Dental Plan. St. Mary s Health System Evansville, IN. Summary Plan Description. Effective January 1, 2012

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1 St. Mary s Health System Evansville, IN Dental Plan Summary Plan Description Effective January 1, 2012 ENABLING STRENGTHS INSPIRED PEOPLE My Life. Even Better.

2 Plan Outline Effective date: January 1, 2014 St. Mary s Health System Comprehensive Dental Plan Evansville, IN Who Is Eligible When Coverage Begins Coverage Options Dependent Age Limit Active full-time and part-time employees regularly authorized to work at least 40 hours per pay period First of the month coincident with or following one month of service Employee Only, Employee + Spouse, Employee + Child(ren), Employee + Family Eligibility continues to child s 26 th birthday (coverage ends on 26 th birthday) Claims Administrator Annual Deductible Individual Family Annual Maximum Preventive and Diagnostic Services Basic Restorative* 80% Major Restorative* 50% Orthodontia (child to age 19, no adult) Your Cost for Coverage Delta Dental of Missouri $50 $150 maximum $1,500 (excludes Orthodontia) 100% 50% $1,500 lifetime maximum You and your Employer share the cost of this coverage. See your enrollment materials for the current rates. * Deductible applies to these services January 2012 Dental Plan SPD ii

3 Your Contact Information For Questions About Eligibility For Questions About Benefits, Billing/Claims and How the Plan Works To Find Providers in the Delta Dental Network Your local Human Resources Department Delta Dental of Missouri To speak with the Customer Service Department, call Monday - Friday 7:00 a.m. 5:00 pm CST For 24/7 automated call services, call the Benefit 24 Line To find answers online, go to Click on your Health Ministry to conduct a provider search To File a Claim Claims Administrator Delta Dental of Missouri P.O. Box 8690 St. Louis, MO To Appeal a Claim For COBRA Information Delta Dental of Missouri Appeals Committee Gravois Road St. Louis, MO Ceridian Benefit Services January 2012 Dental Plan SPD iii

4 Contents Plan Outline... ii Your Contact Information... iii Introduction... 1 Glossary... 2 Section 1: Eligibility and Participation... 5 Eligibility... 5 Enrollment... 5 Change Events... 6 Participant Contributions... 7 Family and Medical Leave Act... 7 When Coverage Begins... 7 When Coverage Ends... 7 COBRA Continuation Coverage... 8 USERRA Continuation Coverage Qualified Medical Child Support Order Right to Amend or Discontinue the Plan Section 2: Dental Benefits How the Dental Plan Works Covered Expenses Predetermining Your Benefits Section 3: Expenses Not Covered Section 4: Claims Procedures Filing a Claim Timing of Claims Review If Your Claim is Denied Appealing a Denied Claim Overpayment of Claims Misrepresentations Right of Recovery Section 5: Coordination of Benefits How Coordination of Benefits Works Section 6: Your ERISA Rights Receiving Information About Your Plan and Benefits Continuing Your Group Health Coverage Prudent Actions by Plan Fiduciaries Enforcing Your Rights Assistance with Your Questions Section 7: Group Health Plan Privacy Practice Notice January 2012 Dental Plan SPD iv

5 Our Responsibilities How We May Use and Disclose Your Health Information Other Uses of Health Information Your Rights Regarding Your Health Information Who This Notice Applies To Changes to This Notice Complaints Section 8: Plan Information January 2012 Dental Plan SPD v

6 Introduction Ascension Health and your Participating Employer offer dental benefits to you and your Eligible Dependents. The Ascension Health Dental Plan encourages you to visit your dentist twice a year for regular cleanings and checkups and to take care of your dental needs as they arise to keep your teeth and smile healthy. This Information Is a Summary The information in this summary plan description (SPD) is intended to serve as a summary of the Ascension Health Dental Plan (Plan), effective January 1, You should refer to the official Plan document for details. If there are any discrepancies between the information in this SPD and the official Plan document, the terms of the Plan document will prevail. You or your refers to the Eligible Associate, any Eligible Dependents, any Qualified Beneficiary or other continuation participant covered under the Plan. Days refers to calendar days. This SPD does not constitute a contract of employment or a guarantee of benefits or future employment. In addition, your eligibility for and participation in the Plan as described in this SPD should not be construed as an employment contract. Certain words in this SPD are capitalized. These words are defined in the Glossary section. You may find it helpful to consult the Glossary section as you read this SPD. The following pages of this SPD explain provisions that generally apply to Eligible Associates of all Participating Employers that offer dental benefits. The Plan Outline section of this SPD contains specific requirements and provisions that apply to Eligible Associates of your Participating Employer. January 2012 Dental Plan SPD 1

7 Glossary The following terms may help you in reading and understanding this SPD. Associate Any individual who is classified by a Participating Employer as an employee. Basic Restorative Services Dental services that involve certain preservation or restoration of a tooth or gums. Birthday Rule The practice of assigning Primary payment responsibility to the plan of the individual whose birthday occurs first in the calendar year when coordinating benefits between two dental plans. Change Event A change in status or change in family status event that is described in the Internal Revenue Code Section 125 cafeteria plan adopted by the Participating Employer of the Eligible Associate. Change of Benefits Date The effective date of a mid-year election change due to a Change Event. The Change of Benefits Date for a Change Event related to birth, adoption or placement for adoption is the date of the birth, adoption or placement for adoption. The Change of Benefits Date for all other Change Events is as soon as administratively possible after the requested change is filed. Child The Eligible Associate s natural child, legally adopted child, child placed with Eligible Associate for adoption, foster child, or stepchild. Child shall also include any child for whom the Eligible Associate has been granted court-appointed full legal custody or guardianship. COBRA The continuation of health coverage that must be offered in accordance with the Consolidated Omnibus Budget Reconciliation Act of Coinsurance The portion of covered dental expenses a Participant pays after paying the deductible. Deductible The amount of covered expenses an individual and/or family must satisfy in a Plan Year before being eligible for certain benefits to be payable by the Plan. Delta Dental The claims administrator for the Plan. Eligible Associate An Associate who is in the class of Associates eligible to participate in the Plan, as specified in the Addendum/Joinder Agreement of each Plan applicable to the Participating Employer and the Plan Outline section of this SPD. Eligible Associate does not include a leased employee or independent contractor, regardless of any retroactive reclassification as a common law employee. January 2012 Dental Plan SPD 2

8 Eligible Dependent* An Eligible Associate s Spouse or Child who is either less than age 26, or a Child who is age 26 or older if: Unmarried, Permanently and totally disabled prior to the attainment of age limits under the Plan, Receiving over half his or her support from the Eligible Associate or Eligible Associate s Spouse, and Eligible to be claimed as a dependent on the Eligible Associate s or Eligible Associate s Spouse s federal income tax return. A Child is permanently and totally disabled if he or she is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months. *Please Note: Your Participating Employer may have elected age 19 or age 24 for students as the age limit for coverage under this Plan. Please see the Plan Outline section of this SPD for the applicable age limits. Entry Date The date as specified in the Plan Outline section of this SPD on which you become a Participant in the Plan after completing the required enrollment process and satisfying any waiting period applicable to you. ERISA The Employee Retirement Income Security Act of 1974, as amended. Health Ministry A legal entity related to Ascension Health. Major Restorative Services Dental services that involve the creation or preservation of crowns, dentures and bridgework. Network Dentists A defined group of general dentists and specialists who have agreed, typically through contractual arrangements with Delta Dental, to accept Delta Dental s reimbursement schedule as payment-in-full for services rendered and have agreed to abide by Delta Dental s policies. Non-Network Dentists General dentists and specialists who do not participate in the Delta Dental Network. Orthodontic Services Services involving the straightening of teeth or correcting the improper alignment of biting or chewing surfaces of upper and lower teeth. Participant Any Eligible Associate, Eligible Dependent, Qualified Beneficiary, other continuation participant or other individual who is covered in accordance with the Plan and the Eligibility and Participation and Plan Outline sections of this SPD. Participant Contribution Any amount the Plan Administrator may require you to contribute for coverage under the Plan (see the Plan Outline section of this SPD). Participating Employer The Plan Sponsor or any Health Ministry that adopts the Plan. January 2012 Dental Plan SPD 3

9 Plan The Ascension Health Dental Plan, as amended from time to time. Plan Administrator Ascension Health, or such other person or committee that Ascension Health may appoint to administer the Plan. Plan Outline A brief description of some of the key features of the Plan as offered by your Participating Employer. Plan Sponsor Ascension Health. Plan Year The calendar year. Preventive and Diagnostic Services Dental services that involve the diagnosis and prevention of dental disease. Primary The plan whose benefits are paid first. Qualified Beneficiary Any person afforded rights of continued benefits under COBRA as a result of a qualifying event as defined in COBRA. Qualified Beneficiary includes only the following: Eligible Associate Eligible Associate s Spouse Eligible Dependent Child Child placed for adoption with the Eligible Associate during the continuation period Secondary The plan that pays its benefits after the Primary Plan for the purpose of coordinating benefits. Spouse An individual legally married to an Eligible Associate (even if legally separated), including an individual who is the common-law spouse, in states that recognize common-law marriage, of an Eligible Associate, if such individual and the Eligible Associate are of opposite sex. Usual, Customary and Reasonable (UCR) Charge A fee for service based on what other area dentists with similar qualifications would charge for the same or similar procedure. January 2012 Dental Plan SPD 4

10 Section 1: Eligibility and Participation When you first become eligible to enroll in the Plan, your local Human Resources Department will provide an enrollment package that explains how to enroll, the deadline, and your share of the cost of coverage. As an Eligible Associate, you may enroll yourself and any Eligible Dependents. You must notify your local Human Resources Department of any change (marriage, birth of a Child, change of address, etc.) within 30 days of the event. If you don t enroll when first eligible, you may enroll later at the next Open Enrollment date (or earlier if your situation changes). Throughout the Eligibility and Participation section, the terms you or your refer only to the Eligible Associate. Eligibility All Associates in your Participating Employer s class of Eligible Associates may participate in the Plan. Please see the Plan Outline section of this SPD for your Participating Employer s eligibility requirements. Dependents Eligible Associates may also enroll any Eligible Dependents. Coordination of Benefits This Plan allows coordination of benefits with other dental plan coverage. Please see the Coordination of Benefits section for more information. Double Eligibility If you and your Spouse are both Eligible Associates, both of you may enroll in your own individual coverage, or you may elect coverage with one as the Eligible Associate and the other as an Eligible Dependent Spouse. However, only one of you may cover any Eligible Dependent Children. If you and your Eligible Dependent Child are both Eligible Associates, both of you may enroll in your own individual coverage, or you may elect coverage as the Eligible Associate with your Child covered as an Eligible Dependent. Enrollment This section describes the enrollment process for dental benefits. Initial Enrollment Period When you first become an Eligible Associate, your local Human Resources Department will send you an enrollment package. It will explain all of the steps you Enroll on Time If you fail to enroll by the deadline date stated in your enrollment package, you and your dependents will not have coverage under the Plan until the next enrollment opportunity. January 2012 Dental Plan SPD 5

11 need to take to enroll yourself and any of your Eligible Dependents as well as the deadline date for enrolling. If you enroll by the deadline, you and your Eligible Dependents will become enrolled on the Entry Date specified by your Participating Employer. (Please see the Plan Outline section of this SPD.) If you fail to enroll yourself during the initial enrollment period, or enroll yourself but do not enroll any Eligible Dependents, you may enroll yourself and/or your Eligible Dependents during the next Open Enrollment Period or after a Change Event. Open Enrollment Period Days When stating enrollment deadlines in terms of number of days, we mean calendar days. You may choose or change your participation in the Plan during your Participating Employer s annual Open Enrollment Period. The choices you make during the Open Enrollment Period will become effective on the first day of the next Plan Year. Once payroll deductions have started, you may not make any changes in your choices until the next Plan Year or until you have a Change Event. Change Events Because your benefit elections are part of a Section 125 plan, tax laws prevent you from changing your benefit elections during the Plan Year, except in the case of a life event change, or Change Event. You may change your benefit elections during the year only if: You have a qualifying change in status, You report the change within 31 days of the event, The change affects your eligibility under one of the employer-provided benefit plans, and The election you make is consistent with your change in status. Examples of qualifying changes in status are: Update Your Address Be sure to file your current address and any changes of address with your local Human Resources Department. Any communication addressed to you at your latest post office address on file will be binding upon you for all purposes of the Plan. You get married or divorced A change in dependent Children through birth, adoption, custody, court order, or death Your Spouse becomes employed or unemployed Your Child no longer meets the eligibility requirements You become disabled Your Spouse becomes disabled or dies January 2012 Dental Plan SPD 6

12 You change from full-time to part-time, or part-time to full-time employment You, your Spouse, or your dependent has a change in residence To change your benefit elections, you must request the change in writing within 31 days after the Change Event and identify the event that resulted in the change you are requesting. The requested change must be consistent with the Change Event. For example, if one of your covered dependents no longer qualifies as an Eligible Dependent, you may cancel coverage for that covered dependent, but you may not cancel coverage for other covered Eligible Dependents. Or, if you have single coverage and marry, you may elect family coverage. Election changes will be effective on your Change of Benefits Date. If you file the request later than 31 days after the Change Event, no changes will be made to your elections or Participant Contributions, but you may make the necessary change during the next Open Enrollment Period for the following Plan Year. Participant Contributions Contributions may be required to participate in the Plan. Your enrollment materials will include details about any required Participant Contributions, based upon the type and level of coverage in which you are enrolled. Family and Medical Leave Act If you take a leave of absence under the Family and Medical Leave Act of 1993, you have the option of continuing or discontinuing your coverage in the Plan. Consult with your local Human Resources Department to discuss your options under the Plan before taking the leave. When Coverage Begins Coverage begins on the Entry Date indicated in the Plan Outline section of this SPD, provided you have completed any required enrollment materials and have made any required contributions. When Coverage Ends Eligible Associates Your coverage ends at 11:59 p.m. on the last day of the month in which you no longer meet the definition of Eligible Associate. You may continue coverage, at your cost, for a limited time. (Please see the COBRA Continuation Coverage section of this SPD.) Different rules may apply in the event of salary continuation or severance payments. January 2012 Dental Plan SPD 7

13 Eligible Dependents Your dependents coverage ends at 11:59 p.m. on the date in which they no longer meet the definition of Eligible Dependent. Termination for Cause Your coverage can also be terminated for Cause. If your coverage is terminated retroactively, you may be required to repay benefits you received after the date your coverage is terminated. Coverage Can Be Terminated for Cause Your coverage can be terminated for: Your failure to complete, sign and/or provide to the Plan Administrator any information, document or form that Ascension Health determines is reasonably necessary for the administration of the Plan or Plan Sponsor functions Willful engagement in misconduct that is materially injurious to the Plan Dishonesty in connection with the provision of benefits under the Plan Fraudulent or unethical conduct or an intentional misrepresentation of a material fact related to or affecting the provision of benefits under the Plan Being indicted or charged with any crime constituting a felony Failure to pay any amounts due to the Plan or a Participating Employer Coverage can be terminated retroactively for: Failure to timely pay Participant Contributions Fraudulent or unethical conduct or an intentional misrepresentation of a material fact related to the provision of benefits under the Plan Reinstatement If, during the same Plan Year, you terminate employment and return to employment within 30 days, your prior elections will be reinstated automatically. However, if you return after 30 days or longer, you will be treated as a new hire (see Initial Enrollment Period ) unless your Participating Employer has a different rule for reinstatement. COBRA Continuation Coverage Under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), Qualified Beneficiaries have the option of continuing health care coverage for up to 18 months at group rates if you would otherwise lose coverage because of any of the following events: You no longer are employed by your Participating Employer (whether voluntarily or involuntarily, except if terminated for gross misconduct). January 2012 Dental Plan SPD 8

14 Your work hours are reduced below the minimum level necessary to be eligible for the Plan. You move to a position with your Participating Employer in which you are not eligible to participate in this Plan. While termination of employment normally triggers a right to only 18 months of continuation coverage, if your employment terminates less than 18 months after you become entitled to Medicare, the continuation coverage for your Eligible Dependents who are Qualified Beneficiaries can continue for 36 months after the date on which you become entitled to Medicare. Each Qualified Beneficiary will have an independent right to elect continuation coverage. Covered Eligible Dependents who are Qualified Beneficiaries can continue to be covered under the Plan for up to 36 months if they would otherwise lose coverage due to any of the following events: The Eligible Associate dies The Eligible Associate and his or her Spouse divorce or become legally separated An Eligible Dependent Child no longer satisfies the Plan s definition of Eligible Dependent (for example, the Child reaches the Eligible Dependent age limit) Qualified Beneficiaries are subject to the same rights and rules as those who participate in the Plan. Extended Coverage for Disabled Individuals Qualified Beneficiaries may be able to extend coverage for themselves and other family members who are Qualified Beneficiaries for up to an additional 11 months if they: Are disabled on the date of eligibility for continuation coverage, or Become disabled within the first 60 days of the continuation coverage period. To qualify, the Social Security Administration must officially determine that the person became disabled prior to the 61 st day of the continuation coverage period. Also, that person must notify the Participating Employer in writing of this disability determination before the first 18 months of continuation coverage ends and within 60 days after receiving notification from Social Security that the disability determination has been made. (Please see the Your Contact Information section of this SPD). If the disability ends during the 11 months of extended coverage, the Qualified Beneficiary must notify the Participating Employer within 30 days. Continuation coverage will end on the last day of the month in which the disability ends. Cost Individuals who choose continuation coverage must pay for such coverage. They will be charged up to 102% of the full cost of coverage depending on the coverage option for the Plan they choose. Disabled Qualified Beneficiaries and their family members who choose to January 2012 Dental Plan SPD 9

15 continue coverage beyond their initial 18-month continuation period will be charged up to 150% of the full cost of coverage during the 11-month disability extension. Contributions must be paid from the date coverage otherwise would have ended. Second Qualifying Event If a Qualified Beneficiary other than an Eligible Associate elects continuation coverage and experiences a second qualifying event within the initial 18-month period, he or she may be able to extend coverage further, but only up to a total of 36 months. The second qualifying event must occur while the Qualified Beneficiary has continuation coverage. For example, the family of an Eligible Associate who is laid off becomes eligible for 18 months of continuation coverage. They elect the coverage and then, 7 months later, the Eligible Associate dies. The surviving covered Eligible Dependents are entitled to 36 months of continuation coverage from the date of the Eligible Associate s termination of employment (the initial qualifying event). You must send a written notice of the second qualifying event to the Participating Employer at the address shown in the Your Contact Information section of this SPD. Notification You must notify the Participating Employer within 60 days after a divorce or legal separation occurs or within 60 days after a covered Eligible Dependent Child loses eligible status. This notice must be sent to the Participating Employer at the address shown in the Your Contact Information section of this SPD. Failure to provide this notice within the required timeframe will result in a loss of COBRA continuation coverage rights. Once the Participating Employer receives the notice, the Participating Employer will send a continuation of coverage notice to the individuals in question along with a continuation of coverage election form, which allows the individuals to indicate whether they want such coverage. Individuals must elect continuation coverage within 60 days after the later of: The date active coverage ceases under the Plan, or The date of the notice informing such individuals of their COBRA continuation rights. Termination Continuation coverage will end before the maximum coverage period if one of these events occurs: You fail to make contributions on time You become entitled to Medicare after you have elected COBRA continuation coverage The Participating Employer stops providing group health care coverage for Associates January 2012 Dental Plan SPD 10

16 You become covered under another group health program after you have elected COBRA continuation coverage You cease to be disabled during the 11-month disability extension period The Plan Administrator terminates your coverage for Cause If you become covered under another group health program, your continuation coverage would not have to terminate early if your new plan excludes or limits coverage of preexisting conditions that apply to you. Under those circumstances you could continue to receive the full benefits of your continuation coverage (not only benefits for preexisting conditions) until your original eligibility period of 18, 29 or 36 months ends or until the preexisting conditions limitation or exclusion ends, whichever occurs first. If you have questions concerning your continuation coverage rights, you should contact the COBRA service provider (see the Your Contact Information section of this SPD). In order to protect your family s COBRA rights, you should keep your Participating Employer and the Plan Administrator informed of any changes in the addresses of your family members. You should also keep a copy, for your records, of any notices sent to the Plan Administrator or your Participating Employer. USERRA Continuation Coverage If you are called to serve in the United States uniformed services, your benefits under the Plan may be protected by the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA). You may qualify to choose to continue coverage under the Plan for up to 24 months from the date your leave of absence begins. USERRA was signed into law in order to ensure that, under certain conditions, those who serve their country can retain their civilian employment and benefits. The continuation coverage mandated under USERRA is separate coverage from that provided under COBRA, although they may run concurrently, which means that they begin at the same time. However, COBRA coverage can continue for up to 18 months, while USERRA coverage can continue for up to 24 months. In addition, COBRA coverage may be terminated for additional reasons that do not apply to USERRA coverage. Eligibility for TRICARE (formerly CHAMPUS) or active duty military coverage will not terminate coverage under USERRA continuation coverage. If your period of uniformed service is less than 30 days, you are not required to pay more for USERRA coverage than the amount you pay for coverage under the Plan as an active Eligible Associate. For longer periods, your cost for USERRA coverage will be the same as for COBRA continuation coverage 102% of the full cost of coverage. If you were ever on a leave of absence due to military service or are thinking about leaving employment to serve in the military, please contact your local Human Resources Department to learn more about your rights under USERRA. January 2012 Dental Plan SPD 11

17 Qualified Medical Child Support Order The Plan will provide benefits in accordance with the applicable requirements of any Qualified Medical Child Support Order (as defined in Section 609(a) of ERISA) as soon as administratively feasible after the Plan Administrator determines that the medical child support order is a Qualified Medical Child Support Order, as described below. Definitions For purposes of this section, the following terms will have the meanings given them below: Alternate recipient means any Child of a Participant who is recognized under a medical child support order as having a right to participate in the Plan. Medical child support order means a judgment, decree or order issued by a court of competent jurisdiction, including approval of a settlement agreement, which is either made pursuant to a State domestic relations law and provides for child support and/or health benefit coverage for a child of a Participant, or which enforces a law relating to medical child support described in section 1908 of the Social Security Act, as added by section of the Omnibus Budget Reconciliation Act of 1993 (Medicaid), with respect to the Plan. Qualified Medical Child Support Order (QMCSO) means a medical child support order which creates, recognizes or assigns to an alternate recipient the right to receive medical benefits for which a Participant is eligible under the Plan. In order to be qualified, the order must: Clearly specify the name and address of the Participant and each alternate recipient covered by the order and reasonably describe the type of coverage to be provided or the manner in which such coverage can be determined Specify the period to which the order applies and the plans which are subject to the order Not require that the Plan provide any type or form of benefit or any option not otherwise provided under the Plan, except to the extent necessary to meet the requirements of a law relating to medical child support described in section 1908 of the Social Security Act (Medicaid) Procedures The Plan Administrator will use the following procedures to verify whether any judgment, decree or order is a QMCSO and to administer the provision of benefits under any such order, subject to such changes as are consistent with applicable law and regulations. Upon receiving a medical child support order, the Plan Administrator will promptly notify the Participant and the alternate recipient of the receipt of the order and the Plan's procedures for determining whether the order is a QMCSO. Within a reasonable period thereafter, the Plan Administrator will determine whether the order satisfies the requirements for a QMCSO and notify the parties of its decision. January 2012 Dental Plan SPD 12

18 The alternate recipient will be permitted to designate a representative for the receipt of copies of notices that are sent to the alternate recipient. Status of Alternate Recipients For all purposes under ERISA, an alternate recipient will be treated as a beneficiary under the Plan. Right to Amend or Discontinue the Plan Ascension Health and your Participating Employer are committed to maintaining the Plan. However, Ascension Health (the Plan Sponsor) reserves the right to amend or terminate the Plan in whole or in part, at any time, and for any reason, without advance notice. Amendment or termination of the Plan shall be effective if it is approved in writing by a duly authorized officer of Ascension Health, or if it is adopted pursuant to Ascension Health s procedures allocating or delegating authority to act on behalf of Ascension Health, as such procedures exist from time to time. Any Participating Employer will be permitted to discontinue or revoke its participation in the Plan. Coverage under this Plan will automatically terminate with respect to all Participants of a Participating Employer as of the date the Participating Employer ceases to participate in the Plan. January 2012 Dental Plan SPD 13

19 Section 2: Dental Benefits Depending on the level of coverage you choose, your dental benefits can cover a range of services from regular checkups to major dental reconstruction. The Plan emphasizes preventive care, recognizing that regular checkups and diagnostic services are key to maintaining healthy teeth and gums. How the Dental Plan Works Levels of Coverage The Plan offers three levels of coverage: Base Benefit: This level does not require deductibles. However, only preventive and basic dental services are covered; you do not have benefit coverage for major dental services or orthodontia. You pay coinsurance for basic dental services. To see what Dental Plan option(s) are offered by your Participating Employer, as well as a summary of coinsurance and deductible amounts and Plan limits and maximums, please see the Plan Outline section of this SPD. Comprehensive: This level requires a deductible and covers preventive, basic and major dental services. In most cases, with this level you pay a higher percentage of coinsurance than with the Comprehensive Plus option. Comprehensive Plus: This level requires a deductible and covers preventive, basic and major dental services, as well as orthodontia. With this option, in most cases you pay the lowest percentage of coinsurance. Plan Options Regardless of the level of coverage you choose, each Participating Employer will offer one or both of the following Plan options. Please see the Plan Outline section of this SPD for the Plan option(s) available to you. Incentive Plan Option: If your Participating Employer offers the Incentive Plan option, you will have a choice of two networks: The Delta Dental PPO The Delta Dental Premier Both networks cover the same services, but the Delta Dental PPO has deeper discounts. January 2012 Dental Plan SPD 14

20 With the Incentive Plan option, you may use any qualified dentist, but will usually save money if you use a dentist who is a member of either of the Delta Dental Networks. This is because Network Dentists have agreed to charge negotiated rates to Participants in this Plan and won t charge more than Usual, Customary and Reasonable fees for services. After you satisfy your dental Deductible (if applicable), you pay a percentage of covered expenses (or Coinsurance) up to the Usual, Customary and Reasonable Charge, depending on the type of service or supply required; the Plan pays the rest, up to Plan maximums. (See the Plan Outline section of this SPD for your Coinsurance amounts and Plan maximums.) To find a dentist in the Delta Dental Network, go online to Then, click on your Health Ministry to conduct a provider search for a dentist near you. If you receive services from a Non-Network Dentist and are billed more than the Usual, Customary and Reasonable Charge, you are responsible for paying the difference, in addition to your Coinsurance amount. Traditional Plan Option: If your Participating Employer offers the Traditional Plan option, you receive the same benefits, regardless of the dentist you use. However, by using a Network Dentist, you do not have to file a claim and are protected against balance billing (when an individual is billed the difference between what the dentist charges and what the Plan pays for a specific service). Usual, Customary and Reasonable When you receive dental care, the Plan pays a percentage of the actual covered expense, or what is considered to be a Usual, Customary and Reasonable Charge for a particular covered service or supply whichever is less. What is considered to be a Usual, Customary and Reasonable Charge is determined by Delta Dental according to industry standards and based on the amount typically chaged by: The treating dentist for that service or supply, and Similar dentists in the same area for comparable services or supplies. Covered Expenses The Plan covers dental expenses for services and supplies that are: Considered to be required to treat a condition, disease or injury, and January 2012 Dental Plan SPD 15

21 Medically or dentally necessary and appropriate according to current standards of good dental practice. Please note, however, that major dental services are not covered under the Base Benefit level of coverage. A list of covered expenses in each category follows. Expenses are considered incurred on the date of service not the date of billing. Preventive and Diagnostic Services Routine periodic exams; twice every year Periapical and bitewing x-rays; twice every year Full-mouth/panoramic x-rays; once every three years Dental prophylaxis (periodic cleaning, scaling and polishing) performed by a dentist or dental hygienist; twice every year Periodontal cleanings, maximum of four periodontal cleanings every year (combined with regular cleanings) Topical fluoride application for Children to age 19; once per calendar year Topical application of sealant on first and second permanent molars for Children to age 16; one per tooth every three years Palliative treatment emergency services for pain Space maintainers to age 19; one per life per quadrant of the mouth Basic Restorative Services Restorative services using silver alloy or composite resin filling material; once per affected tooth in a 24-month period Gold or cast restorations covered only when teeth cannot be restored with other filling materials, such as inlays Periodontics (treatment for diseases of the gums) Endodontics (root canal filling) and pulpal therapy (therapy for the soft tissue of a tooth) Simple and surgical extractions of teeth Oral surgery performed in the dentist s office General anesthesia administered in the dentist s office, when considered necessary and when administered in conjunction with covered oral surgery Osseous surgery Biopsy and exam of oral tissue January 2012 Dental Plan SPD 16

22 Major Restorative Services* Initial bridge, first installation of full or partial dentures and adding teeth Replacement or alteration of dentures or fixed bridge; once every five years Replacement of full denture; once every five years Repair of bridges and dentures Relining dentures Night guards for harmful habits, such as bruxism or the parafunctional grinding of the teeth; one per lifetime Replacement of congenitally missing teeth Crowns and buildup for crowns; once every five years Implants *If alternative treatments are available, the Plan will pay the least costly professionally satisfactory treatment for Major Restorative Services, such as crowns and fixed bridges, in which case the benefits may be based on the cost of a removable partial denture. Please note that major dental services are not covered under the Base Benefit level of coverage. Orthodontia Refer to the Plan Outline section of this SPD for the Coinsurance, age limits and lifetime maximums. Annual Maximum The Plan pays a maximum amount in benefits per Participant each Plan Year. (Please see the Plan Outline section of this SPD.) Predetermining Your Benefits If your dental care is not urgent in nature and the cost is estimated to be more than $200, it is best for your dentist to submit a treatment plan to Delta Dental before treatment is to begin so that your benefits can be predetermined. By predetermining your benefits, you will know the expected cost in advance, as well as how much of the cost will be paid by the Plan versus how much will be paid by you. Predetermining your benefits for dental expenses that are expected to exceed $200 is suggested, but not required, and does not guarantee payment. To receive a predetermination of benefits, your dentist should submit your treatment plan at least 14 days before the service is to be done. Delta Dental will send a Notice of Predetermined Benefits to your dentist so he or she can share it with you prior to starting your treatment. January 2012 Dental Plan SPD 17

23 Section 3: Expenses Not Covered The Plan will not pay for the services or supplies listed in this section. Dietary planning, plaque control or oral hygiene instruction Treatment for temporomandibular joint dysfunction (TMJ) Local anesthesia when billed separately by a dentist Replacement of a dental appliance or device that is lost, stolen or missing Athletic mouthguards Protective cases used to store dental devices or appliances Duplicate prosthetic devices or appliances Treatment or surgery for cosmetic purposes Treatment or appliances for restoring vertical dimension Services or supplies considered experimental or under clinical investigation Any charges incurred while the patient is not covered by the Plan Charges exceeding the Usual, Customary and Reasonable Charge Charges that exceed Plan maximums Services or supplies that are not required according to accepted standards of dental practice Services or supplies that are not recommended, prescribed or approved by a dentist Charges for missed appointments or completion of required claim forms Charges resulting from an injury suffered while committing a crime Charges for sterilization of equipment Charges for infection control Any illness or injury for which Workers Compensation benefits are paid, or would be paid, if claimed Services or benefits for the treatment of any sickness or injury caused by a war or any act of war (declared or undeclared) or service in the armed forces of any country Services or benefits that the Plan is unable to provide because of any law or regulation of the federal, state or local government, or any action taken by any agency or federal, state or local government with regard to the law or regulation Treatment furnished by a state or federal hospital Services or supplies that are provided or payable by any governmental agency Services or supplies that are furnished primarily for the convenience of you, the family or a dentist Services for which the patient incurs no charge Treatment for myofacial pain dysfunction syndrome Any services not specifically stated, including hospital charges Services rendered by a dentist beyond the scope of his/her license Hypnosis, hypnotic anesthesia, acupuncture or acupressure January 2012 Dental Plan SPD 18

24 Complete occlusal adjustments (adjustments affecting the contact between the upper and lower teeth) Bases, liners, anesthetics and application of caries removal solutions used in conjunction with restorations Charges covered under a terminal liability, extension of benefits or similar provision of a plan being replaced by this Plan Charges for home or hospital visits Temporary or treatment crowns, bridges or dentures, or crowns or bridges used for periodontal splinting Orthognathic surgery (surgical repositioning of the jaw) or any service or supply to correct deformities of the jaw Analgesia and nitrous oxide Routine postoperative care, if billed separately General anesthesia or intravenous sedation, unless administered during covered oral surgery Dental care not expressly specified in this SPD Dental care for treatment of complications arising out of or from dental care that is not a benefit under the Plan Charges for duplication of records or radiographs Charges for precision attachments Dental care to replace tooth structure loss due to attrition or abrasion Claims not received by the end of the year after the year in which the services and supplies were received Charges for multiple visit services for prosthetics that began prior to the date coverage was effective in this Plan Professional services, care, treatment and referrals rendered by the your family including, your mother, father, grandmother, grandfather, aunt, uncle, cousin, brother, sister, niece, nephew, son, daughter, grandson, granddaughter, or any person who resides with you Charges for replacement of filling restorations more than once in a 24-month period, unless the damage to that tooth was caused by accidental injury not related to the normal function of the tooth or teeth Other services as indicated in the Plan Outline section of this SPD Any Dental Services or prescription drug coverage which would violate the Ethical and Religious Directives for Catholic Health Care Services as approved and promulgated from time to time by the United States Conference of Catholic Bishops January 2012 Dental Plan SPD 19

25 Section 4: Claims Procedures When you receive dental care from a Network Dentist, no claim forms are necessary. If you receive dental care from a Non-Network Dentist, you will need to file a claim for reimbursement. The claim must be submitted by the end of the year following the Plan Year in which the dental expense was incurred. Filing a Claim If you use a Non-Network Dentist and need to file a claim, you can either: Obtain a dental claim form from your local Human Resources Department, and then at the time of your appointment, ask your dentist to complete the dentist section, or At your appointment, ask the dentist to complete the dentist section of a standard American Dental Association-approved claim form. For reimbursement from a Non- Network Dentist, mail your claim to: Delta Dental of Missouri P.O. Box 8690 St. Louis, MO In most cases, you will then need to complete the remainder of the form and mail it to Delta Dental; Non-Network Dentists usually will not file claims for you. Claims for Dental Care While Traveling If you need dental care while traveling out of the country and a claim form is unavailable, obtain an itemized bill from the dentist that includes the following: Provider s name and office address Name of Participant who received dental care Reason for treatment Charge for each of the services and materials provided Dental procedure code for each service provided Send this bill to Delta Dental and include the following information: Your name, address and Social Security Number, The Eligible Associate s Participating Employer s name Delta Dental will send you an explanation of benefits (EOB) explaining what services were and were not covered when a claim is filed, and if you owe any money for services or supplies. January 2012 Dental Plan SPD 20

26 For the Participant who received dental care, his or her: Name Date of birth Relationship to the Eligible Associate If applicable, other insurance information necessary for coordination of benefits Timing of Claims Review The Plan s procedure for reviewing claims depends upon the type of claim filed: Urgent Care Claims, Pre-Determination Claims, Post-Service Claims and Ongoing Care Claims. A review of any denied claim may be sought by you, your dentist, or your authorized representative. Urgent Care Claims An Urgent Care Claim is a request for payment for services where application of the time periods for non-urgent care determinations could seriously jeopardize your life or health or your ability to regain maximum function or would subject you to severe pain that cannot be managed without treatment. In the case of an Urgent Care Claim, Delta Dental will usually process your claim within 72 hours after receipt of your claim. Pre-Determination Claims A Pre-Determination Claim is a request for pre-authorization that is not required but recommended when dental claims exceed $200 in order for you to know what services are covered and what is payable under the Plan. In the case of a Pre-Determination Claim, Delta Dental will usually process your claim within 14 days after receipt of the treatment plan from your dentist. Post-Service Claims A Post-Service Claim is a request for payment for services that have already been rendered. In the case of a Post-Service Claim, Delta Dental will notify you of an adverse benefit determination within 30 days after receipt of the claim. This period may be extended one time for up to 15 days if an extension is necessary due to matters beyond the control of the Plan. If such an extension of time is taken, Delta Dental will notify you, prior to the expiration of the initial 30-day period, of the circumstances requiring the extension of time and the date by which a decision is expected to be rendered. If such an extension is necessary due to your failure to submit the information necessary to decide the claim, the notice of extension will specifically describe the required information. You must provide the specified information within 45 days after receipt of such notice. Ongoing Care Claims An Ongoing Care Claim is for services that will be provided (or are being provided) over a period of time or a number of treatments. If the Plan Administrator has approved an ongoing course of treatment, Delta Dental will notify you of any reduction or termination of the course of treatment far enough in advance of the reduction or termination to allow you to appeal and obtain a determination on review before the benefit is reduced or terminated. January 2012 Dental Plan SPD 21

27 If Your Claim is Denied If your claim is denied, Delta Dental will notify you of the adverse benefit determination. Every notice of adverse benefit determination will be provided in writing or electronically and will include: The specific reason or reasons for the adverse determination, In the case of a claim involving urgent care, a description of the expedited review process applicable to such claims, If you need assistance understanding your benefit determination or have questions about your rights to appeal a denied claim, contact the Delta Dental Customer Service Department at Reference to the specific Plan provisions on which the determination is based, A description of any additional material or information necessary to perfect the claim and an explanation of why such material or information is necessary, and A description of the Plan s review procedures and the time limits applicable to such procedures. In the case of an adverse benefit determination concerning a claim involving urgent care, the notice may be provided orally, provided that a written or electronic notice is furnished not later than three days after the oral notice is provided. You are entitled to receive, upon request and free of charge, a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon in making the adverse determination and an explanation of the scientific or clinical judgment for a determination that is based on a medical necessity, experimental treatment or other similar exclusion or limit. Appealing a Denied Claim If you disagree with the claim denial, you, your provider or an authorized representative may file an appeal within 180 days after you receive the notice. You may submit written comments, documents and other information, and you may receive, upon request and free of charge, reasonable access to and copies of all documents, records and other information relevant to your claim. If you wish to appeal a denied claim, contact the Delta Dental Customer Service Department at or send notification of your desire to appeal within 180 days from receipt of your claim denial. Be sure to include the following: Your name ID and claim numbers Also, indicate whether the person requesting the appeal is the Eligible Associate, Eligible Dependent or authorized representative. If you think a coding error may have caused this claim to be denied, you have the right to the billing and diagnosis codes used for your claim. You can receive this information from your provider or Delta Dental. January 2012 Dental Plan SPD 22