WCA Group Health Trust Holmen School District

Transcription

1 WCA Group Health Trust Holmen School District Dental Benefit Plan Group Number: Revised: July 1, 2017

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3 SUMMARY PLAN DESCRIPTION EMPLOYEE DENTAL PLAN FOR WCA GROUP HEALTH TRUST HOLMEN SCHOOL DISTRICT GROUP NUMBER: Underwritten By: WCA Group Health Trust 22 East Mifflin Street Suite 900 Madison, Wisconsin (866) (toll-free) Revision Date: July 1, 2017 Authorized Representative Authorized Representative, WCA Group Health Trust Title Title Date SIGNED Date

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5 IMPORTANT MESSAGE You should report ANY CHANGE IN ELIGIBILITY to Your Employer as soon as possible. Changes in eligibility include: Marriage or divorce Death of any Dependent Birth or adoption of a child Dependent child reaching the limiting age Total Disability Retirement Medicare eligibility For specific details on maintaining coverage under the Plan, refer to SECTION 3 - ELIGIBILITY.

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7 TABLE OF CONTENTS SECTION 1 DENTAL BENEFITS PAYMENT OF CLAIMS 1-1 IMPORTANT MESSAGE ABOUT YOUR PLAN 1-2 PRE-DETERMINATION 1-2 ALTERNATE PROCEDURES 1-2 OPTIONAL TREATMENT 1-2 SCHEDULE OF BENEFITS 1-3 DENTAL BENEFITS 1-3 DENTAL BENEFITS 1-5 DEDUCTIBLE AND COINSURANCE INFORMATION 1-5 DENTAL COVERED EXPENSES 1-6 PREVENTIVE SERVICES 1-6 BASIC SERVICES 1-6 MAJOR SERVICES 1-7 PROSTHODONTIC SERVICES 1-7 ORTHODONTIC SERVICES 1-8 PRO-RATED BENEFITS FOR REPLACEMENTS 1-10 LIMITATIONS AND EXCLUSIONS 1-11 APPLIANCE AND SERVICE SPECIFIC 1-11 EXPERIMENTAL OR UNPROVEN SERVICES 1-11 PHYSICAL APPEARANCE 1-12 PROVIDERS 1-12 SERVICES UNDER ANOTHER PLAN 1-12 OTHER 1-13 EXTENSION OF BENEFITS 1-13 SECTION 2 DEFINITIONS DEFINITIONS 2-1 SECTION 3 ELIGIBILITY ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE 3-1 RETIRED EMPLOYEES 3-1 EMPLOYEE ELIGIBILITY 3-2 EMPLOYEE EFFECTIVE DATE OF COVERAGE 3-2

8 DEPENDENT ELIGIBILITY 3-2 DEPENDENT EFFECTIVE DATE OF COVERAGE 3-3 RETIREE COVERAGE 3-3 ANNUAL OPEN ENROLLMENT PERIOD 3-4 SPECIAL ENROLLMENT RIGHTS 3-5 MEDICAID/STATE CHILD HEALTH PLAN 3-6 SPOUSAL TRANSFER PROVISION 3-7 BENEFIT CHANGES 3-7 DISABILITY CONTINUATION 3-7 SURVIVORSHIP CONTINUATION 3-8 TERMINATION OF COVERAGE 3-10 RESCISSION OF COVERAGE 3-10 IMPORTANT NOTICE FOR ACTIVE EMPLOYEES AND SPOUSES AGE 65 AND OVER 3-11 FAMILY AND MEDICAL LEAVE ACT (FMLA) 3-12 EMPLOYEE ELIGIBILITY 3-12 TYPES OF LEAVE 3-12 REINSTATEMENT OF COVERAGE UPON RETURN TO WORK 3-13 DEFINITIONS 3-13 UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA) 3-15 CONTINUATION OF COVERAGE DURING MILITARY LEAVE 3-15 REINSTATEMENT OF COVERAGE FOLLOWING MILITARY LEAVE 3-15 CONTINUATION OF BENEFITS 3-17 THE CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA) 3-17 SECTION 4 GENERAL PLAN INFORMATION COORDINATION OF BENEFITS 4-1 RECOVERY RIGHTS 4-4 GENERAL RECOVERY RIGHTS PROVISIONS 4-4 GENERAL PROVISIONS 4-6 ALTERNATE RECIPIENTS 4-6 AMENDMENTS TO OR TERMINATION OF THE PLAN 4-6 ASSIGNMENT 4-6 CLERICAL ERROR 4-6 CONFORMITY WITH APPLICABLE LAWS 4-6 CONTRIBUTIONS TO THE PLAN 4-7 COOPERATION 4-7 FAILURE TO ENFORCE PLAN PROVISIONS 4-7 FREE CHOICE OF PROVIDER 4-7 HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT 4-7 LEGAL ACTIONS 4-7 PAYMENT OF CLAIMS 4-7

9 PHYSICAL EXAMINATION 4-8 PRIVACY OF PROTECTED HEALTH INFORMATION 4-8 PROOF OF LOSS 4-10 PROTECTION AGAINST CREDITORS 4-11 REPRESENTATIONS 4-11 RIGHT TO NECESSARY INFORMATION 4-11 SECURITY 4-11 TERMINATION OF THE PLAN 4-11 TIME OF CLAIM DETERMINATION 4-12 CLAIM APPEAL PROCEDURE 4-13 FIRST LEVEL OF APPEAL 4-13 SECOND LEVEL OF APPEAL 4-13 FEDERAL EXTERNAL REVIEW PROGRAM 4-15

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11 SECTION 1 DENTAL BENEFITS

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13 PAYMENT OF CLAIMS The Plan will pay for Your Covered Expenses to the extent provided in the Plan, subject to the coinsurance, maximums and all other terms, provisions, limitations, conditions and exclusions of the Plan. 1-1

14 IMPORTANT MESSAGE ABOUT YOUR PLAN PRE-DETERMINATION You should request predetermination for dental services or a series of dental services that are required for crowns, fixed bridgework, partial and complete dentures and orthodontics. The Plan Administrator will advise You what expenses may be covered under the Plan, taking into account alternate procedures, services or courses of treatment based upon professionally endorsed standards of dental care. Predetermination is not a guarantee of benefits. Predetermination is only valid for 180 days. If treatment begins more than 180 days after the date of Predetermination, You should submit another treatment plan. Predetermination is not a guarantee of payment. Payment of Covered Expenses is subject to all Plan provisions. To be a Covered Expense, the work must be done while coverage is in effect. ALTERNATE PROCEDURES In all cases in which You or Your Dentist select a more expensive service or supply than that which is Dentally Necessary, the Plan will pay only the portion of the charge for the service or supply which is Dentally Necessary. OPTIONAL TREATMENT The Plan will only pay up to the amount that is Dentally Necessary. In all cases where a more expensive service is selected than what is Dentally Necessary, the difference in cost will not be covered. The Plan will only pay for the amount that is needed to restore the tooth or dental arch to contour and function. 1-2

15 NOTE: UMR, Inc. is the Plan s Claims Administrator. UMR, Inc. provides clerical and claim processing services to the Plan. UMR, Inc. is not financially responsible for the funding or payment of claims processed under the Plan, nor is UMR, Inc. a fiduciary to this Plan. SCHEDULE OF BENEFITS DENTAL BENEFITS PLAN YEAR INDIVIDUAL MAXIMUM BENEFIT Preventive, Basic, Major and Prosthodontic Services (combined): $1,000 paid. DENTAL BENEFITS PLAN PAYS YOU PAY BENEFIT SUMMARY TEXT PAGE Deductible per Plan Year Individual Family $0 $0 $25 3 per family The amount You must pay each year before the Plan will begin paying any benefits. The family maximum is three Covered Persons per family. Plan Year means July 1 through June All Covered Expenses under the Plan are payable subject to all Plan limitations, exclusions and maximums. The deductible limits shown apply to all Covered Expenses unless stated otherwise below. COVERED EXPENSES PAYABLE AT BENEFIT SUMMARY TEXT PAGE Preventive Services 100% after the deductible Oral exams, routine cleanings, bitewing and full mouth x-rays, fluoride treatments and sealants. 1-6 Refer to the Preventive Services section for frequency and age limitations. Basic Services 80% after the deductible Fillings, endodontics, periodontics, and oral surgery. 1-6 Occlusal Adjustments: 100%, deductible waived Refer to the Basic Services section for more information. Occlusal Adjustments: Limited to $100 paid per Lifetime. 1-3

16 COVERED EXPENSES PAYABLE AT BENEFIT SUMMARY TEXT PAGE Major Services 50% after the deductible Onlays and crowns. Refer to the Major Services section for more information. 1-7 Prosthodontic Services 50% after the deductible Bridges, dentures and dental implants. Refer to the Prosthodontic Services section for more information. 1-7 Orthodontic Services 50%, deductible waived Orthodontic diagnosis, treatment and appliances. 1-8 Lifetime Maximum: $1,500 paid. For any Covered Person. Refer to the Orthodontic Services section for more information. Limitations and Exclusions Not Payable List of exclusions that apply to all Covered Expenses. A service that is normally covered or Dentally Necessary may be excluded when provided with an excluded item

17 DENTAL BENEFITS DEDUCTIBLE AND COINSURANCE INFORMATION Covered Expenses under the Dental plan are payable, after satisfaction of the deductible, when applicable, at the coinsurance percentages and up to the maximum benefits shown on the Schedule of Benefits. The benefit period for this Plan is a Plan Year. (Plan Year means July 1 through June 30.) Deductible The deductible applies to each Covered Person, each Plan Year. Only charges that are a Covered Expense may be used to satisfy the deductible. The amount of the deductible is shown on the Schedule of Benefits. Maximum Family Deductible The maximum deductible per family is shown on the Schedule of Benefits. No further deductibles will be taken during a Plan Year once this maximum has been met. Coinsurance The deductible must be satisfied each Plan Year. Benefits are then payable at the percentage rate shown on the Schedule of Benefits. Benefits are payable up to any Plan maximums. 1-5

18 DENTAL COVERED EXPENSES PREVENTIVE SERVICES Note: The services listed below are also covered for Emergencies. The benefits that apply under non- Emergency situations will also apply in Emergency situations. 1. Oral exams. Limited to two exams per Plan Year. 2. Full mouth or panorex x-rays. Limited to once in 24-month period, unless necessary due to an Injury. 3. Bitewing x-rays. Limited to two sets per Plan Year. 4. Periapical x-rays. 5. X-rays for diagnosis and for providing treatment of dental disease or Injury. 6. Cleanings (routine prophylaxis). Limited to twice per Plan Year. 7. Topical fluoride treatments. Covered for Dependent children under 19 years of age only. Limited to twice per Plan Year. A cleaning performed with a fluoride treatment is a separate dental service. 8. Sealants. Covered for Dependent children under 17 years of age only. Limited to bicuspids and molar teeth only. Limited to once per tooth every five years. 9. Pulp vitality tests. 10. Office visits and consultations in conjunction with Covered Expenses. 11. Emergency office visits and x-rays. BASIC SERVICES Note: The services listed below are also covered for Emergencies. The benefits that apply under non- Emergency situations will also apply in Emergency situations. 1. Space maintainers. Covered for Dependent children under 19 years of age only. Fixed appliances to maintain a space created by the premature loss of a primary tooth or teeth. 2. Restorative Fillings. Amalgam, silicate, acrylic, synthetic porcelain and composite fillings. Composite/resin fillings on molars are not covered. Gold foil fillings are not covered. 3. Stainless Steel Crowns. 4. Endodontics. Root canal treatments, root canal fillings, pulp vitality tests and other related procedures. 5. Periodontics. Periodontal maintenance, debridement and exams, and other related procedures necessary to treat a disease of the supporting tissues of the teeth. Periodontal splinting is not a covered expense. 1-6

19 Basic Services - continued 6. Extraction of teeth. Includes extractions for orthodontics. 7. Oral Surgery. Including pre- and post-operative care. 8. Local or general anesthesia or analgesia administered in connection with a Covered Expense. 9. Injections of antibiotic drugs by the attending Dentist. 10. Denture repairs. 11. Occlusal adjustments. Limited to $100 paid per Lifetime. 12. Bruxism appliances to prevent clenching and grinding of teeth. Duplicate appliances are not covered. Replacements of lost or stolen appliances are not covered. Personalization of the appliance is not a Covered Expense. MAJOR SERVICES 1. Onlays. (Inlays are not covered.) 2. Crowns. 3. Laminates. Not covered if wholly or primarily cosmetic. 4. Veneers. Not covered if wholly or primarily cosmetic. 5. Porcelain and similar facings. Covered on any tooth, except molars. 6. Maintenance of onlays and crowns. Limitations for Major Restorative Services The following services are not covered: inlays; study models; porcelain and similar facings on molars; laminates and veneers or any other services that are wholly or primarily cosmetic. Replacement of crowns, onlays, laminates and veneers will only be covered if it was installed at least five years prior to its replacement. This provision will be waived when replacement is due to an Accidental Injury that occurred while You are covered under this Plan. This provision will be waived when replacement is required due to the involvement of an additional tooth surface. Replacement of an appliance that can be made serviceable will not be covered. Note: Benefits for the replacement of crowns, onlays, laminates and veneers that are less than five years old, but are determined to be unserviceable, will be payable on a pro-rated basis. An explanation and example of how the benefits are pro-rated is shown later in this section. PROSTHODONTIC SERVICES 1. Installation of removable or fixed bridgework. 2. Installation of partial and complete dentures, including six month post-installation care. 1-7

20 Prosthodontic Services - continued 3. Temporary bridges and dentures. 4. Additions to bridges and dentures. 5. Dental implants. Covered only if they are the most cost-effective of all alternative procedures. 6. Repair and recementing of bridges. 7. Tissue conditioning. 8. Relining and rebasing dentures. Limited to once every 36 months. Limitations for Prosthodontic Services The following services are not covered: Personalization and specialization services; precision and semiprecision attachments; or study models. Replacement of a bridge or denture will only be covered if it was installed at least five years prior to its replacement. This provision will be waived if: 1. Replacement is Dentally Necessary due to the placement of an initial opposing full denture; 2. Replacement is Dentally Necessary due to the extraction of additional natural teeth. Such extraction must leave the bridge or partial denture unserviceable; 3. The bridge or denture is damaged beyond repair while in the oral cavity. The Injury must occur while You are covered under this Plan; or 4. The existing denture is a temporary denture, placed while You were covered under this Plan. Replacement by a permanent denture must be required and performed within 12 months of the date the temporary denture was placed. Note: Benefits for the replacement of bridges, dentures and implants that are less than five years old, but are determined to be unserviceable, will be payable on a pro-rated basis. An explanation and example of how the benefits are pro-rated is shown later in this section. Expense incurred to replace at any time a bridge or denture that meets, or can be made to meet, commonly held dental standards of functional acceptability is not covered. The initial installation of a bridge or denture, replacing natural teeth that were extracted prior to Your effective date is not covered. It will be covered if: 1. Dentally necessary due to the loss or extraction of additional natural teeth after Your effective date; or 2. It would have been covered under the Employer s prior plan, had that plan remained in force. ORTHODONTIC SERVICES 1. Orthodontic diagnosis. 2. Interceptive and corrective treatment. 1-8

21 Orthodontic Services continued 3. Orthodontic appliances. 4. Related services, including x-rays, space maintainers and regainers, and study models. (Note: Extractions for orthodontics are covered under the Basic Services benefit.) Limitations for Orthodontic Services Orthodontic services are covered for any Covered Person. Replacements of lost or stolen appliances are not covered. Duplicate appliances are not covered. If the plan of orthodontic treatment is terminated prior to completion, benefits will end on the date treatment ends. If a patient becomes ineligible for the orthodontic benefit, that benefit will end on that date. 1-9

22 PRO-RATED BENEFITS FOR REPLACEMENTS This applies to the replacement of crowns, onlays, laminates, veneers, bridgework, dentures and implants. Replacements are limited to once every five years. If the replacement is required before the end of the five year period, the benefit will be payable on a pro-rated basis, as shown below. 1. Calculate the age of the original restoration, in full months, on the date it is replaced. Divide by 60 months (60 months = five years). The result is the percentage of reimbursement. 2. Calculate the amount the Plan would pay if the restoration were at least five years old. 3. Multiply Item #1 by Item #2. Example You are receiving a crown to replace an original crown that is 23 months & six days old. Your crown coverage is subject to a coinsurance of 80%. 1. The age of the original crown (23 full months) divided by 60 months (five years) = 39%. 2. The charge for the new crown is $600. The reimbursement for crowns is 80%. If the original crown was at least 5 years old, the benefit would be $480 ($600 x 80%). 3. The amount payable for the 23-month replacement crown is $ (39% x $480). 1-10

23 LIMITATIONS AND EXCLUSIONS The Plan does not provide benefits for: APPLIANCE AND SERVICE SPECIFIC 1. Replacement of lost, missing, broken or stolen appliances or duplicate appliances and the replacement or repair of an orthodontic appliance; 2. Preventive control programs including: oral hygiene instruction; plaque control; dietary planning; lab tests; anaerobic culture, except in connection with periodontal disease; sensitivity testing; and bite registrations; 3. Caries susceptibility testing; bacteria cultures; 4. Histopathologic exams; 5. Surgical and non-surgical treatment of any jaw joint problem, including but not limited to appliances and therapy. Jaw joint problems include: temporomandibular joint disorder (TMJ); craniomaxillary or craniomandibular disorders; other conditions of the joint linking the jawbone and skull; conditions of the facial muscles used in expression or mastication; and symptoms thereof including headaches; 6. Appliances or restorations for: increasing vertical dimension; restoring occlusion; replacing tooth structure lost by attrition; correction of congenital or developmental malformations or mounted case occlusal analyses. (Note: occlusal adjustments are covered, subject to the limit shown on the Schedule of Benefits.) 7. Splinting procedures; 8. Study models, except as stated under the Orthodontic Benefits; 9. Gold foil fillings; 10. Inlays; 11. Athletic mouth guards; 12. Desensitizing treatment; 13. Take-home dental or oral hygiene supplies; 14. Therapeutic drug injections, prescription drugs and non-prescription drugs. (Note: Injections of antibiotic drugs by the attending Dentist are covered, as shown under the Basic Services benefit.) or 15. Oral sedation. EXPERIMENTAL OR UNPROVEN SERVICES 1. Dental services that do not have uniform professional endorsement; or 2. Any procedure or drug that does not have scientific evidence that permits conclusions as to its effect on health outcomes. Scientific evidence is only evidence that is obtained from well designed and soundly conducted studies. Such studies must have been published in recognized peer review journals. The study must show a measurable effect on health outcomes that can be duplicated outside of the study s setting. 1-11

24 Limitations and Exclusions - continued PHYSICAL APPEARANCE 1. Cosmetic dentistry, including personalization or characterization of dentures and crown facings, abutments or pontics; laminates or veneers, except as stated; any other service that is wholly or primarily cosmetic; or 2. Precision attachments, precision partials or treatment partials, except as stated elsewhere in this Plan. PROVIDERS 1. Fees for treatment by other than a Dentist. The following services when performed by a licensed dental hygienist will be covered: scaling or cleaning of teeth; and topical application of fluoride. These services must be done under the supervision and guidance of the Dentist in accordance with generally accepted dental standards; 2. Any service or supply: a. not authorized or prescribed by a Dentist, b. authorized or prescribed by a Dentist, but excluded under this Plan, c. provided in connection with or as a result of any service or supply that is not a Covered Expense; 3. Services provided by a person who ordinarily resides in Your home or who is a Family Member; 4. Telephone, computer or Internet consultations between You and any provider. Completion of forms. Any appointment You did not attend; or 5. Hospital calls made by a Dentist. SERVICES UNDER ANOTHER PLAN 1. Workers Compensation. The Plan does not pay for services that are eligible for Workers Compensation benefits, whether or not the benefits were applied for; 2. Any service or supply for which no charge is made, or for which You would not be required to pay if You did not have this coverage; 3. Any service or supply provided by or payable under any plan or law of any government or any political subdivision (this does not include Medicare or Medicaid); 4. Any service or supply provided in the care of any service related Injury or Sickness (past or present) if You are in a Hospital or facility owned or operated by the United States Government or any of its agencies; or 5. Any charges covered under the Employer s medical benefit plan. Such charges include but are not limited to Hospital charges, services of an anesthesiologist and prescription drugs. 1-12

25 Limitations and Exclusions continued OTHER 1. Services or supplies not Dentally Necessary; 2. That portion of any fee that is in excess of the fee for the Dentally Necessary treatment. That portion of any fee that is in excess of the services needed to restore the tooth or dental arch to contour and function; 3. Any expense incurred before Your coverage under this Plan begins; 4. Any expense incurred after the date Your coverage under the Plan terminates, except as specifically described; 5. Any dental expense due to commission or attempt to commit a civil or criminal battery or felony; 6. Any loss caused or contributed to by: a. war or any act of war, whether declared or not, or b. any act of international armed conflict, or any conflict involving armed forces of any international authority; or 7. Any dental expense unless specifically indicated. EXTENSION OF BENEFITS When Your coverage under this Plan terminates all benefits end, except as stated below. Coverage for procedures that are in progress will be provided as follows: 1. Crowns, Onlays, Laminates and Veneers: If the teeth were fully prepared before Your termination date, the necessary impressions of the teeth were taken before Your termination date and the necessary lab and processing was ordered before Your termination date. Services must be completed within 60 days after Your termination date. 2. Dentures (Full and Partial Removable): If the impressions were taken before Your termination date and the necessary lab and processing was ordered before Your termination date. Services must be completed within 60 days of Your termination date. 3. Fixed Bridges: If the teeth were fully prepared and impressions were taken before Your termination date and lab and processing were ordered before Your termination date. Services must be completed within 60 days of Your termination date. 4. Dental Implant Services: If the preparation and necessary impressions were taken before Your termination date and lab and processing was ordered before Your termination date. Services must be completed within 60 days of Your termination date. Replacement of a tooth that was extracted or accidentally lost after Your termination date is not a Covered Expense. The Plan must remain in effect for Extension of Benefits to be payable. (You have up to 90 days after Your termination date to submit claims for these Extended Benefits.) 1-13

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27 SECTION 2 DEFINITIONS

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29 DEFINITIONS Certain words and phrases used in this Summary Plan Description are defined below as an explanation of how the terms are used in the Plan. Defined words are capitalized throughout the Plan. Accident A happening by chance and without intention or design. A happening which is unforeseen, unexpected and unusual at the time it occurs. Actively at Work An Employee is Actively at Work if he or she is employed by the Employer on a regular basis and meets the minimum requirements set by the Employer for eligibility under the Plan. An Employee is not considered Actively at Work if he or she has been laid off or is absent from work for reasons other than those which entitle the Employee to leave under family and medical leave laws or a Health Factor, and such layoff or absence from work is for such a period of time that the employee is no longer eligible for the benefits of this Plan pursuant to the rules or policies established by the Employer or the terms of any applicable collective bargaining agreement. Amendment A written document that changes the provisions of the Plan. It must be duly authorized and signed by the Plan Administrator. Business Associate A Business Associate is a person who provides, other than in the capacity of a Plan Employee, legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation or financial services to or for the Plan where the provision of the service involves the disclosure of individually identifiable health information from the Plan or from another Business Associate to the person. Calendar Year A 12 month period of time that starts on January 1 and ends on December 31. Claims Administrator The person or entity employed by the Plan Administrator to provide administrative services in connection with the operation of the Plan and any other functions, including the processing of claims. If no Claims Administrator is employed by the Plan Administrator, Claims Administrator will mean the Plan Administrator. Cosmetic Dentistry Services provided by a Dentist for the purpose of improving appearance, when form and function are satisfactory and not pathological condition exists. Covered Dependent An Employee s eligible Dependent who is properly enrolled in the Plan. Dental Revised 7/1/17 2-1

30 Definitions continued Covered Employee An Employee who is eligible and properly enrolled in the Plan. Covered Expense Expense Incurred by You or Your Covered Dependent for services or supplies provided by a Qualified Practitioner if the Expense Incurred is covered by the Plan and not excluded by the Plan. Expenses must be incurred while You are covered for that benefit under this Plan. Covered Person A Covered Employee or Covered Dependent. Custodial Care Care to assist in the activities of daily living. Care that is not likely to improve Your dental condition. Dentally Necessary A service or supply provided by or under the supervision of, a Dentist that is required for prevention of, or to identify or treat, a Sickness or Injury, and which the Plan Administrator determines is: 1. Consistent with the prevention of Sickness or Injury, or diagnosis and treatment of Your Sickness or Injury; 2. Appropriate under the standards of acceptable dental practice to prevent or treat Sickness or Injury; 3. Not solely for convenience; and 4. The most appropriate service or supply which can be safely provided to You and accomplishes the desired result in the most economical manner. Dentist An individual who is duly licensed to practice dentistry or perform oral surgery in the state where the dental service is provided and is operating within the scope of that license. Dependent 1. A covered Employee s legal spouse. 2. A covered Employee s domestic partner who is of the same or opposite sex and who shares a committed relationship with the Covered Employee which has the following characteristics: 2-2 a. living together at the same residence for at least six months, b. having a mutual and exclusive commitment to each other's well-being, c. being financially interdependent by sharing common assets and common debts, d. neither party being married to anyone nor having another domestic partner,

31 Definition of Dependent continued e. not being related by blood closer than would bar marriage in the state of their residence, and f. both parties being of age for legal marriage 3. A Covered Employee s married or unmarried: natural born, blood related child; step-child; legally adopted child; child placed in the Employee s legal guardianship by court order; or a child placed with the Employee for the purpose of adoption and for which the Employee has a legal obligation to provide full or partial support; whose age is less than the limiting age. The limiting age for each Dependent child is the last day of the month in which such child reaches age 26. Coverage may be extended (beyond age 26) for a Dependent child if all of the following requirements are met: a. The Dependent child is a full-time student, regardless of age, and b. The Dependent child was called to federal active duty in the national guard or in a reserve component of the U.S. armed forces while attending an institution of higher education on a full-time basis, and c. The Dependent child was under age 27 when called to federal active duty. Dependent children who are eligible for this extension, covered under the Plan and drop below full-time student status due to Injury or Sickness may be covered until the earliest of the following, when certification of the medical need for the leave is provided to the Plan by the child s attending Qualified Practitioner: 1. the date the child s coverage would terminate for reasons other than not being a full-time student, months from the date the child was no longer a full-time student. Dependent children who are eligible for this extension will be covered for up to four months following the close of a school term, provided they are enrolled as a full-time student for the next following school term. 4. A Covered Employee s grandchild, as long as the Employee s Covered Dependent child or legal ward, who is the parent of the grandchild, is not yet 18 years old or marries, whichever occurs first. A Covered Dependent child who attains a limiting age while covered under this Plan will remain eligible for benefits if the Plan Administrator determines that all of the following conditions exist at the same time: 1. The child is mentally or physically handicapped; 2. The child is incapable of self-sustaining employment because of mental retardation or physical handicap; 3. The child is chiefly dependent on the Covered Employee for support and maintenance; and 4. The child never married. That child that child will remain an eligible Dependent of a Covered Employee or may be enrolled as the Dependent of a new Employee. If the child has not continuously satisfied all of the conditions above since reaching a limiting age, the child will not be eligible for coverage under the Plan. You must provide satisfactory proof that the above conditions exist on and after the date the limiting age is reached. Such proof may not be requested more often than annually after two years from the date the first proof was provided. If satisfactory proof is not submitted, the child's coverage will cease on the date such proof is due. Dental Revised 7/1/17 2-3

32 Definition of Dependent - continued Right To Check Dependent Eligibility The Plan reserves the right to check the eligibility status of a Dependent at any time during the year. You and Your Dependent have an obligation to notify the Plan when the Dependent s eligibility status changes during the year. Please notify Your Employer of any status changes. Effective Date The effective date stated on the front of this Plan. Emergency Any Injury or Sickness which requires immediate treatment and which if not immediately treated would jeopardize or impair the health of the Covered Person. An Emergency may or may not be life threatening. A condition is considered to be an Emergency care situation when a sudden and serious condition such that a Prudent Layperson could expect the patient s life would be jeopardized, the patient would suffer severe pain, or serious impairment of bodily functions would result unless immediate medical care is rendered. Examples of an Emergency care situation may include, but are not limited to: chest pain; hemorrhaging; syncope; fever equal to or greater than 103 F; presence of a foreign body in the throat, eye, or internal cavity; or a severe allergic reaction. Employee You, when You are regularly employed by the Employer. Employer Holmen School District, which employs the Covered Employee. Enrollment Date The first day of Your eligibility period or if earlier, Your effective date of coverage under this Plan. If You are a Late Applicant Your Enrollment Date is Your effective date of coverage under this Plan. Expense Incurred For dental expenses, the fee charged for services and supplies. The Expense Incurred date is: the date the service is completed; or the date that the teeth are prepared for fixed bridges, crowns, or onlays; or the date the final impression is made for dentures or partials. Family A Covered Employee and the Covered Employee s Covered Dependents. Family Member Your lawful spouse. Your child. Your parent. Your grandparent. Your brother or sister. Any person related in the same way to Your Covered Dependent. 2-4

33 Definitions continued Health Factor The health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability, including whether an individual is a victim of domestic violence or engages in activities such as motorcycling, horseback riding, snowmobiling or similar activities, or disability of any Employee or any Dependent of any Employee. Injury Physical damage to Your body caused by an external force. Damage must be due directly and independently of all other causes to an Accident. Late Applicant An Employee who enrolls for coverage more than 30 days after they are eligible to be covered. A Dependent who is enrolled for coverage more than 30 days (60 days for a newborn child or an adopted child) after they are eligible to be covered. Lifetime When used in reference to benefit maximums and limitations, the entire time You are covered under this Plan, whether or not Your coverage under the Plan is continuous. In no circumstances does Lifetime mean Your life span. Medicare Title XVIII, Parts A and B, of the Social Security Act as enacted and amended. Named Fiduciary WCA Group Health Trust, which has the authority to control and manage the operation of the Plan. Plan This Plan of Dental Benefits as established by the Employer. The term Plan includes any schedules, attachments and Amendments to the Plan. Prior, current and successive Plan will be considered one Plan and not separate and distinct Plans. This Summary Plan Description provides a description of the Plan. Plan Administrator or Trust WCA Group Health Trust. Plan Sponsor The Plan Sponsor of the Plan is the WCA Group Health Trust. Plan Year A 12-month period of time that starts on July 1 and ends on June 30 th. Dental Revised 7/1/17 2-5

34 Definitions - continued Post-Service Claim Any claim that is not a Pre-Service Claim. Pre-Service Claim Any claim for a benefit that is conditioned, in whole or in part, on obtaining prior approval from the Plan for the medical care. Protected Health Information Protected Health Information means individually identifiable health information that is: transmitted or maintained in any form or medium; is created or received by a health care provider, the Plan; an Employee or health care clearinghouse; and relates to the past, present or future physical or mental health or condition of an individual, the provision of health care to an individual or the past, present or future payment for the provision of health care to an individual. Prudent Layperson A person with average knowledge of health and medicine who is not formally educated or specialized in the field of medicine. Qualified Practitioner A Dentist or other professional practitioner authorized by law to practice dentistry at the time and place dental services are performed. Sickness 1. A disease or disturbance in function or structure of Your body. It must cause physical signs and/or symptoms and if left untreated, will result in a deterioration of the health state of the structure or systems of Your body; 2. Muscle tiredness or soreness resulting from overexertion in a physical activity; or 3. Pregnancy. Total Disability or Totally Disabled Your inability due to Sickness or Injury to perform the substantial full-time duties of any job with the Employer. You also cannot be working for wage or profit for anyone, including Yourself. For Dependents, it means the inability due to Sickness or Injury to carry on all of the normal activities of a healthy person of the same age and sex. Urgent Care Any care that in the opinion of Your Qualified Practitioner is an urgent care situation. Any care that the use of non-urgent care time frames would put Your life, health or ability to regain maximum function at risk. You and Your You as the Covered Employee. Any of Your Dependents, unless otherwise indicated. 2-6

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37 SECTION 3 ELIGIBILITY

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39 ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE The Employee Coverage section applies to Employees hired on or after the effective date of this Plan. The Dependent Coverage section applies to Dependents that are added on or after the effective date of this Plan. Employees who were covered under any plan that this Plan replaces will be covered on the effective date of this Plan. Coverage will include Dependents of such an Employee. You must have met the eligibility requirements of the Plan. EMPLOYEES ON A PAID LEAVE OF ABSENCE If You are on an Employer-approved paid leave of absence on the date this Plan takes effect and You would be Actively-at-Work on that date, except for the fact that You are on the leave of absence, You are eligible for coverage under this Plan if: 1. You belong to the eligible class of Employees specified by the Employer; 2. Your leave is a type of leave that is available to all Employees in the eligible class (for example, paid sick leave or sabbatical leave); 3. Both You and Your Employer anticipate that You will return to work at the end of Your leave; and 4. Your Employer pays the required premium. If You meet all of these criteria, You are eligible for coverage under this Plan on the date this Plan becomes effective. Your coverage will begin on the Plan s effective date if Your completed enrollment form is received by the Plan Administrator within 30 days of the date that this Plan becomes effective. Coverage will be extended for a maximum of two consecutive years from the date Your leave began, even though You started Your leave before the effective date of this Plan. (Note: The two year period will begin on the date Your leave of absence began, not on the date Your coverage under this Plan started.) RETIRED EMPLOYEES If You are retired on the date this Plan takes effect, You are eligible for coverage under this Plan on the effective date of the Plan, if all of the following apply: 1. The Active Employees in the eligible class from which You retired are covered by this Plan; 2. On the day before this Plan takes effect, You were covered under the group health policy that this Plan replaces; and 3. Your enrollment form is received within 30 days of the date this Plan takes effect. Refer to the Retiree Coverage section of this Plan for more information about Retiree coverage. 3-1

40 EMPLOYEE ELIGIBILITY You are eligible for coverage under the Plan if You are an Employee who meets the eligibility requirements of the Employer. You are eligible to be covered on the date Your employment with the Employer begins. This is Your eligibility date. EMPLOYEE EFFECTIVE DATE OF COVERAGE You must enroll on forms accepted by the Plan Administrator. Each Employee s effective date of coverage is determined as follows: 1. Your completed forms are received by the Plan Administrator within 30 days of the date You are eligible. This is a timely enrollment. Your coverage will be effective on Your eligibility date. 2. Your completed enrollment forms are received by the Plan Administrator more than 30 days after Your eligibility date. This is late enrollment. You will not be eligible to enroll for coverage until the next Annual Open Enrollment Period, except as shown under the Changes in Status and Special Enrollment Rights sections of this Plan. Employee Coverage will begin at 12:01 AM, Standard Time, on Your effective date. You must actually begin performing work with the Employer before coverage will be effective under the Plan. Please refer to the Special Enrollment Rights section of this Plan for additional enrollment rights and events. DEPENDENT ELIGIBILITY Each Dependent is eligible for coverage on the later of: 1. The date the Employee is eligible for coverage, if the Employee has Dependents on that date; 2. The date of the Covered Employee s marriage for any Dependents acquired on that date; 3. The date of birth of the Covered Person s natural born child; 4. The date a valid court order is issued which, by federal law or Plan provision, requires the Plan to provide coverage; 5. For an adopted child: An adopted child is eligible for coverage on the date that a court makes a final order granting adoption or on the date that the child is legally placed with the Covered Employee for adoption, whichever is earlier. Coverage for the adopted child will begin on the date of eligibility if the required enrollment form for the adopted child is received by the Plan Administrator within 60 days of that date; or 6. For a legal ward: A legal ward is eligible for coverage on the date established by the court order as the date which You begin guardianship. Coverage for the legal ward will begin on the date he or she became eligible if: a. You have family coverage in effect; and b. The Plan Administrator receives the required enrollment form to add the legal ward within 30 days after he or she first became eligible. 3-2

41 Dependent Eligibility - continued Dependents may only be covered if the Employee is covered. Check with Your Employer on how to enroll for Dependent coverage. Late enrollment may result in a delay of coverage. DEPENDENT EFFECTIVE DATE OF COVERAGE Each Dependent must be enrolled on forms accepted by the Plan Administrator. Each Dependent s effective date of coverage is determined as follows: 1. The completed forms are received by the Plan Administrator within 30 days of the Dependent s eligibility date. This is a timely enrollment. That Dependent is covered on their eligibility date. 2. An eligible newborn child of a Covered Person is covered for 60 continuous days from the moment of birth. If the newborn s enrollment forms are received by the Plan Administrator within 60 days of the date of birth, then the newborn will be a Covered Dependent effective the moment of birth. 3. If the newborn s enrollment forms are received by the Plan Administrator more than 60 days and within one year after the date of birth and the Covered Employee makes all past due premium payments with interest at the rate of 5 ½% per year, then the newborn child will be a Covered Dependent effective the moment of birth. 4. If You marry after Your coverage is effective, You should apply for Family Coverage within 30 days of Your marriage. If You do, Your Family Coverage becomes effective on the date of the marriage. 5. The completed forms are received by the Plan Administrator more than 30 days after the Dependent s eligibility date, this is considered late enrollment. Such Dependent will not be eligible to enroll for coverage until the next Annual Open Enrollment Period, except as shown under the Changes in Status and Special Enrollment Rights sections of this Plan. Dependent coverage will begin at 12:01 AM, Standard Time, on the Dependent s effective date of coverage under the Plan. Please refer to the Special Enrollment Rights section of this Plan for additional enrollment rights and events. RETIREE COVERAGE If You were covered under this Plan on the date of Your retirement, You may be eligible for Retiree Coverage under this Plan at the time of Your retirement. Retiree Coverage will apply according to the terms of Your current bargaining agreement or employee contract. If You elect Retiree Coverage, the Retiree Coverage will run concurrent with COBRA Continuation. If an alternate coverage is offered (e.g. Retiree Coverage), COBRA will be reduced to the extent such coverage satisfies the requirements of COBRA. Alternate coverage includes continuation by: state law; USERRA; or any other plan provision (including retiree coverage) which runs concurrent with COBRA coverage. The Special Enrollment Rights provision stated in this Plan does not apply to Retiree Coverage. NOTE: If You are Medicare eligible, claims must be submitted to Medicare first. After Medicare has processed Your claim, the claim and the Medicare EOB should be submitted to this Plan. 3-3

42 ANNUAL OPEN ENROLLMENT PERIOD Each year, Your Employer will provide an enrollment period. Once You have made elections for the year, Your choices cannot be changed until the next Annual Open Enrollment Period, except as shown under the Changes in Status and Special Enrollment Rights sections of this Plan. Completed enrollment forms must be received by the Plan Administrator before the end of the Annual Open Enrollment Period. If Your completed enrollment form is not received by that time, You will not be able to enroll in the Plan or make changes until the next Annual Open Enrollment Period, except as shown under the Changes in Status and Special Enrollment Rights sections of this Plan. Your Employer will notify You when the Annual Open Enrollment Period is each year. Note: The Annual Open Enrollment Period does not apply to Retiree Coverage. Changes In Status If You have a change in status, as defined by the IRS, You have 30 days from the date of that change to make new elections under this Plan. Any changes in Your elections must be consistent with Your change in status or they will not be allowed. Change in status means only a change as stated below. 1. Legal Marital Status. Your marriage, divorce, legal separation, annulment or the death of Your legal spouse; 2. Number of Dependents. An increase or decrease in the number of Dependents You have due to birth, adoption, placement for adoption or the death of a dependent; 3. Employment Status. Any of the following events that change the employment status of You or Your Dependent, including: termination or commencement of employment, strike or lockout, commencement or return from unpaid leave, change in worksite, and any change in employment status that results in a loss or gain of eligibility under the Section 125 plan or the underlying benefit plan; 4. Dependent Status. Your Dependent satisfies or ceases to satisfy eligibility requirements for coverage; 5. Residence. Any change in residence for You or Your Dependent; 6. FMLA Leave Status. At the time a leave under the FMLA begins the Employee may change elections to the extent allowed under the federal Family and Medical Leave Act; 7. COBRA Continuation. You or Your Dependent become eligible for and elect continuation coverage under the Employer's group health plan as provided by COBRA or a similar State law; 8. Judgment, Decree or Court Order. An order resulting from a divorce, legal separation, annulment, change in legal custody or Qualified Medical Child Support Order as defined by ERISA which requires you or another individual to provide health coverage for Your Dependent child; 9. Entitlement to Medicare or Medicaid. A gain or loss of eligibility under Medicare, Part A or Part B, or Medicaid for You or Your Dependent; 10. HIPAA Special Enrollment Rights. An event which qualifies as a special enrollment right under the Health Insurance Portability and Accountability Act; 11. Significant Cost Increase. Election changes are limited to increasing Your election to cover the cost increase or changing the election to provide for a similar benefit offered by the employer; 3-4

43 Annual Open Enrollment Period continued 12. Significant Curtailment of Coverage. An overall reduction in coverage provided to all participants that results in a general reduction in coverage under the plan; 13. Addition or Elimination of a Benefit Option. Election changes are limited to electing the new benefit option in the case of an added benefit option or electing a similar benefit in the case of the elimination of a benefit option; 14. Changes in a Dependent's Coverage under Another Employer's Plan. Election changes are limited to changes that result from a change under the plan of Your spouse's, ex-spouse's or other Dependent s employer. To qualify as a change in status under this plan the change must be permitted under the other employer plan and Section 125 of the Internal Revenue Code or be the result of a differing election period under the other employer plan. If You have questions regarding whether an event qualifies as a change in status, the Claims Administrator will answer them. SPECIAL ENROLLMENT RIGHTS If You have a special enrollment event, the Plan will provide a new enrollment date for You to enter the Plan as shown below. At that time, You will be able to enroll in the Plan without being subject to the Late Applicant provisions of the Plan. If the Plan has more than one benefit option, You will be able to select from all options for which You are eligible. Loss of Other Coverage If You declined coverage under this Plan in favor of other group coverage or COBRA continuation and coverage under the other group plan or COBRA: 1. Ends due to Your exhaustion of the maximum COBRA period; 2. Ends due to Your loss of eligibility, for any reason; 3. Ends employer contributions towards the cost of the other coverage; or 4. Your contribution amount required under this Plan decreases by at least 10% of the total contribution (premium) in any 12-month period, Then a special enrollment event has occurred. At that time, an Employee or Dependent may enroll in this Plan as follows: 1. When the Employee has a loss of coverage, the Employee and any eligible Dependents may enroll. The Dependents do not have to have had a loss of coverage at that time to be enrolled; 2. When a Dependent has a loss of coverage, that Dependent and the Employee may enroll, as well as other eligible Dependents that did not have a loss of coverage. The Employee and the other Dependents do not have to have had a loss of coverage at that time to enroll. You must enroll in this Plan within 30 days of the date of a loss of other coverage to be a timely entrant to the Plan. You must provide proof that the other coverage was lost due to one of the above shown reasons. Coverage under this Plan will not be effective until such proof is provided. Coverage under this Plan will be effective on the day coverage under the other group plan ends. 3-5