ASSOCIATION FOR LOS ANGELES DEPUTY SHERIFFS, INC. January 1, 2014 Prudent Buyer Dental Plan WL15047-1 114 PPO Plan Non-Std.
CERTIFICATE OF INSURANCE Anthem Blue Cross Life and Health Insurance Company 21555 Oxnard Street Woodland Hills, California 91367 This Certificate of Insurance, including any amendments and endorsements to it, is a summary of the important terms of your dental plan. It replaces any older certificates issued to you for the coverages described in the Summary of Benefits. The Group Policy, of which this certificate is a part, must be consulted to determine the exact terms and conditions of coverage. Your employer will provide you with a copy of the Group Policy upon request. Your dental care coverage is insured by Anthem Blue Cross Life and Health Insurance Company (Anthem Blue Cross Life and Health). The following pages describe your health care benefits and includes the limitations and all other policy provisions which apply to you. The insured person is referred to as you or your, and Anthem Blue Cross Life and Health as we, us or our. All italicized words have specific policy definitions. These definitions can be found in the DEFINITIONS section of this certificate.
COMPLAINT NOTICE Should you have any complaints or questions regarding your dental coverage, and this certificate was delivered by a broker, you should first contact the broker. You may also contact us at: Anthem Blue Cross Life and Health Insurance Company Customer Service 21555 Oxnard Street Woodland Hills, CA 91367 818-234-2700 or ASSOCIATION FOR LOS ANGELES DEPUTY SHERIFFS, INC. Benefit Services Division 828 W. Washington Blvd. Los Angeles, CA 90015 If the problem is not resolved, you may also contact the California Department of Insurance at: California Department of Insurance Claims Service Bureau, 11th Floor 300 South Spring Street Los Angeles, California 90013 1-800-927-HELP (4357) In California 1-213-897-8921 Out of California 1-800-482-4833 Telecommunication Device for the Deaf E-mail Inquiry: Consumer Services link at www.insurance.ca.gov
Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY PRUDENT BUYER DENTAL PLAN An insured person enrolled in this dental plan must also be enrolled in the Anthem Blue Cross HMO medical plan or in the Prudent Buyer medical plan, offered under the Agreements between ALADS and Anthem. This dental plan is insured by Anthem Blue Cross Life and Health Insurance Company, with administrative services provided by Anthem Blue Cross.
TABLE OF CONTENTS TYPES OF PROVIDERS... 1 SUMMARY OF BENEFITS... 2 DENTAL BENEFITS... 2 YOUR DENTAL BENEFITS... 4 HOW MAXIMUM ALLOWED AMOUNT IS DETERMINED... 4 DENTAL DEDUCTIBLES AND BENEFIT MAXIMUMS... 5 DENTAL CONDITIONS OF SERVICE... 6 DENTAL CARE THAT IS COVERED... 7 DENTAL CARE THAT IS NOT COVERED... 8 REIMBURSEMENT FOR ACTS OF THIRD PARTIES... 12 COORDINATION OF BENEFITS... 13 HOW COVERAGE BEGINS AND ENDS... 16 HOW COVERAGE BEGINS... 16 HOW COVERAGE ENDS... 24 CONTINUATION OF COVERAGE... 27 EXTENSION OF BENEFITS... 32 GENERAL PROVISIONS... 32 INDEPENDENT MEDICAL REVIEW OF DENIALS OF EXPERIMENTAL OR INVESTIGATIVE TREATMENT... 37 INDEPENDENT MEDICAL REVIEW OF GRIEVANCES INVOLVING A DISPUTED HEALTH CARE SERVICE... 39 BINDING ARBITRATION... 41 DEFINITIONS... 42 MAXIMUM ALLOWABLE CHARGE SCHEDULE... 45 COMPLAINT NOTICE...Inside Back Cover WL15047-1 114 PPO Plan Non-Std.
TYPES OF PROVIDERS PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS DENTAL CARE MAY BE OBTAINED. Participating Dentists. Anthem Blue Cross Life and Health has established a network of various types of "Participating Dentists". These dentists are called "participating" because they have agreed to participate in our preferred dentist organization network (PPO), which we call the Prudent Buyer Plan. Participating dentists have agreed to a rate they will accept as reimbursement for covered services. The amount of benefits payable under this plan will be different for non-participating dentists than for participating dentists. We publish a directory of Participating Dentists. You can get a directory from the ALADS Benefit Hotline by calling 1-800-842-6635. Non-Participating Dentists. Non-participating dentists are dentists which have not signed any contract with us and are not in our Prudent Buyer Plan network. The maximum allowed amount payable under this plan will be different for non-participating dentists than for participating dentists. 1
SUMMARY OF BENEFITS THE BENEFITS OF THIS CERTIFICATE ARE PROVIDED ONLY FOR THOSE SERVICES THAT ARE MEDICALLY NECESSARY. THE FACT THAT YOUR DENTIST PRESCRIBES OR ORDERS A SERVICE DOES NOT, IN ITSELF, MEAN THAT THE SERVICE IS A MEDICALLY NECESSARY SERVICE OR THAT THE SERVICE IS COVERED. CONSULT YOUR BOOKLET OR TELEPHONE US AT THE NUMBER SHOWN ON YOUR IDENTIFICATION CARD IF YOU HAVE ANY QUESTIONS REGARDING WHETHER SERVICES ARE COVERED. This summary provides a brief outline of your benefits. You need to refer to the entire certificate for complete information about the benefits, conditions, limitations and exclusions of your plan. Second Opinions. If you have a question about your dental condition or about a plan of treatment which your dentist has recommended, you may receive a second dental opinion from another dentist. This second opinion visit will be provided according to the benefits, limitations, and exclusions of this plan. If you wish to receive a second dental opinion, remember that greater benefits are provided when you choose a participating dentist. You may also ask your dentist to refer you to a participating dentist to receive a second opinion. All benefits are subject to coordination with benefits under certain other plans. The benefits of this plan may be subject to the REIMBURSEMENT FOR ACTS OF THIRD PARTIES section. DENTAL BENEFITS DENTAL DEDUCTIBLES (per calendar year) Insured Person Deductible... $50 Family Deductible... $150 Exception: The Dental Deductible does not apply to Diagnostic and Preventive Services. PAYMENT RATES After the Dental Deductible has been satisfied, we will pay the percentage of the maximum allowed amount shown below, for the type of services received, up to the Dental Benefit Maximum: Participating Dentists Diagnostic & Preventive Services... 100% 2
Restorative Services... 90% Oral Surgery... 90% Endodontic Services... 90% Periodontic Services... 60% Prosthodontic Services (Fixed & Removable)... 60% Orthodontic Services... 50% Non-Participating Dentists Diagnostic & Preventive Services... 100% Restorative Services... 85% Oral Surgery... 85% Endodontic Services... 85% Periodontic Services... 50% Prosthodontic Services (Fixed & Removable)... 50% Orthodontic Services... 50% DENTAL BENEFIT MAXIMUMS Calendar Year Maximum... $1,500 Orthodontic Lifetime Maximum... $1,500 3
YOUR DENTAL BENEFITS We will pay the maximum allowed amount for covered dental charges you incur while covered under this plan, subject to all terms, conditions, limitations and exclusions specified in this certificate. HOW MAXIMUM ALLOWED AMOUNT IS DETERMINED This section describes how the amount of reimbursement for covered services or supplies is determined. Reimbursement for dental services rendered by participating and non-participating dentists is based on this plan s maximum allowed amount for the covered service or supply you receive. The maximum allowed amount for this plan is the maximum amount of reimbursement we will allow for services and supplies: That meet the requirements under YOUR DENTAL BENEFITS, to the extent such services and supplies are covered under your plan and are not excluded; That are medically necessary; and That are provided in accordance with all applicable utilization review or other requirements set forth in your plan. Participating dentists have agreed not to charge you more than the maximum allowed amount. When you choose a participating dentist, you will not be responsible for any amount in excess of the maximum allowed amount for the covered services of a participating dentist. Your share of the cost of your dental care may be greater if you choose a non-participating dentist. You will be responsible for any billed charge which exceeds the maximum allowed amount for services provided by a non-participating dentist. Important: If you decide to receive dental services that are not covered under this plan, a participating dentist may charge you his or her usual and customary rate for those services. Prior to providing you with dental services that are not a covered benefit, the dentist should provide a treatment plan that includes each anticipated service to be provided and the estimated cost of each service. If you would like more information about the dental services that are covered under this plan, please call us at the customer service telephone number listed on your ID card. To fully understand your coverage under this plan, please carefully review this Certificate of Insurance document. 4
DENTAL DEDUCTIBLES AND BENEFIT MAXIMUMS After we subtract the Dental Deductible from the total maximum allowed amount, we will pay benefits which apply to such expense, up to the applicable Dental Benefit Maximums. The Deductible amount, Payment Rates, and Dental Benefit Maximums are set forth in the SUMMARY OF BENEFITS. DENTAL DEDUCTIBLES Only charges for covered services will apply toward satisfaction of the Dental Deductible. Insured Person Deductible. Each calendar year, you will be responsible for satisfying the Insured Person Deductible before we begin to pay benefits under the plan. You are not required to satisfy your Dental Deductible before we will pay dental benefits for Diagnostic and Preventive Services. Covered dental charges incurred during the last quarter of any year and applied toward the Dental Deductible for that year, also counts toward the Dental Deductible for the next year. Family Deductible. If enrolled members of a family pay Deductible expense during a calendar year, equal to the Family Deductible amount shown in the SUMMARY OF BENEFITS, then the Dental Deductible for all insured family members is considered to have been met. No further Dental Deductible is required for the remainder of the year. DENTAL BENEFIT MAXIMUMS Calendar Year Maximum. Your benefits, excluding orthodontics, are subject to the Calendar Year Maximum shown in the SUMMARY OF BENEFITS. We will not pay any benefit in excess of that amount for covered dental charges incurred during a calendar year for each insured person. Also, all payments are subject to any waiting periods and limitations specified in this certificate. Orthodontic Lifetime Maximum. Your orthodontic benefits are subject to the Orthodontic Lifetime Maximum shown in the SUMMARY OF BENEFITS. We will not pay any orthodontic benefits in excess of that amount during an insured person s lifetime. 5
DENTAL CONDITIONS OF SERVICE The following conditions of service must be met in order for the expense incurred to be covered. 1. You must incur this expense while you are covered for dental benefits under this plan. Expense is incurred on the date you receive the service or supply for which the charge is made. 2. The service must be provided by a licensed dentist, physician, or dental hygienist and must be for preventive care or for treatment of dental disease, defect or injury. 3. The expense must be incurred for a dental service or supply that is included under DENTAL CARE THAT IS COVERED. Additional limits are included under specific benefits in the SUMMARY OF BENEFITS. 4. The expense must not be for a dental service or supply listed under DENTAL CARE THAT IS NOT COVERED. If the service or supply is partially excluded, then only that portion which is not excluded will be covered. 5. The expense must not exceed any of the maximum benefits or limitations of this plan. 6. If we determine that more than one treatment plan would be considered medically necessary for a dental condition, any amount exceeding the cost of the least expensive professionally acceptable treatment plan is not covered. PRE-TREATMENT REVIEW If your dentist anticipates the expense for any course of treatment to exceed $300, you MUST submit a request for a pre-treatment benefit estimation form, which should be prepared by your dentist before any treatment begins. We will review this request and send a copy of our response to the insured person and the dentist. If you or your dentist disagree with a pre-treatment review decision, you or your dentist may request reconsideration. Any requests for reconsideration (either by telephone or in writing) must be directed to the address and the telephone number included on your written copy of our response. 6
WAITING PERIODS There are waiting periods which apply to some of the services listed in YOUR DENTAL BENEFITS: DENTAL CARE THAT IS COVERED. Benefits will not be provided until the waiting periods listed below are met: Prosthodontics and Periodontics. You must be enrolled for dental benefits under this plan for 12 consecutive months to be eligible for benefits for removable or fixed prosthodontics, including inlays and crowns, or for periodontic services. Missing Teeth. You must be enrolled for dental benefits under this plan for 12 consecutive months to be eligible for benefits for partial dentures, complete dentures, or fixed bridges to replace teeth which were missing prior to the effective date of your coverage for dental benefits. Exception: These waiting periods will not apply to any insured person who was covered under a County of Los Angeles sponsored group dental plan immediately before the effective date of coverage of this plan. DENTAL CARE THAT IS COVERED Each of the following services or supplies is covered subject to DENTAL CONDITIONS OF SERVICE, provided it meets the requirements explained under HOW COVERED DENTAL EXPENSE IS DETERMINED, and is not for, or in connection with, an exclusion or limitation listed under DENTAL CARE THAT IS NOT COVERED. Diagnostic and Preventive Services Examinations X-rays Teeth cleaning and fluoride application Restorative Services Fillings Oral Surgery Extractions of teeth and minor oral surgery. (General anesthesia will be covered with the oral surgery if determined to be medically necessary.) Endodontic Services Root canal therapy 7
Treatment to prevent or correct conditions that affect the tooth pulp, root and related tissue Periodontic Services Scaling and other procedures to prevent or treat diseases or defects to your gums Prosthodontic Services (Fixed and Removable) Preparation and installation of bridges Crowns attached to a bridge Crowns not attached to a bridge Preparation and installation of partial or complete dentures (including repairs) Cast restorations, porcelain inlays Orthodontic Services One case per lifetime Consultation All adjustments All retainers 24 months of active orthodontic treatment Subject to the Orthodontic Lifetime Maximum shown in the SUMMARY OF BENEFITS DENTAL CARE THAT IS NOT COVERED No payment will be made under YOUR DENTAL BENEFITS for expense incurred for, or in connection with, any of the items below. (The titles given to these exclusions and limitations are for ease of reference only; they are not meant to be an integral part of the exclusions and limitations and do not modify their meaning.) Services Provided Before or After the Term of This Coverage. Services received before your effective date or during an inpatient hospital stay that began before your effective date. Services received after your coverage ends, except as specifically stated under EXTENSION OF BENEFITS. 8
Experimental or Investigative Procedures. Any procedures which are considered experimental or investigative or which are not widely accepted as proven and effective procedures within the organized dental community. Medically Necessary. Any services or supplies which are not medically necessary. (See DEFINITIONS.) Workers' Compensation. Any work-related conditions if benefits are recovered or can be recovered, either by adjudication, settlement or otherwise under any workers' compensation, employer's liability law or occupational disease law, even if you did not claim those benefits. Government Programs. Services provided by, or payment made by, any local, state, county or federal government agency including Medicare and any foreign government agency. No Charge Services. Services received for which no charge is made to you or for which no charge would be made to you in the absence of insurance coverage. Results Of War. Disease contracted or injuries sustained as a result of war, declared or undeclared or from exposure to nuclear energy, whether or not the result of war. Provider Related To Insured Person. Professional services received from a person who lives in your home or who is related to you by blood or marriage. Excess Expense. Any amounts in excess of the maximum allowed amount or the Dental Benefit Maximums. Professionally Acceptable Treatment. If more than one treatment plan would be considered medically necessary for a dental condition, any amount exceeding the cost of the least expensive professionally acceptable treatment plan is not covered. Transfer Of Care. If you transfer from the care of one dentist to another dentist during the course of treatment, or if more than one dentist renders services for one dental procedure, we shall be liable only for the amount for which we would have been liable if one dentist had rendered the services. Hospital Charges. Hospital costs and any additional charges by the dentist for hospital treatment. Services Not Included as a Covered Procedure. Services not included under DENTAL CARE THAT IS COVERED unless they are similar in nature to an included procedure; in such event the benefit payable will be based on the most nearly comparable services included. 9
Treatment By An Unlicensed Dentist. Charges for treatment by other than a licensed dentist or physician, except charges for dental prophylaxis performed by a licensed dental hygienist under the supervision and direction of a dentist. Treatment of the Joint of the Jaw. Diagnosis or treatment by any method of any condition related to the jaw joint (temporomandibular joint) or associated musculature, nerves and other tissues. Vertical Dimension and Attrition. Procedures requiring appliances or restorations (other than those for replacement of structure lost due to dental decay) that are necessary to alter, restore or maintain occlusion. These include but are not limited to: Changing the vertical dimension Replacing or stabilizing tooth structure lost by attrition, abrasion, or erosion Realignment of teeth Gnathological recording Occlusal equilibration Periodontal splinting Prosthetic Replacements. Replacement of fixed or removable prosthesis for which benefits were paid, if replacement occurs within five years of the original placement, unless the prosthesis is a stayplate used during the healing period for recently extracted anterior teeth. Crown Replacements. Replacement of crowns and cast restorations including porcelain crowns and inlays for which benefits were paid by Anthem Blue Cross Life and Health or an affiliated company, if replacement occurs within five years of the original placement. Denture Repairs, Adjustments or Relines. Repairs, adjustments or relines of full or partial dentures or other prosthesis are not covered for a period of six months from the initial placement if they were paid for under this plan. Lost or Stolen Dentures or Appliances. Replacement of existing full or partial dentures or prosthetic appliances which have been lost or stolen if replacement occurs within five years of the original placement. Prosthetics (patients under sixteen years old). Fixed bridges, removable cast partials, cast crowns, with or without veneers, and inlays for patients under sixteen years old. 10
Implants. Implants (materials implanted into or on bone or soft tissue), or the removal of implants. However, if implants are provided in connection with a covered prosthetic appliance, we will allow the cost of a standard complete or partial denture, or a bridge, toward the cost of the implants and the prosthetic appliances. Malignancies and Neoplasms. Services for treatment of malignancies and neoplasms. Cosmetic Dentistry. Any services performed for cosmetic purposes, unless they are for correction of functional disorders or as a result of an accidental injury occurring while you were covered for dental benefits under this plan. Congenital or Developmental Malformation. Services to correct a congenital or developmental malformation including but not limited to cleft palate, maxillary and mandibular (upper and lower jaw) malformations, enamel hypoplasia (lack of development), fluorosis (discoloration of the teeth), and anodontia (congenitally missing teeth). X-rays. More than one set of full-mouth X-rays or its equivalent in a three-year period. Oral Exams. Oral exams are limited to two per calendar year. Prophylaxis or Periodontal Prophylaxis. Prophylaxis or periodontal prophylaxis treatments exceeding two treatments in a calendar year. Periodontal prophylaxis must be preceded by active periodontal treatment, such as scaling and root planing or osseous (gum) surgery. Sealants. Sealants are limited to children under 16 years of age for permanent molars, unrestored. Treatment is limited to once every thirty six (36) months per tooth. Prescription Drugs and Medications. Any prescribed drugs, premedication or analgesia. Oral Hygiene. Oral hygiene instruction. ORTHODONTIC CARE THAT IS NOT COVERED Myofunctional Therapy. Myofunctional therapy and related services. (Myofunctional therapy involves the use of muscle exercises as an adjunct to orthodontic mechanical correction of malocclusion.) Surgical Procedures Incidental to Orthodontic Treatment. Surgical procedures incidental to orthodontic treatment including, but not limited to, extraction of teeth solely for orthodontic reasons, exposure of impacted teeth, correction of micrognathia or macrognathia, or repair of cleft palate. 11
Orthodontic Services Provided Before or After the Term of Your Coverage. Orthodontic treatment received prior to your effective date or after the termination of your coverage. TMJ or Hormonal Imbalance Orthodontic Services. Orthodontic treatment related to temporomandibular joint disturbances (TMJ) and/or hormonal imbalance. Orthodontic Records. Orthodontic records including, but not limited to, cephalometric tracing, photographs, study models and diagnostic radiographs. REIMBURSEMENT FOR ACTS OF THIRD PARTIES Under some circumstances, an insured person may need services under this plan for which a third party may be liable or legally responsible by reason of negligence, an intentional act or breach of any legal obligation. In that event, we will provide the benefits of this plan subject to the following: 1. We will automatically have a lien, to the extent of benefits provided, upon any recovery, whether by settlement, judgment or otherwise, that you receive from the third party, the third party's insurer, or the third party's guarantor. The lien will be in the amount of benefits we paid under this plan for the treatment of the illness, disease, injury or condition for which the third party is liable, but, not more than the amount allowed by California Civil Code Section 3040. 2. You must advise us in writing, within 60 days of filing a claim against the third party and take necessary action, furnish such information and assistance, and execute such papers as we may require to facilitate enforcement of our rights. You must not take action which may prejudice our rights or interests under your plan. Failure to give us such notice or to cooperate with us, or actions that prejudice our rights or interests will be a material breach of this plan and will result in your being personally responsible for reimbursing us. 3. We will be entitled to collect on our lien even if the amount you or anyone recovered for you (or your estate, parent or legal guardian) from or for the account of such third party as compensation for the injury, illness or condition is less than the actual loss you suffered. 12
COORDINATION OF BENEFITS If you are covered by more than one group dental plan, your benefits under This Plan will be coordinated with the benefits of those Other Plans, as shown below. These coordination provisions apply separately to each insured person, per calendar year, and are largely determined by California law. DEFINITIONS The meanings of key terms used in this section are shown below. Whenever any of the key terms shown below appear in these provisions, the first letter of each word will be capitalized. When you see these capitalized words, you should refer to this Definitions provision. Allowable Expense is any necessary, reasonable and customary item of expense which is at least partially covered by at least one Other Plan covering the person for whom claim is made. When a Plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service rendered will be deemed to be both an Allowable Expense and a benefit paid. Other Plan is any of the following: 1. Group, blanket or franchise insurance coverage; 2. Group service plan contract, group practice, group individual practice and other group prepayment coverages; 3. Group coverage under labor-management trusteed plans, union benefit organization plans, employer organization plans, employee benefit organization plans or self-insured employee benefit plans. The term "Other Plan" refers separately to each agreement, policy, contract, or other arrangement for services and benefits, and only to that portion of such agreement, policy, contract, or arrangement which reserves the right to take the services or benefits of other plans into consideration in determining benefits. Principal Plan is the plan which will have its benefits determined first. This Plan is that portion of this plan which provides benefits subject to this provision. EFFECT ON BENEFITS This provision will apply in determining a person s benefits under This Plan for any calendar year if the benefits under This Plan and any Other Plans, exceed the Allowable Expenses for that calendar year. 13
1. If This Plan is the Principal Plan, then its benefits will be determined first without taking into account the benefits or services of any Other Plan. 2. If This Plan is not the Principal Plan, then its benefits may be reduced so that the benefits and services of all the plans do not exceed Allowable Expense. 3. The benefits of This Plan will never be greater than the sum of the benefits that would have been paid if you were covered under This Plan only. ORDER OF BENEFITS DETERMINATION The following rules determine the order in which benefits are payable: 1. A plan which has no Coordination of Benefits provision pays before a plan which has a Coordination of Benefits provision. 2. A plan which covers you as an insured member pays before a plan which covers you as a dependent. 3. For a dependent child covered under plans of two parents, the plan of the parent whose birthday falls earlier in the calendar year pays before the plan of the parent whose birthday falls later in the calendar year. But if one plan does not have a birthday rule provision, the provisions of that plan determine the order of benefits. Exception to Rule 3: For a dependent child of parents who are divorced or separated, the following rules will be used in place of Rule 3: a. If the parent with custody of that child for whom a claim has been made has not remarried, then the plan of the parent with custody that covers that child as a dependent pays first. b. If the parent with custody of that child for whom a claim has been made has remarried, then the order in which benefits are paid will be as follows: i. The plan which covers that child as a dependent of the parent with custody. ii. The plan which covers that child as a dependent of the stepparent (married to the parent with custody). iii. The plan which covers that child as a dependent of the parent without custody. iv. The plan which covers that child as a dependent of the stepparent (married to the parent without custody). 14
c. Regardless of a and b above, if there is a court decree which establishes a parent's financial responsibility for that child s health care coverage, a plan which covers that child as a dependent of that parent pays first. 4. The plan covering you as a laid-off or retired employee or as a dependent of a laid-off or retired employee pays after a plan covering you as other than a laid-off or retired employee or the dependent of such a person. But, if either plan does not have a provision regarding laid-off or retired employees, provision 6 applies. 5. The plan covering you under a continuation of coverage provision in accordance with state or federal law pays after a plan covering you as an employee, a dependent or otherwise, but not under a continuation of coverage provision in accordance with state or federal law. If the order of benefit determination provisions of the Other Plan do not agree under these circumstances with the order of benefit determination provisions of This Plan, this rule will not apply. 6. When the above rules do not establish the order of payment, the plan on which you have been enrolled the longest pays first unless two of the plans have the same effective date. In this case, Allowable Expense is split equally between the two plans. OUR RIGHTS UNDER THIS PROVISION Responsibility For Timely Notice. We are not responsible for coordination of benefits unless timely information has been provided by the requesting party regarding the application of this provision. Reasonable Cash Value. If any Other Plan provides benefits in the form of services rather than cash payment, the reasonable cash value of services provided will be considered Allowable Expense. The reasonable cash value of such service will be considered a benefit paid, and our liability reduced accordingly. Facility of Payment. If payments which should have been made under This Plan have been made under any Other Plan, we have the right to pay that Other Plan any amount we determine to be warranted to satisfy the intent of this provision. Any such amount will be considered a benefit paid under This Plan, and such payment will fully satisfy our liability under this provision. Right of Recovery. If payments made under This Plan exceed the maximum payment necessary to satisfy the intent of this provision, we have the right to recover that excess amount from any persons or organizations to or for whom those payments were made, or from any insurance company or service plan. 15
ELIGIBLE STATUS HOW COVERAGE BEGINS AND ENDS HOW COVERAGE BEGINS 1. Insured Members. You are eligible to enroll as an insured member if you are covered under an Anthem Blue Cross medical plan and if you are one of the following: a. An active, full-time peace officer employed by the County of Los Angeles who is eligible to be a member of the Association for Los Angeles Deputy Sheriffs, Inc. b. An active, full-time lifeguard employed by the County of Los Angeles. c. An active, full-time County Police Officer or Coroner Investigator employed by the County of Los Angeles. d. An active, full-time County Police Supervisory or Supervising Coroner Investigator employed by the County of Los Angeles. e. An active, full-time employee in Bargaining Unit 614 or 621 employed by the County of Los Angeles. f. An active, full-time employee in Bargaining Unit 701 employed by the County of Los Angeles. g. An active, full-time peace officer employed by the City of San Diego who is eligible to be a member of the San Diego Police Officers Association. As used above, County of Los Angeles employees are considered to be active employees if they consecutively earn their benefit contribution for the current month by being in a continuous pay status for at least 8 hours during the prior month. 2. Family Members. The following are eligible to enroll as family members: (a) Either the insured member s spouse or domestic partner; and (b) A child. Definition of Family Member 1. Spouse is the insured member s spouse under a legally valid marriage. 2. Domestic partner is the insured member s domestic partner under a legally registered and valid domestic partnership. 16
For a domestic partnership, other than one that is legally registered and valid, in order for the insured member to include their domestic partner as a family member, the insured member and domestic partner must meet the following requirements: a. Both persons have a common residence. b. Neither person is married to someone else nor a member of another domestic partnership with someone else that has not been terminated, dissolved, or adjudged a nullity. c. The two persons are not related by blood in a way that would prevent them from being married to each other in California, or if they reside in another state or commonwealth, that state or commonwealth; d. Both persons are at least 18 years of age. e. Both persons are capable of consenting to the domestic partnership. f. Both partners must provide the group with a signed, notarized, affidavit certifying they meet all of the requirements set forth in 2.a through 2.e above, inclusive. As used above, "have a common residence" means that both domestic partners share the same residence. It is not necessary that the legal right to possess the common residence be in both of their names. Two people have a common residence even if one or both have additional residences. Domestic partners do not cease to have a common residence if one leaves the common residence but intends to return. 3. Child is the insured member s, spouse s or domestic partner s natural child, stepchild, legally adopted child, or a child for whom the insured member, spouse, or domestic partner has been appointed legal guardian by a court of law, subject to the following: a. The child is under 26 years of age. b. The unmarried child is 26 years of age, or older and: (i) was covered under the prior plan, was covered as a family member of the insured member under another plan or health insurer, or has six or more months of other creditable coverage, (ii) is chiefly dependent on the insured member, spouse or domestic partner for support and maintenance, and (iii) is incapable of selfsustaining employment due to a physical or mental condition. A physician must certify in writing that the child is incapable of selfsustaining employment due to a physical or mental condition. 17
We must receive the certification, at no expense to us, within 60- days of the date the insured member receives our request. We may request proof of continuing dependency and that a physical or mental condition still exists, but not more often than once each year after the initial certification. This exception will last until the child is no longer chiefly dependent on the insured member, spouse or domestic partner for support and maintenance due to a continuing physical or mental condition. A child is considered chiefly dependent for support and maintenance if he or she qualifies as a dependent for federal income tax purposes. c. A child who is in the process of being adopted is considered a legally adopted child if we receive legal evidence of both: (i) the intent to adopt; and (ii) that the insured member, spouse or domestic partner have either: (a) the right to control the health care of the child; or (b) assumed a legal obligation for full or partial financial responsibility for the child in anticipation of the child s adoption. Legal evidence to control the health care of the child means a written document, including, but not limited to, a health facility minor release report, a medical authorization form, or relinquishment form, signed by the child s birth parent, or other appropriate authority, or in the absence of a written document, other evidence of the insured member s, the spouse s or domestic partner s right to control the health care of the child. d. A child for whom the insured member, spouse or domestic partner is a legal guardian is considered eligible on the date of the court decree (the eligibility date ). Anthem Blue Cross Life and Health must receive legal evidence of the decree. Such child must be enrolled as set forth in the "Enrollment" provision described below, or will be subject to the "Late Enrollment" requirements described in the "Effective Date" provision. ENROLLMENT Every eligible insured member must enroll within 60 days from the eligibility date. The insured member s eligibility date is the initial date of hire, promotion, appointment or reinstatement of employment with the County of Los Angeles. This initial enrollment must include any eligible family members the insured member wants to cover. The insured member must enroll newly acquired family members with the County of Los Angeles within 90 days from their eligibility date. If any of these steps are not followed, your coverage may be denied. 18
An insured person enrolled under the policy for dental care benefits must also be enrolled for medical care benefits offered under the Agreement between ALADS and Anthem or ALADS and Anthem Blue Cross HMO. An insured person cannot be enrolled under the policy for dental care benefits only. 19
EFFECTIVE DATE Your effective date of coverage is subject to the timely payment of premium charges on your behalf. If this condition has been met, the date on which you become covered is determined as follows: 1. Timely Enrollment for Newly Hired Employees. If you enroll yourself and any eligible family members for coverage within 60 days from your initial eligibility date, then your coverage will begin as follows a. For insured members, on the first day of the month following one full month of active employment from the date you file the enrollment application. b. For family members, the date the insured member s coverage begins. The family member s eligibility date is the date the insured member becomes eligible for coverage. Exceptions to the Waiting Period If, after you have completed the waiting period, you cease to be eligible due to termination of employment, and you return to an eligible status after the date your employment terminated, you will become eligible on the first day of the month following the date you return. If you were covered under the prior plan, the time you spent under the prior plan will be used to satisfy, or partially satisfy, your waiting period under this plan. 2. Timely Enrollment for Newly Acquired Family Members. If you are enrolled for coverage within 90 days from your eligibility date (e.g., marriage or domestic partnership, or the birth, adoption, or placement for adoption of a child) and if the required documentation is received by the 25th day of any month, then your coverage will begin on the first day of the following month, except for birth, adoption, placement for adoption or legal guardianship. For a newborn child, adopted child, a child placed for adoption or a child for whom the insured member, spouse or domestic partner is a legal guardian, coverage begins as of the date of birth, adoption, placement for adoption or date of the court decree. 3. Late Enrollment. If you file an enrollment application more than 60 days from your eligibility date (or 90 days for newly acquired family members), you must wait until the group s next Annual Enrollment Period to enroll. 4. Disenrollment. If you voluntarily choose to disenroll from coverage under this plan, you will be eligible to reapply for coverage as set 20
forth in the Enrollment provision above, during the next annual enrollment period (see ANNUAL ENROLLMENT PERIOD). You may enroll earlier than the next Annual Enrollment Period if you meet the condition listed under SPECIAL ENROLLMENT PERIODS. Important Note for Newborn and Newly-Adopted Children. If the insured member, spouse or domestic partner (if the spouse/domestic partner is enrolled) are already covered the following provisions will apply: 1. Any child born to the insured member, spouse or domestic partner will be covered from the moment of birth; and 2. Any child being adopted by the insured member, spouse or domestic partner will be covered from the date on which either: a. The adoptive child's birth parent, or other appropriate legal authority, signs a written document granting the insured member, spouse or domestic partner the right to control the health care of the child (in the absence of a written document, other evidence of the insured member's, spouse's or domestic partner s right to control the health care of the child may be used); or b. The insured member, spouse or domestic partner assumed a legal obligation for full or partial financial responsibility for the child in anticipation of the child s adoption. The written document referred to above includes, but is not limited to, a health facility minor release report, a medical authorization form, or relinquishment form. In both cases, coverage will be in effect for 31 days. For coverage to continue beyond this 31-day period, the insured member must enroll the child within 90 days from the date the child was born or otherwise acquired. Special Enrollment Periods You may enroll without waiting for the group s next annual enrollment period if you are otherwise eligible under any one of the circumstances set forth below: 1. You have met all of the following requirements: a. You were covered as an individual or dependent under either: i. Another employer group dental plan or dental insurance coverage, including coverage under a COBRA continuation; or 21
ii. A state Medicaid plan or under a state child health insurance program (SCHIP), including the Healthy Families Program or Access for Infants and Mothers (AIM) Program. b. Your coverage under the other dental plan wherein you were covered as an individual or dependent ended as follows: i. If the other dental plan was another employer group dental plan or dental insurance coverage, including coverage under a COBRA continuation, coverage ended because you lost eligibility under the other plan, your coverage under a COBRA continuation was exhausted, or employer contributions toward coverage under the other plan terminated. For eligible members who are County of Los Angeles employees, you must properly enroll with the group within 90 days after the date your coverage ends or the date employer contributions toward coverage under the other plan terminate. For members of the San Diego Police Officers Association, you must properly enroll with the group within 30 days after the date your coverage ends or the date employer contributions toward coverage under the other plan terminate. Loss of eligibility for coverage under an employer group dental plan or dental insurance includes loss of eligibility due to termination of employment or change in employment status, reduction in the number of hours worked, loss of dependent status under the terms of the plan, termination of the other plan, legal separation, divorce, death of the person through whom you were covered, and any loss of eligibility for coverage after a period of time that is measured by reference to any of the foregoing. ii. If the other dental plan was a state Medicaid plan or a state child health insurance program (SCHIP), including the Healthy Families Program or the Access for Infants and Mothers (AIM) Program, coverage ended because you lost eligibility under the program. You must properly enroll with the group within 60 days after the date your coverage ended. 22
2. For eligible members who are County of Los Angeles employees, a court has ordered coverage be provided for a spouse, domestic partner or dependent child under your employee dental plan and an application is filed within 90 days from the date the court order is issued. For members of the San Diego Police Officers Association, a court has ordered coverage be provided for a spouse, domestic partner or dependent child under your employee dental plan and an application is filed within 30 days from the date the court order is issued. 3. You have a change in family status through either marriage or domestic partnership, or the birth, adoption, or placement for adoption of a child: a. For eligible members who are County of Los Angeles employees, if you are enrolling following marriage or domestic partnership, you and your new spouse or domestic partner must enroll within 90 days of the date of marriage or domestic partnership. For members of the San Diego Police Officers Association, if you are enrolling following marriage or domestic partnership, you and your new spouse or domestic partner must enroll within 30 days of the date of marriage or domestic partnership. Your new spouse or domestic partner s children may also enroll at that time. Other children may not enroll at that time unless they qualify under another of these circumstances listed above. b. If you are enrolling following the birth, adoption, or placement for adoption of a child, your spouse (if you are already married) or domestic partner, who is eligible but not enrolled, may also enroll at that time. Other children may not enroll at that time unless they qualify under another of these circumstances listed above. For eligible members who are County of Los Angeles employees, application must be made within 90 days of the birth or date of adoption or placement for adoption. For members of the San Diego Police Officers Association, application must be made within 30 days of the birth or date of adoption or placement for adoption. Effective date of coverage. For enrollments during a special enrollment period as described above, coverage will be effective on the first day of the month following the date you file the enrollment application, except as specified below: 1. If a court has ordered that coverage be provided for a dependent child, coverage will become effective for that child on the earlier of (a) the first day of the month following the date you file the enrollment application or (b) within 30 days after we receive a copy 23
of the court order or of a request from the district attorney, either parent or the person having custody of the child, the employer, or the group administrator. 2. For enrollments following the birth, adoption, or placement for adoption of a child, coverage will be effective as of the date of birth, adoption, or placement for adoption. ANNUAL ENROLLMENT PERIOD The group has an annual enrollment period once each year, during the month of October. During that time, an individual who meets the eligibility requirements as an insured member under this plan may enroll. An insured member may also enroll any eligible family members at that time. Persons eligible to enroll as family members may enroll only under the insured member s plan. For anyone so enrolling, coverage under this plan will begin on the first day of January following the end of the Annual Enrollment Period. Coverage under the former plan ends when coverage under this plan begins. HOW COVERAGE ENDS Your coverage ends, without notice from us, as provided below: 1. If the policy terminates, your coverage ends at the same time. The policy may be cancelled or changed without notice to you. 2. If the group no longer provides coverage for the class of insured persons to which you belong, your coverage ends on the effective date of that change. If this policy is amended to delete coverage for family members, a family member s coverage ends on the effective date of that change. 3. Coverage for family members ends when the insured member's coverage ends. 4. Coverage ends at the end of the period for which premium has been paid to us on your behalf when the required premium for the next period is not paid. 5. Coverage for a domestic partner ends when the domestic partnership ceases to meet the eligibility requirements of a domestic partnership. If a domestic partnership ends, a new domestic partner may not be enrolled under this plan until the new domestic partnership meets the eligibility requirements. 24
6. If you voluntarily cancel coverage at any time, coverage ends on the premium due date coinciding with or following the date of voluntary cancellation, as provided by written notice to us. 7. If you no longer meet the requirements set forth in the "Eligible Status" provision of HOW COVERAGE BEGINS, your coverage ends as of the premium due date coinciding with or following the date you cease to meet such requirements. Exceptions to Item 7: a. Leave of Absence. If you are an insured member and the group pays premium to us on your behalf, your coverage may continue during a temporary leave of absence approved by the group. This time period may be extended if required by law. b. Handicapped Children. If a child reaches the age limit shown in the "Eligible Status" provision of this section, the child will continue to qualify as a family member if he or she is (i) covered under this plan, (ii) chiefly dependent on the insured member, spouse or domestic partner for support and maintenance, and (iii) incapable of self-sustaining employment due to a physical or mental condition. A physician must certify in writing that the child has a physical or mental condition that makes the child incapable of obtaining self-sustaining employment. We will notify the insured member that the child s coverage will end when the child reaches the plan s upper age limit at least 90-days prior to the date the child reaches that age. The insured member must send proof of the child s physical or mental condition within 60-days of the date the insured member receives our request. If we do not complete our determination of the child s continuing eligibility by the date the child reaches the plan s upper age limit, the child will remain covered pending our determination. When a period of two years has passed, we may request proof of continuing dependency due to a continuing physical or mental condition, but not more often than once each year. This exception will last until the child is no longer chiefly dependent on the insured member, spouse or domestic partner for support and maintenance or a physical or mental condition no longer exists. A child is considered chiefly dependent for support and maintenance if he or she qualifies as a dependent for federal income tax purposes. Note: If a marriage or domestic partnership terminates, the insured member must give or send to the group written notice of the termination. Coverage for a former spouse or domestic partners, and their dependent children, if any, ends according to the Eligible Status provisions. If Anthem Blue Cross Life and Health suffers a loss because of the insured member failing to notify the group of the termination of their marriage or 25