the local delivery system. The program was developed in conjunction with actively practicing dentists in all specialty areas of expertise and is reviewed at least annually to ensure that criteria are applied consistently. Any utilization review conducted under the Agreement is done retrospectively or at the time a claim for services has been submitted for reimbursement. In order for a submitted claim to be covered, the procedure must be a covered procedure. If a procedure is not a covered procedure then the claim for that procedure will be denied in accordance with this Agreement. Coverage of certain procedures may also be limited by frequency, age, effective dates of coverage, etc which are stated in this Agreement. There are also a number of listed procedures which are only considered a covered expense if a patient presents with a specified health history and/or has been diagnosed with a specified condition. During the claims review of these specific procedures, there may be a determination by a licensed dental practitioner that the procedure that was performed was not determined to be medically appropriate in accordance with the criteria that has been established in accordance with our utilization review program. In these situations, the claim for that procedure may be denied or partially reimbursed in accordance with the benefit for an alternate procedure. For all claims submissions you and your dentist will receive an explanation of benefits which details how each submitted procedure was reimbursed and/or the reason for denial. A Covered Individual, or the Covered Individual s agent, parent or guardian if the Covered Individual is a minor, has the right to appeal any decision to deny coverage for health care services recommended by a dentist. An appeal may be made by submitting a written request to DSM USA Insurance Company, Inc., N. Corporate Pkwy, Mequon, WI

21 Article 7 - Filing a Claim 7.1 Explanation Of Benefits (EOB) Each time the Plan processes a claim under this Agreement, a written notice will be sent to the Covered Individual explaining the benefits for that claim. This notice will explain how the Plan paid the claim or the reasons it was denied. The notice is called an Explanation of Benefits or EOB. 7.2 Who Files A Claim A. Participating Dentists will file claims directly with the Plan for the services covered by this Agreement. The Plan will make benefit payments within sixty (60) days to them. B. When a Covered Individual receives services from a Non-participating Dentist, either the Covered Individual or the dentist may file a claim. Subscribers can obtain claims forms from the Plan Sponsor, or the Plan will mail to him or her all the forms that are needed. 7.3 Time Limit Completed claims forms should be submitted to the Plan within ninety (90) days of the date services were rendered. Failure to submit the claim within the time required does not invalidate or reduce a claim if it was not reasonably possible to submit the claim within the time required, if the proof is furnished as soon as reasonably possible and, except in the absence of legal capacity of the Covered Individual, not later than one (1) year from the time the Covered Individual should have submitted the claim. If benefits are denied because a Participating Dentist fails to submit a claim on time, the Covered Individual will not be responsible for paying the dentist for the portion of the dentist s charge that would have been a benefit under the dental plan. This provision applies only if he or she properly informed the Participating Dentist that he or she was a Covered Individual by presenting his or her dental plan identification card. The Covered Individual will be responsible for his or her patient liability, if any. 7.4 Filing and Payment of Claims When a Covered Individual files a claim for the services of a Non-participating Dentist, the following rules apply. The Covered Individual must obtain an Attending Dentist s Statement claims form from the Plan Sponsor or the Plan. As the Plan does not require a written request for a claims form, the Covered Individual may also call the Customer Service Department at 1-(844) to request a form. A Covered Individual may request a claims form at any time after services are rendered keeping in mind that completed claims forms must be submitted to the Plan no more than ninety (90) days after services are rendered, except under circumstances set out in Section 7.3 above. 21

22 All claims are payable by the Plan upon the Plan s receipt of written or electronic proof of loss or claim for payment for services provided. The Plan shall within 15 working days for electronic claims or 30 calendar days for paper claims after such receipt mail or send electronically to the Subscriber or other person claiming payments for such benefits or a letter or electronic notice which states the reasons the Plan may have for failing to pay the claim and which also gives the person so notified a written itemization of any documents or other information needed to process the claim or any portions thereof which are not being paid. If the Plan disputes a portion of the claim, any undisputed portion of the claim shall be paid by the Plan. When all of the listed documents or other information needed to process the claim has been received by the Plan, the Plan shall then have 15 working days for electronic claims or 30 calendar days for paper claims within which to process and either mail payment for the claim or a letter or notice denying it giving the Subscriber or other person claiming payments under this Agreement the reasons for such denial. Receipt of any proof, claim, or documentation by an entity which administers or processes claims on behalf of the Plan shall be deemed receipt by the Plan. The Plan shall pay to the Subscriber or other person claiming payments under this Agreement interest equal to 12 percent per annum on the proceeds or benefits due under the terms of this Agreement for failure to comply with this Section Access To Dental Records And/Or Other Relevant Records Covered Individuals agree that when they claim benefits under this Agreement, they must give the Plan the right to obtain all dental records and/or other related information that it needs from any other source for claims processing purposes. This information will be kept strictly confidential and is subject to federal and state privacy and confidentiality regulations. Participating Dentists have agreed to give us all information necessary to determine benefits under the Agreement and have agreed not to charge for this service. If Covered Individuals receive services from Non-participating Dentists, they must obtain all dental records or other related information needed to determine their benefits. The Plan will not pay the dentist in order to obtain this information. If the Non- Participating Dentist does not provide the required information, the Plan may not be able to provide benefits for the dentist s services. A complete record of the policyholder s claims experience shall be provided, upon request. This record shall be made available not less than thirty (30) days prior to the date upon which premiums or contractual terms of the policy may be amended. 22