Dental Program Effective January 1, 2013 Introduction... 2 A Snapshot of Your Dental Coverage... 2 The CIGNA Traditional Dental Plan + PPO... 2 The Deductible... 3 Copayments... 3 Coisurance... 3 Annual and Lifetime Maximums... 3 Alternative Procedures... 3 Covered Dental Services - CIGNA Traditional Dental Plan + PPO... 4 Preventive and Diagnostic Services... 4 Basic Services... 4 Major Services... 5 Orthodontia Services... 5 Dental Expenses Not Covered CIGNA Traditional Dental Plan + PPO... 5 Exclusions... 5 Coordination of Benefits (COB)... 6 Third Party Liability... 6 When Dental Coverage Ends... 7 Employee... 7 Spouse... 7 Child... 8 COBRA Continuation Coverage... 8 Filing Claims... 8 Predetermination of Benefits... 8 If Your Claim Is Denied Appeal Procedures... 9 Defective Claims... 9 Initial Claim Review... 9 Initial Benefit Determination... 9 Review of Initial Benefit Denial... 10 Review Procedures for Denials... 10 Statute of Limitations... 12 Assignments... 12 1
Introduction There are many things you can do to protect your health. One of the easiest is to follow a regular program of dental hygiene and treatment. Research shows that dental disease; perhaps more than any other can frequently be avoided if a proper care and treatment program is followed. The PCA dental program, through its design incentives, places emphasis on preventive treatment. It also provides assistance if you require more serious, and costly, dental treatment. The way the program pays benefits depends on which dental option you choose. A Snapshot of Your Dental Coverage Here is a snapshot of your dental coverage. The items within the chart (including the types of covered services) are described in detail on the pages that follow. Provision COVERAGE CATEGORIES DENTAL OPTIONS Description Employee only; employee + spouse; employee + child(ren); employee + family CIGNA Traditional Dental Plan + PPO DEDUCTIBLE Preventive and Diagnostic (P&D), and Orthodontia Services Basic and Major Services COINSURANCE Preventive and Diagnostic (P&D) Basic Services Major Services Orthodontia ANNUAL MAXIMUM PAID BY PLAN (per covered individual) (P&D, Basic, Major) LIFETIME MAXIMUMS $0 $50 per person; $150 per family PLAN PAYS: 100% of covered expenses 80% of covered expenses after deductible 50% of covered expenses after deductible 50% of covered expenses $1,500 $1,000 per person for orthodontic services adult or child; $5,000 for periodontal services. The CIGNA Traditional Dental Plan + PPO Employees can visit any dentist they want, employees who use dentists participating in the CIGNA dental PPO network will be billed based on the discounted fees negotiated between CIGNA and the dentist. That translates to savings for the employee since employees pay 20% to 50% of eligible expense, depending on the type of services provided. Also, dentists who participate in the CIGNA PPO network may only bill patients based on CIGNA's prenegotiated rates. That means employees using PPO dentists don't need to worry about being billed for fees that are over CIGNA's reasonable and customary reimbursement limit. If want to find out if your current dentist is in the CIGNA PPO network, or if you want to locate a dentist who participates in the network, you can do so by one of two ways. 2
Go to www.cigna.com and do the following: Click on Provider Directory on the left side of the main page Select Dentist Enter dentist name to search by name or zip code to search for all dentists in that area Click Next Select Cigna Dental PPO Select a Specialty Click Search Go to http://resources.hewitt.com/pca and do the following: Click on Find a Dentist in Your Dental Plan under Dental Under Plan Option(s), choose CIGNA Traditional Dental + PPO The Deductible If you elect coverage under the CIGNA Traditional Dental Plan + PPO, you must meet an annual deductible before the plan pays benefits for covered basic, major, and orthodontia services. Covered expenses from all family members can be added together and applied toward the family deductible. Each covered individual is subject to the individual deductible until the family deductible is met, but no single family member pays more than the individual deductible in any calendar year. Once you meet the family deductible, you don t have to pay any more in deductibles for the rest of that calendar year. Copayments Copayments do not apply to the CIGNA Traditional Dental Plan + PPO option. Coinsurance Your coinsurance is the percentage of charges you pay for covered expenses. The percentage you pay depends on the option you select and the type of service you or your covered dependents receive. Annual and Lifetime Maximums If you have CIGNA Traditional Dental Plan + PPO coverage, you and your covered dependents can each receive up to a certain amount in dental plan benefits each year. In addition, there is a lifetime maximum benefit for orthodontic and periodontal services. Alternative Procedures Sometimes there is more than one way to treat a dental problem (e.g., repairing a tooth with a silver filling instead of gold). The plan always bases its definition of reasonable charges on the least costly procedure that treats the condition and meets acceptable dental standards. For a definition of Reasonable and Customary, see Glossary section of this Benefits Handbook. If you and your dentist decide that you want to pursue a more costly covered treatment, you pay the additional charges. If the plan does not cover the service you choose but covers a less costly alternate procedure, the plan does not pay benefits for the more expensive, non-covered treatment. 3
Covered Dental Services - CIGNA Traditional Dental Plan + PPO The plan pays benefits for certain dental services, including exams, fillings, X rays, and dentures. Be sure to reference the chart on page 2 for the deductible required and the percentage the plan pays for each category of service. Preventive and Diagnostic Services The plan pays benefits for reasonable and customary charges associated with the following services: Dental examinations, including diagnosis and prophylaxis, but not more than two per calendar year. Topical applications of fluoride, two per calendar year. Sealants on back teeth, one treatment per tooth every three calendar years, for children under age 14. Dental X rays. Full mouth X rays are covered once each three calendar years, and bitewing X rays are covered twice per calendar year. Emergency treatment to relieve pain, when no other definitive services are performed. Space maintainers (not for orthodontic treatment), for persons under age 19. Basic Services The plan pays benefits for reasonable and customary charges associated with the following services: Extraction of teeth and cutting procedures to the teeth and/or gums. Anesthetics administered in connection with dental surgery or other listed dental services and injections of antibiotic drugs. Periodontal treatment and treatment of other diseases of the gums and tissues of the mouth. Endodontic treatment, including root canal therapy. Fillings. Note: The plan covers gold fillings only if, in the Claims Administrator s opinion, amalgam, silicate, or plastic materials will not adequately restore the tooth. Repair or recementing of crowns, inlays, bridgework, or dentures, or rebasing of dentures. Oral surgery. Inlays and crowns. Note: The plan covers gold restorations only if, in the Claims Administrator s opinion, amalgam, silicate, or plastic materials will not adequately restore the tooth. 4
Major Services The plan pays benefits for reasonable and customary charges associated with the following services: Initial installation of complete or partial removable dentures or fixed bridgework. Replacement of a previously existing bridge, crown, or denture, but only if, according to common dental standards, it cannot be made useable, and: Denture or bridgework is needed to replace one or more natural teeth extracted while you are covered; The denture or bridgework was installed five or more years before its replacement; or The bridge, crown, or denture has been damaged because of an injury while the patient was covered by the plan. Orthodontia Services The plan pays orthodontia benefits (up to the lifetime maximum) for you and your covered dependents. The plan pays benefits for reasonable and customary charges associated with the following: Preliminary studies, including X rays, diagnostic casts, and an orthodontia treatment plan. Active treatment each month. Fixed or cemented appliances, up to one appliance per person, to guide a tooth or control harmful habits. Every three months, the plan pays benefits for covered orthodontia services. The plan makes the first payment (equal to 25% of the entire treatment) once the appliance is installed. The plan then prorates all remaining payments over the estimated length of treatment. Dental Expenses Not Covered - CIGNA Traditional Dental Plan + PPO The plan does not cover all types of dental expenses. Exclusions Here are examples of expenses the plan does not cover under the CIGNA Traditional Dental Plan + PPO option. If you have any questions about whether an expense is covered, call the Claims Administrator. Dental services provided solely for cosmetic reasons. Replacement of a lost or stolen appliance. Procedures, appliances, or restorations (except full dentures) that are primarily for changing the vertical dimension of the face, or stabilizing periodontally involved teeth. Tooth implants (except the prosthetic over the implant). Personalized dental services such as restorations to artificial teeth, precision attachments, use of magnets, or similar procedures. Any rendered dental service, including the installation, manufacture, or fitting of dental restorations (fillings, inlays, crowns, bridgework, and dentures) that was ordered or started before coverage was in force. Porcelain or acrylic veneers on or replacing the upper and lower first, second, or third molars. Instruction for plaque control, oral hygiene, or diet charged as separate services. 5
Care for injury or any sickness related to your employment and covered under Workers Compensation or similar law. Any care, services, supplies, or devices that are considered experimental or research in nature or that are not approved by the Food and Drug Administration, the American Medical Association, the American Dental Association, or the appropriate specialty society; or any drugs labeled Caution limited by Federal law to investigational use. Charges by a hospital that is owned or operated by, or that provides services to, the U.S. government when the dental condition is related to military service. Charges you are not legally required to pay or to the extent payment is unlawful. Charges that exceed reasonable and customary limits. Services that are not medically necessary. Education or training. Services for which you or a dependent is entitled to payment through a public program other than Medicaid or MediCal. Any portion of expenses payable under an auto insurance policy written to comply with no-fault insurance law or uninsured motorist law. Dental services that are deemed to be medical services. Services and supplies received from a hospital. Bite registrations, precision or semi-precision attachments, or splinting. Coordination of Benefits (COB) If you or your covered dependent has coverage from more than one group dental plan, the two coverage s will be coordinated. Coordination of benefits for this dental program works the same as for the PCA Health Care Plan as described in the Medical Program section of this Benefits Handbook. Third-Party Liability In some situations, another person or insurance company may be legally responsible for your dental expenses. This might happen, for example, if you are in an automobile accident caused by someone else. In that case, the liability for your dental expenses is the other party s, not the PCA dental programs. When this occurs, the PCA Health Care Plan, Dental Program is entitled to repayment from any settlement you receive. When you accept payment from the PCA Health Care Plan, Dental Program, you agree in writing to provide any documents that would allow PCA to recover payments it has made on your behalf, and to refund to PCA whichever is less: The third-party settlement you received; or The amount PCA s program paid. 6
When Dental Coverage Ends Employee The following chart shows when medical coverage ends in certain instances. Employment Status Coverage Ends Termination Death Total Disability (LTD) Non-FMLA Approved Personal Leave of Absence (Unpaid) FMLA Approved Leave of Absence (Unpaid) Disability Non-Occupational Leave of Absence (Paid or Unpaid) Worker s Comp Leave of Absence (Paid or Unpaid) Military Leave of Absence (Paid) Military Leave of Absence (Unpaid) Layoff The date the program is amended or terminated. PCA, the Plan sponsor, reserves the right to terminate the medical program or amend the program in such a manner that you may no longer be eligible to participate in the program; your employer may cease being a Participating Employer or the level of benefits available may be reduced. End of month End of second month following (The company pays the full cost of this continued coverage) End of month End of month Continues up to a maximum of 12 weeks (You pay the same contribution that active employees pay) Continues up to a maximum of 26 weeks (You pay the same contribution that active employees pay) Continues up to a maximum of 26 weeks (You pay the same contribution that active employees pay) Continues up to a maximum of 30 days (You pay the same contribution that active employee pay) End of third month following End of month End of month Important: An amendment or termination of the PCA Health Care Plan, Medical Program may affect not only the coverage s of active employees (and their covered dependents) but also of COBRA participants and former employees who retired, died or otherwise terminated employment. Spouse Coverage for your spouse will end the last day of the month in which the earliest of the following occurs: The date your coverage ends; The date the marriage is legally dissolved; The date your spouse is no longer enrolled for coverage; or The date your spouse enters the armed forces. 7
Child Coverage for your child will end the last day of the month in which the earliest of the following occurs: The date your coverage ends; The date your child is no longer eligible for coverage; The date your child is no longer enrolled for coverage; or The date your child enters the armed forces. If a covered person is hospitalized the day coverage ends or is reduced, full benefits for the hospitalized patient will continue until he or she is released. COBRA Continuation Coverage You and your eligible dependents may continue your dental coverage under this program, at your expense, if you terminate employment or if coverage ends for one of several reasons. This opportunity is part of a federal law called COBRA, the Consolidated Omnibus Budget Reconciliation Act. Details of COBRA coverage are provided in the Health & Welfare Benefits Overview section of this Benefits Handbook. Filing Claims CIGNA Traditional Dental Plan + PPO participants must complete a claim form to receive benefits. Here s how to file dental claims: As a non-network participant in the CIGNA Traditional Dental Plan, you receive a dental claim form with your enrollment confirmation. Feel free to make copies of this form and use the copies to file claims. If you need a claim form contact your local on-site HR representative. Complete all parts of the form (including the question about other coverage). Send the completed form, along with your bill or receipt, to the Claims Administrator for processing (the address is included on the claim form). To receive benefits, you must submit all claims by December 31 of the calendar year after the incurred expense. If you have any questions regarding a claim, call or write the Claims Administrator. As with the medical plan, you receive an Explanation of Benefits (EOB) form after you file a claim. The EOB shows whether the plan paid or denied the claim (in part or in full) and gives the reason(s) behind the decision. If you (or the patient) have primary coverage under another group plan, be sure to submit claims to the other plan first. Once you receive a statement or an Explanation of Benefits (EOB) from the other plan, submit any remaining expenses to the Claims Administrator. Predetermination of Benefits If your dentist proposes treatment that is expected to cost more than $200, you can find out what charges the plan will cover before the treatment begins. To get a predetermination, have your dentist prepare a treatment plan and submit the plan to the Claims Administrator. Within 10 to 15 business days, you will receive a notice describing how the plan will pay benefits. You should begin the treatment program within 90 days of the day you receive the notice. 8
If Your Claim Is Denied Appeal Procedures Defective Claims In the case of your failure to follow the Plan's procedures for filing a proper claim, the Claims Administrator will notify you of the failure and the proper procedures to be followed in filing a claim. The Claims Administrator will provide notice to you as soon as possible but in the case of a claim requiring prior authorization, the notice will be provided within five (5) days of receipt of the claim by the Claims Administrator. In the case of a failure to follow the proper procedures with respect to a claim involving urgent care, the notice will be provided to you within 24 hours of such receipt. Initial Claim Review The initial claim review will be conducted by the Claims Administrator, who will consider the applicable terms and provisions of the Plan and amendments to the Plan, information and evidence that is presented by you and any other information it deems relevant. Initial Benefit Determination Claim Involving Urgent Care. In the case of a claim involving urgent care, the Claims Administrator will notify you of the benefit determination (whether adverse or not) no later than 72 hours after receipt of the claim by the Claims Administrator, provided that you provide sufficient information to determine whether, and to what extent benefits are payable under the Plan. In the case of your failure to provide sufficient information to determine whether and to what extent a claim involving urgent care is covered by the Plan, the Claims Administrator will notify you within 24 hours after receipt of the claim, of the specific information necessary to complete the claim. You will be afforded a reasonable amount of time, taking into account the circumstances but in no event less than 48 hours, to provide the specified information. The Claims Administrator will notify you of the benefit determination no later than 48 hours following the earlier of (1) the Claims Administrator's receipt of the specified information or (2) the end of the period afforded you to provide the specified additional information. Concurrent Care Decision. In the case of a denial of coverage involving a course of treatment (other than by amendment or termination of the Plan) before the end of such period of time or number of treatments, the Claims Administrator will notify you of such denial at a time sufficiently in advance of the reduction or termination to allow you to appeal and obtain a determination on review of that denial before the benefit is reduced or terminated. Where you want to extend the course of treatment beyond the period of time or number of treatments and it is a claim involving urgent care, the Claims Administrator will notify you of the benefit determination, whether adverse or not, within 24 hours after receipt of the claim by the Claims Administrator (provided that any such claim is made to the Claims Administrator at least 24 hours prior to the expiration of the prescribed period of time or number of treatments). Pre-Service Claim. In the case of a claim involving prior authorization, the Claims Administrator will notify you of the benefit determination (whether adverse or not) within 15 days after receipt of the claim. The Claims Administrator may extend the period for making the benefit determination by 15 days if it determines that such an extension is due to matters beyond the control of the Plan and if it notifies you, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which the Claims Administrator expects to render a decision. 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 will be afforded at least 45 days from receipt of the notice within which to provide the specified information, and the period in which the Claims Administrator is required to make a decision will be suspended from the date on which the notification is sent to you until you adequately respond to the request for additional information. 9
Post-Service Claim. In the case of a claim filed after the medical care has been delivered, the Claims Administrator will notify you of the denial within 30 days after receipt of the claim. The Claims Administrator may extend the period for making the benefit determination by 15 days if it determines that such an extension is due to matters beyond the control of the Plan and if it notifies you, prior to the expiration of the initial 30- day period, of the circumstances requiring the extension of time and the date by which the Claims Administrator expects to render a decision. 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 will be afforded at least 45 days from receipt of the Notice within which to provide the specified information, and the period in which the Claims Administrator is required to make a decision will be suspended from the date on which the notification is sent to you until you adequately respond to the request for additional information. Manner and Content of Notification of Denied Claim. The Claims Administrator will provide you with written or electronic notice of any denial, in accordance with applicable Department of Labor regulations. The notification will set forth: the specific reason or reasons for the denial; reference to the specific provision(s) of the Plan on which the determination is based; a description of any additional material or information necessary for you to perfect the claim and an explanation of why such material or information is necessary; if an internal rule, guideline, protocol or other similar criterion was relied upon in making the denial, the notice will either (1) set forth such specific rule, guideline, protocol or other similar criterion of the Plan that was relied upon or (2) provide a statement that such rule, guideline, protocol or similar criterion was relied upon, and that a copy will be provided free of charge to you upon request; if the denial is based on a medical necessity or experimental treatment or similar exclusion or limit, the notice will provide either (1) an explanation of the scientific or clinical judgment relied upon for the determination or (2) a statement that such explanation will be provided free of charge upon request; a description of the Plan's review procedures and the time limits applicable to such procedures, and if a claim involving urgent care, of the expedited review process; and the following statement: You and your plan may have other voluntary dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your state regulatory agency. Review Of Initial Benefit Denial Procedure for Filing a Review of a Denial. Any appeal of a denial by you must be brought to the Plan Administrator within 180 days after receipt of the notice of denial. Failure to appeal within such 180-day period will be deemed to be a failure to exhaust all administrative remedies under the Plan. The appeal must be in writing utilizing the appropriate form provided by the Plan Administrator (or in such other manner acceptable to the Plan Administrator), provided, however, that if the Plan Administrator does not provide the appropriate form, no particular form is required to be utilized by you. The appeal must be filed with the Plan Administrator at the address listed in the Summary Plan Description. Review Procedures for Denials The Plan Administrator will provide a review that takes into account all comments, documents, records and other information submitted by you without regard to whether such information was submitted or considered in the initial benefit determination; You will have the opportunity to submit written comments, documents, records and other information relating to the claim; 10
You will be provided, upon request and free of charge, reasonable access to and copies of all relevant documents; The review procedure will not require more than two levels of appeals of a denial; The review of a denial will not afford deference to the initial determination made by the Plan Administrator; The individual who will conduct the review process will not be the individual who made the initial denial nor the subordinate of such individual; In deciding an appeal of any denial that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug or other item is experimental, investigational or not medically necessary or appropriate, the Plan Administrator will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. The health care professional will be an individual who was neither consulted in connection with the denial nor the subordinate of any such individual; The Plan Administrator will identify any medical or vocational experts whose advice was obtained on behalf of the Plan in connection with your denial, without regard as to whether the advice was relied upon in making the benefit determination; and In the case of a claim involving urgent care, an expedited review process will be provided. You may request an expedited appeal orally or in writing and all necessary information may be transmitted between the Plan and you by telephone, facsimile, or other available similarly expeditious method. Timing of Notification of Benefit Determination on Review. Claim Involving Urgent Care. In the case of a claim involving urgent care, the Plan Administrator will notify you of the benefit determination on review within 72 hours after receipt of your request for review. Pre-Service Claim. The Plan Administrator will notify you of the benefit determination on review within 30 days after receipt of the request for review. Post-Service Claim. The Plan Administrator will notify you of the benefit determination on review within 30 days after receipt of the request for review. Manner and Content of Notification of Benefit Determination on Review. The Plan Administrator will provide a written or electronic notice of the Plan s benefit determination on review, in accordance with applicable Department of Labor regulations. The notification will set forth: The specific reason or reasons for the denial; Reference to the specific provision(s) of the Plan on which the determination is based; A statement that you are entitled to receive, upon request and free of charge, reasonable access to and copies of all relevant documents; If an internal rule, guideline, protocol or other similar criterion was relied upon in making the denial, the notice will either (1) set forth such specific rule, guideline, protocol or other similar criterion of the Plan that was relied upon or (2) provide a statement that such rule, guideline, protocol or similar criterion was relied upon, and that a copy will be provided free of charge to you upon request; If the denial is based on a medical necessity or experimental treatment or similar exclusion or limit, either (A) an explanation of the scientific or clinical judgment relied upon for the determination or (B) a statement that such explanation will be provided free of charge upon request; and The following statement: You and your plan may have other voluntary dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your state regulatory agency. 11
External Review. To the extent required by applicable law, or to the extent provided by this Plan, you may pursue voluntary levels of appeal or dispute resolution in addition to those provided herein. Failure to pursue a voluntary level of appeal will not constitute failure to exhaust this claims and appeals procedure, all defenses of the Plan based on timeliness will be tolled during the voluntary appeal, and the voluntary appeal may only be pursued after the claims and appeals procedure set forth herein has been complied with by you in it entirety. The Plan provides one level of voluntary appeal in addition to those set forth above. If your claim is denied on appeal, you may request within 60 days of the mailing of the denial that the Plan Administrator review your situation an additional time by complying with the appeal process and submitting any additional documentation to the Plan Administrator for the Plan Administrator to review. If you choose not to pursue this voluntary level of appeal, you may proceed directly to Court. The Plan Administrator s decision on review shall be made within such time frames as set forth under the mandatory appeals process above. Statute Of Limitations No cause of action may be brought by you after you have received a final denial later than one year following the mailing date of such final denial. Assignments Regarding the assignment of your benefits to hospitals, physicians, etc., no benefit payable under the Plan will be subject in any manner to alienation, assignment, pledge, garnishment, execution or levy of any kind, either voluntary or involuntary, prior to actually being received by you or your dependents. However, at your request, payments of benefits may be made directly to any individual or entity for services performed for and on behalf of you and your covered dependents that are payable under the Plan. 12