DENTAL PROGRAM 2015 SUMMARY PLAN DESCRIPTION

Transcription

1 DENTAL PROGRAM 2015 SUMMARY PLAN DESCRIPTION

2 Welcome This is the Summary Plan Description for the dental PROGRAM (the Program ) provided under the Time Warner Group Health Plan (the Plan ) for eligible Time Warner employees. It includes information about the Time Warner Preferred Provider Organization (PPO) and the Preventive Provider Organization (Preventive PPO) dental coverage options. This Summary Plan Description describes the major provisions of the Program as in effect on January 1, 2015 (except as otherwise noted), and provides information participants are legally entitled to know. The terms you and your as used in this Summary Plan Description refer to a Time Warner EMPLOYEE who otherwise meets all the eligibility and participation requirements under the Program and the Plan. Receipt of this Summary Plan Description does not guarantee that the recipient is a PARTICIPANT under the Plan or the Program and/or otherwise eligible for benefits under the Plan or Program. 2 Dental Program Benefits Effective January 1, 2015 TURNER

3 TABLE OF CONTENTS ABOUT THIS SPD... 5 WHO S ELIGIBLE... 5 Employees... 5 Dependents... 5 ENROLLMENT... 8 Active Enrollment... 8 Open Enrollment... 9 Qualified Change in Status PAYING FOR COVERAGE WHEN COVERAGE BEGINS HOW THE DENTAL PPO WORKS ELIGIBLE DENTAL PPO SERVICES Preventive, Diagnostic and Therapeutic Services Basic Restorative Services Major Services Orthodontia Services HOW THE PREVENTIVE DENTAL PPO WORKS ELIGIBLE PREVENTIVE DENTAL PPO SERVICES Preventive, Diagnostic and Therapeutic Services Basic Restorative Services Major Services Orthodontia Services What s Not Covered Dental Program Benefits Effective January 1, 2015 TURNER 3

4 FILING CLAIMS Appeals Claims Fraud WHAT HAPPENS IF You Become Disabled You Take a Leave of Absence You Are No Longer Active You Receive Notice and Severance You Retire WHEN COVERAGE ENDS Benefits After Coverage Ends Continuing Coverage Under COBRA OTHER INFORMATION If You Have Other Coverage Qualified Medical Child Support Orders (QMCSOs) Benefits Lost or Delayed Ownership of Benefits Laws and Regulations Affecting the Plan Plan Administration Plan Facts Your Rights Under ERISA KEY TERMS & DEFINITIONS Dental Program Benefits Effective January 1, 2015 TURNER

5 ABOUT THIS SPD The information in this Summary Plan Description applies to eligible employees of Turner. This summary tries to explain Plan and PROGRAM provisions in everyday language, but you will come across linked words and phrases that have specific meanings within the context of the Program. Click the links for the definitions of these terms, which are also available in KEY TERMS & DEFINITIONS on page 46. Also, be sure to read OTHER INFORMATION on page 37 for important administrative guidelines and facts about your rights under applicable law, the Plan and the Program. If there s any discrepancy between this Summary Plan Description and the official Plan documents, the Plan documents take precedence. You can get a copy of the Plan documents by writing to the PLAN ADMINISTRATOR. Time Warner Inc. or any successor reserves the right to amend, modify, suspend or terminate the Plan, the Program, or any coverage option offered under the Plan, in whole or in part, at any time and for any reason, by action of Time Warner Inc. In addition, the BENEFITS OFFICER may amend the Plan on behalf of Time Warner Inc for changes that do not result in a significant cost to any Employing Company or have a material effect on benefits. Please note that the Plan does not create an employment contract between you and your Company, and does not give you any right, expressed or implied, of continued employment with your Employing Company. WHO S ELIGIBLE Employees You may participate in the PROGRAM if you are a regular full-time salaried employee, or a regular part-time salaried employee working at least 312 hours per quarter. If your scheduled hours are reduced below 312 hours per quarter, your eligibility to participate will end on the last day of the month following the end of the quarter in which the reduction of your scheduled hours occurs. Dependents As an eligible EMPLOYEE, you may extend coverage to your eligible DEPENDENTS including your SPOUSE, domestic partner and children as long as you enroll for dental coverage under the PROGRAM. When you enroll your eligible dependents for coverage, you will be required to certify that each person meets the definition of an eligible dependent a spouse, domestic partner or child as described below. Enrolling individuals who do not qualify for dependent coverage under the Program is considered fraudulent and may result in retroactive cancellation Dental Program Benefits Effective January 1, 2015 TURNER 5

6 of coverage and disciplinary actions up to and including termination of employment. If you are unsure about whether a family member meets the definition of an eligible dependent under the Program, contact the Time Warner Benefits Center at Spouse means the person to whom you were legally married under the laws of the state in which the marriage was performed (including your common-law spouse in states that recognize common-law marriage). If you were legally married in a state that recognizes same-sex marriage, your partner in marriage will not lose status as your spouse for purposes of this Program solely because you move to another state in which your same-sex marriage is not recognized. Domestic partner means: Your same-sex or opposite-sex partner with whom you have entered into a legal civil union under applicable state law, or An adult of the same or opposite sex with whom you have been in an exclusive and committed relationship that is intended to be permanent. You and your partner must be responsible for each other s welfare on a continuing basis. You must have been in the relationship for at least six months. You and your partner must both be at least 18 years old and may not be related by blood to a degree of closeness that would prohibit marriage under applicable state law as an opposite sex couple. Neither of you may be legally married to or in a legal civil union with another person. You may have to have an Affidavit of DOMESTIC PARTNERShip on file with the Company for a domestic partner who is not your legal civil union partner to be eligible for coverage. Dependent Children Your dependent children are eligible for coverage until the end of the calendar year in which they turn age 26, regardless of student status and whether or not they can be claimed as dependents on your federal income tax return. This means that even if your child is married, financially independent, or no longer in school, he or she will be eligible for coverage under the Program through the end of the calendar year in which he or she reaches age 26. Dependent children includes your or your spouse s biological children, stepchildren, foster children, legally adopted children, children for whom adoption procedures have been started, children whom you have been ordered to cover through a Qualified Medical Child Support Order and other children who live with you and for whom you are the appointed legal guardian. Your domestic partner s children are also eligible for coverage as long as they meet all other criteria for coverage of dependent children described above. Your dependent child s spouse or domestic partner and your child s dependent children are not eligible for coverage under the Program. 6 Dental Program Benefits Effective January 1, 2015 TURNER

7 Disabled Children An unmarried disabled adult child who is primarily dependent on you for support and who would otherwise not be eligible due to age limitations under the Program can be enrolled within 30 days of your initial eligibility, subject to verification by the CLAIMS ADMINISTRATOR that the disability occurred before age 26. If you do not enroll this disabled adult child when you first become eligible, you may do so during any subsequent open enrollment period, subject to the same verification. If your unmarried child becomes disabled while covered under the terms of the Program, coverage can continue without regard to age for as long as the child remains disabled and is primarily dependent on you for support. Extended coverage for disabled children is subject to periodic verification by the Claims Administrator. Imputed Income for Domestic Partners and Other Non-Tax Dependents If you elect to cover a domestic partner and/or child who do not qualify for non-taxable medical benefits as a dependent under federal tax rules, the full amount of the Employing Company s contribution toward this coverage generally is treated as imputed income to you (the employee). This means that the amount that the Employing Company pays for dental coverage for your non-tax-dependent domestic partner or child will be shown on the your IRS Form W-2 and will be taxable income for federal and, in most cases, state tax purposes. Former Spouses or Domestic Partners An ex-spouse or former domestic partner is not considered an eligible dependent, even if you are legally required to provide his or her health insurance. However, if you divorce while your spouse is covered by the Program, or if you end your domestic partnership while your domestic partner is covered by the Program, he or she may be able to continue individual coverage for a limited period at his or her own expense, see Continuing Coverage Under COBRA on page 32 for more information. Survivors Surviving spouses or domestic partners and/or dependent children of deceased employees are generally eligible to continue Program participation for a limited period following the employee s death, see Continuing Coverage Under COBRA on page 32 for more information. Dental Program Benefits Effective January 1, 2015 TURNER 7

8 ENROLLMENT Active Enrollment Participation in dental coverage under the PROGRAM is not automatic; you must enroll to have coverage in place. You may enroll yourself and your eligible DEPENDENTS at the following times: Within 30 days of your eligibility date. Your eligibility date is the first day of the month following the date you are hired or otherwise become eligible to participate. If you enroll within 30 days of your eligibility date, your participation begins on your eligibility date. If you do not enroll yourself or your dependents within 30 days of your eligibility date, you must wait until the next open enrollment period unless you have a qualified change in status. You may reject or waive participation in dental coverage under this Program. During the open enrollment period, which is usually held in the fall, in which case your participation begins on the next January 1 and stays in effect throughout the next calendar year. Within 30 days of a qualified change in status, in which case your participation begins on the date of the qualifying event and stays in effect for the rest of the current calendar year. Choosing a Coverage Level You may elect one of the following coverage levels: EMPLOYEE-only Employee-plus-SPOUSE/domestic partner (considered family coverage ) Employee-plus-child(ren) (considered family coverage ) Employee-plus-spouse/domestic partner-plus-child(ren) (considered family coverage ). You cannot enroll dependents for coverage that you waive for yourself. For example, you cannot choose dental coverage for your dependents if you waive it for yourself. Independent Medical, Dental and Vision Elections You make separate elections for medical, dental and vision coverage. For example, you may elect dental coverage without electing medical and vision coverage. You also may elect different coverage levels for each kind of coverage, but you cannot enroll dependents for coverage that you waive for yourself. For example, you may choose employee- 8 Dental Program Benefits Effective January 1, 2015 TURNER

9 only medical coverage, employee-plus-child(ren) dental coverage and employee-plus-spouse/domestic partner-pluschild(ren) vision coverage, but you cannot choose dental coverage for your family if you waive it for yourself. Enrollment in the Flexible Spending Account Plan You may also wish to enroll in the Flexible Spending Account Plan (FSA) to set aside before-tax dollars to pay for any unreimbursed eligible dental expenses you anticipate each year, such as copayments and costs in excess of the amounts covered by this Program. If you enroll in the Basic PPO, the PPO or the HMO options, you will be eligible for the Health Care FSA, which allows you use pre-tax dollars for unreimbursed medical, dental, and vision expenses, including your coinsurance amounts and deductibles. If you enroll in the Health Savings PPO or the Health Savings HMO options, you may contribute to a Limited Purpose FSA, which allows you to use pre-tax dollars for unreimbursed dental and vision expenses only. If you are eligible and enrolled in the Health Savings PPO or the Health Savings HMO, you may also set up a Health Savings Account with Fidelity. Refer to the FSA Summary Plan Description or contact the Time Warner Benefits Service Center at for more information about your eligibility for the FSA Plan. How to Enroll Log onto or call Please call between 8 a.m. EST and 10 p.m. EST with any questions on the enrollment process. Open Enrollment The Company holds an open enrollment each fall, during which you can: Enroll in coverage for the following year, Change your coverage option election, Cancel your own and/or your covered DEPENDENTS coverage, and Add an eligible dependent(s). Whatever election you make during open enrollment takes effect on the next January 1 and stays in effect for the full calendar year unless you experience a qualified change in status and file an amended election within the election period. Generally, if you don t make a change to your PROGRAM election, your election for the prior year remains in effect. Dental Program Benefits Effective January 1, 2015 TURNER 9

10 Qualified Change in Status Your election generally must stay in effect until the end of the current calendar year. Once made, you can t change your election during the calendar year unless you have a qualified change in status. A qualified change in status includes the following: Your legal marital status changes (e.g., through marriage, divorce, legal separation or annulment), or you enter into or dissolve a DOMESTIC PARTNERShip. The number of your eligible DEPENDENTS changes (such as when a child becomes your dependent through birth or adoption, a person s status as an eligible dependent under the PROGRAM changes or a dependent dies). Your covered dependent no longer satisfies the requirements for coverage under the Program because he or she reaches the limiting age, or any similar circumstance. Eligibility for employer-sponsored health coverage is affected because you or your eligible dependent becomes employed or unemployed (and are not rehired within 30 days). Eligibility for employer-sponsored health coverage is affected because you or your SPOUSE or domestic partner takes or returns from an unpaid work-related leave of absence. Eligibility for employer-sponsored health coverage is affected because your or your spouse s or domestic partner s employment status changes from full-time to part-time (or vice versa). Eligibility for employer-sponsored health coverage is affected because you or your spouse or domestic partner go on strike or are locked out, or return from a strike or lockout. The coverage options available to you change because you or your covered dependent changes residences, worksites or Employing Companies. Your spouse s or domestic partner s employer-sponsored plan has a different open enrollment period (and a different plan year), and you would like to make a change to correspond with an election change under your spouse s or domestic partner s plan. COBRA coverage under another plan is exhausted. The BENEFITS OFFICER, in accordance with Internal Revenue Service (IRS) guidelines, determines that there s a significant change in the employer-sponsored health coverage you or your spouse or domestic partner has. 10 Dental Program Benefits Effective January 1, 2015 TURNER

11 A judgment, decree or other order resulting from a divorce, legal separation, annulment or change in legal custody, such as a Qualified Medical Child Support Order requires health coverage for your child or dependent foster child. If you have a qualified change in status, you have until the end of the 30-day election period to change your coverage election. The change in your election must be due to and consistent with the qualified change in status and is subject to IRS code requirements. Once a coverage change has been approved, it generally becomes effective as of the date of the qualifying event. Documentation verifying a qualified change in status must be provided to the PLAN ADMINISTRATOR upon request. Failure to comply will result in the amended election request being denied. Your ability to change coverage during a calendar year is restricted under IRS code rules because contributions for coverage (other than coverage for domestic partners, same-sex spouses, and children who are not eligible for nontaxable medical benefits as a dependent under federal tax law) are made on a before-tax basis. Transfers If you transfer from a nonparticipating division of Time Warner Inc. to an Employing Company, you have until the end of the 30-day election period to enroll. The effective date of your election will be the date of your transfer. If you transfer from one Employing Company to another and already participate in dental coverage under the Program, your election will carry over to your new Employing Company, if possible; otherwise, you must choose one of the dental coverage options your new Employing Company offers. A transfer between Employing Companies does not by itself constitute a qualified change in status; however, you do have a qualified change in status if the coverage options available to you change as a result of your transfer. When Couples Work for an Employing Company If you and your spouse or domestic partner both work for the Company, you decide how your dependents (if any) are to be enrolled. Each of you may enroll individually, one may enroll as a dependent of the other, or one or both may elect family coverage. If you are covered as both an EMPLOYEE and a dependent under the Program, keep in mind that coordination of benefits will apply, see If You Have Other Coverage on page 37 for more information. Newborn or Newly-Adopted Children A newborn or newly-adopted child, or a child for whom adoption procedures have begun, will be covered automatically during the 30-day election period. To maintain coverage beyond then, you must enroll your new child as a dependent before the end of the election period, even if you already had family coverage. Dental Program Benefits Effective January 1, 2015 TURNER 11

12 PAYING FOR COVERAGE You and your Employing Company share the cost of dental coverage for you and your covered DEPENDENTS. Your contributions toward the cost of coverage for a plan year is based on your base pay (or, if you are a part-time EMPLOYEE, your full-time equivalent base pay) as of January 1 of the plan year (or your date of hire, if later). Your contributions for coverage for yourself and any eligible dependent who is permitted to receive non-taxable dental benefits as a dependent under federal tax law are generally are made through before-tax payroll deductions. If you elect to cover any eligible dependent who does not qualify for non-taxable dental benefits as a dependent under federal tax rules, the amount of the Employing Company s contribution toward this coverage generally is treated as imputed income to you. The cost of PROGRAM coverage and the amount of employee contributions for coverage are subject to change and may be revised each January 1 to reflect changes in the cost of coverage from year to year. Refer to or contact the Time Warner Benefits Service Center at for more information about the current contribution requirements. WHEN COVERAGE BEGINS Coverage for you and your family starts on the first day of the month following your date of hire, as long as you enroll within 30 days of your eligibility date. Your eligibility date is the first day of the month following the date you first satisfy the eligibility criteria described in WHO S ELIGIBLE on page 5 (for example, your date of hire or the date you first begin working 20 or more hours per week). If you don t enroll within 30 days of your eligibility date but you decide to enroll during the annual open enrollment period, coverage starts on the following January 1. If you re electing coverage as a result of a qualified change in status, coverage begins on the date of the qualified change in status event as long as you enroll within 30 days of the qualified change in status event (your qualified change in status election period). Determining When Treatment Begins The PROGRAM pays for dental treatment that begins after you or your dependent become covered. The person also must be covered on the date dental treatment is received. While most dental treatment is considered to have been received on the date the work is done, there are some types of treatment that take more than one visit to complete, see Benefits After Coverage Ends on page 31 for more information). 12 Dental Program Benefits Effective January 1, 2015 TURNER

13 HOW THE DENTAL PPO WORKS The PPO dental coverage under the PROGRAM is designed to promote good dental health by providing coverage for a broad range of dental services and supplies. Read this section carefully to fully understand which, and how, dental expenses are covered, keeping in mind that, as a rule, the PPO Option covers only those services that are considered essential to good dental health. The PPO is a fee-for-service dental plan that includes the MetLife Preferred DENTIST (PDP) feature. You may visit any dentist or specialist you wish. However, depending on whether or not you use a PDP (in-network) dentist, there are some differences in how the Program works. Using PDP Dentists When you receive care from a MetLife PDP dentist you will pay less because MetLife has negotiated discounted fees with PDP dentists. Also, PDP dentists will file claims for you at no extra charge. For a directory of participating PDP dentists in your area, go to metlife.com/mybenefits. You can also call MetLife at Using Non-PDP Dentists When you use a non-metlife PDP (out-of-network) dentist, you may need to pay the dentist in full at each visit and then follow the PPO claims procedure. Should a non-pdp dentist charge you more than the REASONABLE AND CUSTOMARY amount, in addition to your normal coinsurance, you will also have to pay the difference between the reasonable and customary charge and your dentist s charge. For example, if the reasonable and customary charge for a routine checkup is $100 but your dentist charges you $125, you d be responsible for the $25 difference. Annual Deductible Each PARTICIPANT IN THE PPO OPTION has to satisfy an annual DEDUCTIBLE before benefits become payable for covered restorative and major services and supplies; there is no deductible for preventive, diagnostic and therapeutic services and supplies or orthodontia expenses. The annual deductible is the amount you must pay out of pocket each year before the PPO option begins to pay for your dental expenses. If you have family coverage, the annual family deductible is satisfied when your family s eligible expenses combined reach the family deductible amount. After one individual satisfies the $50 deductible, the remaining family deductible can be met by any combination of covered DEPENDENTS. Dental Program Benefits Effective January 1, 2015 TURNER 13

14 Your annual deductibles are: $50/person $100/family The following expenses are not applied toward the annual deductible: Covered out-of-network expenses that are over the reasonable and customary charge, and Charges excluded or limited by the Program. Maximum Benefits Maximum benefits are based on the type of service. Preventive, diagnostic, therapeutic, restorative and major services combined $2,000/person maximum for any calendar year Orthodontia $2,000/person maximum for life TMJ $1,000/person maximum for life Before scheduling major dental treatment, you can determine if the procedure would be covered and obtain an estimate of the amount that the CLAIMS ADMINISTRATOR may approve for payment by asking your dentist to file a predetermination of benefits with the Claims Administrator. Predetermination of Benefits When you need extensive dental treatment for example, if it involves crowns or bridges, or if it will cost more than $300 it is advisable to ask your dentist to request a predetermination of benefits. A predetermination is an estimate of the amount that the Claims Administrator may approve for payment if you are covered by the PPO OPTION when your treatment is completed. To receive a predetermination, ask your dentist to fill out the treatment plan on the claim form, explaining what work is to be done and indicating that this is a predetermination estimate. Have your dentist send the form to the Claims Administrator. The Claims Administrator will send your dentist a Notice of Predetermination which estimates how much of the treatment costs will be paid by the PPO option and how much you will have to pay. A predetermination does not guarantee payment. Computations are estimates only and are based on what would be payable on the date the Notice of Predetermination is issued (maximums or coordination of benefits notwithstanding). 14 Dental Program Benefits Effective January 1, 2015 TURNER

15 Payment will depend on your eligibility; whether treatment is NECESSARY; how much of your maximum is left when the predetermination estimate is submitted; and what the primary carrier paid (in those instances where coordination of benefits is necessary). Although the predetermination of benefits procedure is not required, it is advisable as a means of estimating costs and potential benefits. This is especially important for out-of-network procedures or services because out-of-network reimbursement is based on reasonable and customary charges. If you have any questions about a predetermination, contact the Claims Administrator before treatment begins. ELIGIBLE DENTAL PPO SERVICES To be considered for reimbursement, a dental service must meet all of the following criteria: It must be provided or performed by a DENTIST (or for some treatments, such as teeth cleaning, by a licensed dental hygienist working under the dentist s supervision). It must be for NECESSARY dental care. The charge must fall within the REASONABLE AND CUSTOMARY range for that particular service or supply. It has to be a covered expense. You or your dependent must be enrolled in the PROGRAM at the time COVERED CHARGES are incurred. Preventive, Diagnostic and Therapeutic Services There is no DEDUCTIBLE for preventive, diagnostic and therapeutic services and supplies. These services include most types of treatment for common dental problems. The PPO OPTION pays 100% of the REASONABLE AND CUSTOMARY charge for the following: Routine oral exams (two times in any calendar year), Cleaning and scaling of teeth (two times in any calendar year), Bitewing X-rays (two sets in any calendar year up to age 19, one set per calendar year thereafter), Dental Program Benefits Effective January 1, 2015 TURNER 15

16 Complete dental X-ray series, including bitewings, if NECESSARY, or panoramic film but not more than one full mouth X-ray or series in any five-year period and not more than one set of supplementary bitewing X-rays in any calendar year, Laboratory tests to diagnose a condition needing treatment or to check the progress of treatment, Topical fluoride applications for dependent children under age 19 (twice in any calendar year), Topical application of sealants for dependent children under age 19, provided the sealant is applied only to nondecayed first and second molars; sealant benefits do not include the repair or replacement of a sealant on any tooth within three years of its application, Space maintainers and their fittings (includes all adjustments within six months after installation), and Emergency treatment to relieve pain (palliative treatment). Basic Restorative Services The PPO option covers most types of treatment for basic dental problems. Once you have satisfied the annual DEDUCTIBLE, the PPO OPTION pays 80% of the REASONABLE AND CUSTOMARY charge for the following: Extraction of teeth for dental conditions, Oral surgery for dental conditions (oral surgery for medical conditions may be covered under a medical PROGRAM), General anesthetics when NECESSARY for oral surgery, periodontic treatment, fractures or dislocations, Fillings (amalgam, silicate, plastic, synthetic porcelain and composite filling restorations to restore diseased or fractured teeth), Endodontic treatment, including root canal therapy, Periodontic treatment of the gums, tissues and bones supporting the teeth (once every 24 months), Periodontal surgery (once every 36 months), Four periodontal dental maintenance exams per calendar year after active periodontal therapy, including two prophylaxis, for a total of four per year, Repairing or recementing crowns, inlays, onlays, bridgework or dentures, 16 Dental Program Benefits Effective January 1, 2015 TURNER

17 Injectable antibiotics administered by a licensed DENTIST or physician, and Rebasing or relining dentures that are more than six months old (not more than once every 36 months; if the Program pays for a new denture, it will not pay to rebase or reline the old denture). Major Services The PPO option covers most types of treatment for extensive dental problems. Once you have satisfied the annual DEDUCTIBLE, the PPO OPTION pays 60% of the REASONABLE AND CUSTOMARY charge for the following: Charges in connection with implants and any prosthetic appliances attached to such implants, up to the allowance for the covered standard procedure or appliance, Installation of fixed bridgework (including inlays and crowns or abutments) or initial installation of partial or full removable dentures (including any adjustments during the six-month period following installation) to replace missing natural teeth, Inlays, onlays, gold fillings or crowns needed to repair or restore decayed or fractured teeth that cannot be otherwise restored with amalgam, silicate or plastic, Replacement of crowns more than five years old unless earlier replacement is considered appropriate by the CLAIMS ADMINISTRATOR, Replacement of an existing partial or full removable denture or fixed bridgework more than ten years old unless earlier replacement is considered appropriate by the Claims Administrator, Adding teeth to fixed bridgework or partial dentures (to replace missing natural teeth) when considered appropriate by the Claims Administrator, and Appliance for treatment of temporomandibular joint dysfunction (TMJD), but not orthotic braces. Predetermination of benefits for TMJD treatment is strongly recommended. Orthodontia Services The PROGRAM covers certain types of orthodontia services. Orthodontic treatment generally consists of initial placement of an appliance and periodic follow-up visits. Dental Program Benefits Effective January 1, 2015 TURNER 17

18 The benefit payable for the initial placement will not exceed 20% of the maximum benefit amount for orthodontia. The benefit payable for the periodic follow-up visits will be payable on a quarterly basis during the course of orthodontic treatment if: Dental insurance is in effect for the person receiving orthodontic treatment, and Proof is given to MetLife that the orthodontic treatment is continuing. If the initial placement was made prior to this dental insurance being in effect, the benefit payable will be reduced by the portion attributable to the initial placement. If the periodic follow-up visits commenced prior to the dental insurance being in effect: The number of months for which benefits are payable will be reduced by the number of months of treatment performed before this dental insurance was in effect, and The total amount of the benefit payable for the periodic visits will be reduced proportionately. These services include diagnostic procedures and appliances to realign teeth. There is no DEDUCTIBLE for orthodontic treatment. The Program pays 60% of the REASONABLE AND CUSTOMARY charge for eligible orthodontia expenses, up to the per-person lifetime maximum orthodontia benefit of $2,000. Benefits for orthodontic care start when the first active appliances are installed; claims are processed as bills are submitted for services rendered. HOW THE PREVENTIVE DENTAL PPO WORKS The Preventive PPO dental coverage under the PROGRAM is designed to promote good dental health by providing coverage for a broad range of dental services and supplies. Read this section carefully to fully understand which, and how, dental expenses are covered, keeping in mind that, as a rule, the PPO option covers only those services that are considered essential to good dental health. The PPO is a fee-for-service dental plan that includes the MetLife Preferred DENTIST (PDP) feature. You may visit any dentist or specialist you wish. However, depending on whether or not you use a PDP (in-network) dentist, there are some differences in how the Program works. Using PDP Dentists When you receive care from a MetLife PDP dentist you will pay less because MetLife has negotiated discounted fees with PDP dentists. Also, PDP dentists will file claims for you at no extra charge. For a directory of participating PDP dentists in your area, go to metlife.com/mybenefits. You can also call MetLife at Dental Program Benefits Effective January 1, 2015 TURNER

19 Using Non-PDP Dentists When you use a non-metlife PDP (out-of-network) dentist, you may need to pay the dentist in full at each visit and then follow the PPO claims procedure. Should a non-pdp dentist charge you more than the REASONABLE AND CUSTOMARY amount, in addition to your normal coinsurance, you will also have to pay the difference between the reasonable and customary charge and your dentist s charge. For example, if the reasonable and customary charge for a routine checkup is $100 but your dentist charges you $125, you d be responsible for the $25 difference. Annual Deductible Each PARTICIPANT IN THE PREVENTIVE PPO OPTION has to satisfy an annual DEDUCTIBLE before benefits become payable for covered restorative and major services and supplies; there is no deductible for preventive, diagnostic and therapeutic services and supplies or orthodontia expenses. The annual deductible is the amount you must pay out of pocket each year before the Preventive PPO option begins to pay for your dental expenses. If you have family coverage, the annual family deductible is satisfied when your family s eligible expenses combined reach the family deductible amount. After one individual satisfies the $100 deductible, the remaining family deductible can be met by any combination of covered DEPENDENTS. Your annual deductibles are: $100/person $200/family The following expenses are not applied toward the annual deductible: Covered out-of-network expenses that are over the reasonable and customary charge, and Charges excluded or limited by the Program. Maximum Benefits Maximum benefits are based on the type of service. Preventive, diagnostic, therapeutic, restorative and major services combined $1,500/person maximum for any calendar year TMJ $1,000/person maximum for life Dental Program Benefits Effective January 1, 2015 TURNER 19

20 Before scheduling major dental treatment, you can determine if the procedure would be covered and obtain an estimate of the amount that the CLAIMS ADMINISTRATOR may approve for payment by asking your dentist to file a predetermination of benefits with the Claims Administrator. Predetermination of Benefits When you need extensive dental treatment for example, if it involves crowns or bridges, or if it will cost more than $300 it is advisable to ask your dentist to request a predetermination of benefits. A predetermination is an estimate of the amount that the Claims Administrator may approve for payment if you are covered by the Preventive PPO OPTION when your treatment is completed. To receive a predetermination, ask your dentist to fill out the treatment plan on the claim form, explaining what work is to be done and indicating that this is a predetermination estimate. Have your dentist send the form to the Claims Administrator. The Claims Administrator will send your dentist a Notice of Predetermination which estimates how much of the treatment costs will be paid by the Preventive PPO option and how much you will have to pay. A predetermination does not guarantee payment. Computations are estimates only and are based on what would be payable on the date the Notice of Predetermination is issued (maximums or coordination of benefits notwithstanding). Payment will depend on your eligibility; whether treatment is NECESSARY; how much of your maximum is left when the predetermination estimate is submitted; and what the primary carrier paid (in those instances where coordination of benefits is necessary). Although the predetermination of benefits procedure is not required, it is advisable as a means of estimating costs and potential benefits. This is especially important for out-of-network procedures or services because out-of-network reimbursement is based on reasonable and customary charges. If you have any questions about a predetermination, contact the Claims Administrator before treatment begins. ELIGIBLE PREVENTIVE DENTAL PPO SERVICES To be considered for reimbursement, a dental service must meet all of the following criteria: It must be provided or performed by a DENTIST (or for some treatments, such as teeth cleaning, by a licensed dental hygienist working under the dentist s supervision). It must be for NECESSARY dental care. The charge must fall within the REASONABLE AND CUSTOMARY range for that particular service or supply. 20 Dental Program Benefits Effective January 1, 2015 TURNER

21 It has to be a covered expense. You or your dependent must be enrolled in the PROGRAM at the time COVERED CHARGES are incurred. Preventive, Diagnostic and Therapeutic Services There is no DEDUCTIBLE for preventive, diagnostic and therapeutic services and supplies. These services include most types of treatment for common dental problems. The Preventive PPO OPTION pays 100% of the REASONABLE AND CUSTOMARY charge for the following: Routine oral exams (two times in any calendar year), Cleaning and scaling of teeth (two times in any calendar year), Bitewing X-rays (two sets in any calendar year up to age 19, one set per calendar year thereafter), Complete dental X-ray series, including bitewings, if NECESSARY, or panoramic film but not more than one full mouth X-ray or series in any five-year period and not more than one set of supplementary bitewing X-rays in any calendar year, Laboratory tests to diagnose a condition needing treatment or to check the progress of treatment, Topical fluoride applications for dependent children under age 19 (twice in any calendar year), Topical application of sealants for dependent children under age 19, provided the sealant is applied only to nondecayed first and second molars; sealant benefits do not include the repair or replacement of a sealant on any tooth within three years of its application, Space maintainers and their fittings (includes all adjustments within six months after installation), and Emergency treatment to relieve pain (palliative treatment). Basic Restorative Services The Preventive PPO option covers most types of treatment for basic dental problems. Once you have satisfied the annual DEDUCTIBLE, the Preventive PPO OPTION pays 80% of the REASONABLE AND CUSTOMARY charge for the following: Extraction of teeth for dental conditions, Dental Program Benefits Effective January 1, 2015 TURNER 21

22 Oral surgery for dental conditions (oral surgery for medical conditions may be covered under a medical PROGRAM), General anesthetics when NECESSARY for oral surgery, periodontic treatment, fractures or dislocations, Fillings (amalgam, silicate, plastic, synthetic porcelain and composite filling restorations to restore diseased or fractured teeth), Endodontic treatment, including root canal therapy, Periodontic treatment of the gums, tissues and bones supporting the teeth (once every 24 months), Periodontal surgery (once every 36 months), Four periodontal dental maintenance exams per calendar year after active periodontal therapy, including two prophylaxis, for a total of four per year, Repairing or recementing crowns, inlays, onlays, bridgework or dentures, Injectable antibiotics administered by a licensed DENTIST or physician, and Rebasing or relining dentures that are more than six months old (not more than once every 36 months; if the Program pays for a new denture, it will not pay to rebase or reline the old denture). Major Services The Preventive PPO option covers most types of treatment for extensive dental problems. Once you have satisfied the annual DEDUCTIBLE, the Preventive PPO OPTION pays 50% of the REASONABLE AND CUSTOMARY charge for the following: Charges in connection with implants and any prosthetic appliances attached to such implants, up to the allowance for the covered standard procedure or appliance, Installation of fixed bridgework (including inlays and crowns or abutments) or initial installation of partial or full removable dentures (including any adjustments during the six-month period following installation) to replace missing natural teeth, Inlays, onlays, gold fillings or crowns needed to repair or restore decayed or fractured teeth that cannot be otherwise restored with amalgam, silicate or plastic, 22 Dental Program Benefits Effective January 1, 2015 TURNER

23 Replacement of crowns more than five years old unless earlier replacement is considered appropriate by the CLAIMS ADMINISTRATOR, Replacement of an existing partial or full removable denture or fixed bridgework more than ten years old unless earlier replacement is considered appropriate by the Claims Administrator, Adding teeth to fixed bridgework or partial dentures (to replace missing natural teeth) when considered appropriate by the Claims Administrator, and Appliance for treatment of temporomandibular joint dysfunction (TMJD), but not orthotic braces. Predetermination of benefits for TMJD treatment is strongly recommended. Orthodontia Services The Preventive PPO option does not cover orthodontia services. What s Not Covered Like all plans of this type, there are certain dental expenses that do not qualify for coverage. The following is a partial list of expenses not covered by the PROGRAM; you may obtain a complete list of ineligible expenses by contacting the CLAIMS ADMINISTRATOR. Charges for preparing medical reports, itemized bills or claim forms, Mailing, shipping or handling expenses, Charges for broken appointments or telephone calls, Charges for any sales or other tax, Charges for services and supplies that exceed Program limits, Charges for services for which no charge would be made if no other coverage existed, or for which there is no cost to the person receiving them, Charges for services in excess of REASONABLE AND CUSTOMARY levels, Charges for services rendered or for treatments started before the effective date of coverage, Dental Program Benefits Effective January 1, 2015 TURNER 23

24 Charges that are payable by another group medical or dental program, subject to coordination of benefits rules, Charges you are not legally required to pay, Cosmetic dentistry or reconstructive surgery or treatment, except expenses for surgery or treatment required to correct damage caused by accidental injury sustained while coverage is in effect, Crowns and restorations for periodontal splinting, Crowns, restorations and fillings other than those specifically listed under Basic Restorative Services on page 16, Expenses for replacement of lost or stolen dentures, Facings or veneers on false molars or molar crowns, General anesthetics unless required because of oral surgery, periodontal treatment, fracture or dislocation, Instruction or training in dental hygiene or diet care, Methods of treatment considered to be experimental in nature, Orthotic braces for mandibular repositioning, Replacement of a bridge, denture, gold restoration or implants and any prosthetic appliance attached to the implants within ten years of their original installation, Replacement of a crown less than five years old, unless earlier replacement is considered appropriate by the Claims Administrator, sealants, except as described under Preventive, Diagnostic and Therapeutic Services on page 15, Services covered by Workers Compensation or similar legislation, Services furnished for or by the U.S. Government, or any other government, that results in no charge for the treatment provided, Services provided at no cost or when received as a result of legal action or settlement, Services, supplies or treatment furnished solely because of the setting if the service, supply or treatment could safely and adequately be furnished in a physician s or DENTIST s office or other less costly setting, Telephone consultations, 24 Dental Program Benefits Effective January 1, 2015 TURNER

25 Treatment other than by a dentist or physician unless performed under their supervision and direction; however, scaling or cleaning of teeth and topical application of fluoride may be performed by a licensed dental technician under the direction of a dentist or physician, Treatment received in government hospitals or a hospital where payment is not required, Treatment, services and supplies (including prescription drugs) that are unlawful where the person resides when the expenses are incurred, and Work done or an appliance used to increase vertical dimension or for splinting or to restore occlusion. This list is not an all-inclusive list. If you have any questions about whether an expense is covered, please contact the Claims Administrator. FILING CLAIMS For the PPO and Preventive PPO, you don t need claim forms for in-network services. When you visit a network provider, you pay the cost-sharing amount directly to the provider. If you receive a bill for in-network services other than for the appropriate balance, do not pay it. Immediately report the error to the CLAIMS ADMINISTRATOR. For out-ofnetwork services, claim forms are available from the Time Warner Benefits Service Center at or from the Claims Administrator. Submit all completed dental claim forms for out-of-network services directly to the Claims Administrator. Benefits are payable upon receipt of adequate proof of coverage as required by the Claims Administrator. You should submit your claim within 90 days of your date of service. Please note that the Claims Administrator will not pay claims submitted later than 12 months from the date of service. Assigning Benefits You can have the Claims Administrator pay claims to you or have payments made to your DENTIST. You are responsible for any expenses your dentist charges that are not fully reimbursed by the assigned payment sent to your dentist. Denied Claims If benefits are denied for any reason, you have the right to appeal the denial, see Appeals on page 27 for more information. Dental Program Benefits Effective January 1, 2015 TURNER 25

26 Claims for Benefits In order to receive the benefits for which you may be eligible in dental coverage under the Plan described here, you or your beneficiary may first be required to file a claim. The law allows a reasonable amount of time for: The applicable Claims Administrator to evaluate a claim directly related to determining whether you have incurred a covered expense for which benefits are payable under the PROGRAM and determining the amount of, and administering the payment of, any such benefits based on the information contained in the written claim, or The PLAN ADMINISTRATOR to evaluate a claim related to your eligibility to participate in the Plan and the Program and to evaluate a claim, other than directly related to determining whether you have incurred a covered expense for which benefits are payable under the Program, based on the information contained in the written claim. Routine requests for information regarding your benefits under the Program will not be considered benefit claims subject to the Program s claims and appeals procedures. All claims should be directed to the applicable administrator (either the Claims Administrator or the Plan Administrator) and the entire claim procedure and appeal process is handled through that administrator. If you have any questions as to which administrator you should direct your claim, please contact the Time Warner Benefits Service Center at Claims Filed with the Plan Administrator All claims that must be directed to the Plan Administrator must be filed within one year after the claimant first knew or should have known that he/she had a claim for benefits under the Program. Claims Filed with the Claims Administrator All claims that must be directed to the Claims Administrator must be filed within 12 months from the date of service. Claims Procedure The time within which your claim must be approved or denied will depend on the type of claim you file. Generally, you will be notified of the denial (in whole or in part) of your claim not later than 30 days after your claim is received, unless special circumstances require a longer period of time for reaching a decision. If a longer period of time is required, you will be notified within the original 30-day period and a single extension of up to 15 days may be utilized. If your claim did not include enough information to make a decision, you will be notified and afforded at least 45 days to provide the specified information. 26 Dental Program Benefits Effective January 1, 2015 TURNER