2016 Dental Choice & Dental Choice Plus

Transcription

1 Form No A (09-15) For Office Use Only Electronic System ID Signature of Agent Date (mm/dd/yy) Agent s Name Blue Cross of Idaho No. Independent Producer (Agent) Information Health information requested or disclosed may include, but is not limited to: claims records, correspondence, medical records, billing statements, diagnostic imaging reports, laboratory reports, dental records, or hospital records (including nursing records and progress notes). An insurance carrier or group health plan. Any other institution providing care, treatment, consultation, pharmaceuticals or supplies or; A clinic, hospital, long-term care or other medical facility; A physician, dentist, pharmacist or other physical or behavioral healthcare practitioner; Health information requested or disclosed may be related to treatment or services performed by: I acknowledge and understand my health plan may request or disclose health information about me or my dependents (persons who are eligible for benefits coverage and are listed on the application) for the purpose of facilitating healthcare treatment, payment or for the purpose of business operations necessary to administer healthcare benefits; or as required by law. Spouse s Signature Date (if applying for coverage) I affirm that I have reviewed all answers given on this application and, regardless of whether an independent producer or other person has filled out the answers for me, I verify that the answers are true and complete. Applicant/Responsible Party Signature Date I understand that this application will become part of the contract between the insurance carrier and me. If this application is approved, coverage for me and any eligible persons named on this application will begin on the effective date assigned by the insurance carrier. The insurance carrier may terminate or rescind an insured s coverage for any intentional misrepresentation, omission of fact by, concerning or on behalf of any insured that was or would have been material to the insurance carrier s acceptance of a risk, extension of coverage, provision of benefits, or payment of any claim. No independent producer, agent or employee of the insurance carrier can change any part of this application or waive the requirement that I answer all questions completely and accurately. By signing this application, I represent that all my answers are complete and accurate to the best of my knowledge and belief and that I understand and agree to the following conditions: I affirm the answers in this Dental Choice/Dental Choice Plus Individual Enrollment Application are complete and correct. I am providing these answers as part of the application procedure required by this insurance carrier to enroll in its insurance coverage. I understand that the insurance carrier will rely on each answer in making its determination to extend coverage and to determine the type of coverage offered. I understand if I have made any misstatement or omission in this application, the insurance carrier may take any action available by law, including but not limited to, retroactive adjustment of premiums or claims. Further, I understand that any fraud or intentional misrepresentation of material fact in my completion of this application is cause for retroactive termination of coverage by the insurance carrier and/or other action available at law. I will promptly inform the insurance carrier in writing if anything happens before my coverage takes effect that makes an answer on this application incomplete or incorrect. Following receipt of a fullyexecuted application, coverage will be in force as of the effective date determined by the insurance carrier under applicable law. Statement of Understanding Address (if different than dependent) Print Name Date (mm/dd/yyyy) By completing this section and signing this application, I represent that the person listed as the applicant on this application is under 18 years of age and is making application for health coverage with my full knowledge and consent. I hereby accept full responsibility for the payment of premiums and the answers and information provided in this application. Parent or Guardian Consent to Application CONTACTING BLUE CROSS OF IDAHO Feel free to contact Blue Cross of Idaho at On our website shoppers.bcidaho.com Visit or call our local offices at: MERIDIAN 3000 East Pine Avenue Meridian, ID COEUR D ALENE 1450 Northwest Boulevard, Suite 106 Coeur d Alene, ID LEWISTON TWIN FALLS 1503 Blue Lakes Blvd. N. Twin Falls, ID POCATELLO 275 South 5th Avenue Suite 150 Pocatello, ID IDAHO FALLS 1910 Channing Way Idaho Falls, ID by Blue Cross of Idaho, an independent licensee of the Blue Cross and Blue Shield Association 2016 Dental Choice & Dental Choice Plus Dental plans that meet Affordable Care Act requirements Form No (09-15)

2 Dental Choice Plans Whatever plan you re looking for, we ve got you covered. Good oral health is an important part of overall health. Our Dental Choice sm and Dental Choice Plus sm plans offer low deductibles and out-of-pocket maximums, with no waiting periods for Basic and Major Dental Services for covered members under age 19. IMPACT OF THE AFFORDABLE CARE ACT (ACA) It s important to know that pediatric dental insurance is considered one of the 10 essential health benefits according to the ACA. Blue Cross of Idaho Dental Choice and Dental Choice Plus plans include dental benefits for those under age 19 that meet ACA requirements. Stop problems before they start Preventive care is a top priority under both the Dental Choice and Dental Choice Plus plans. In fact, both plans pay 100 percent of the maximum allowable charge for all preventive dental care after you make your copayment when you visit an in-network provider. Preventive services include regular exams, cleanings, X-rays and fluoride treatment. Dental Choice/Dental Choice Plus Individual Enrollment Application Applicant Information (Employee) You are: o New Applicant o Responsible Party (Applying only for dependent coverage) Male Female Legal Name (first, middle initial, last) Date of Birth (mm/dd/yy) Social Security No. (required) Marital Status Single Married Other Street Address City, State, Zip Code Billing Address (if different from mailing list) Preferred Daytime Phone Number Alternate Phone Number Address Do you have a current Idaho s driver s license or Idaho identification card? Yes No Idaho driver s license or identification card number Expiration date If you are unable to provide an Idaho driver s license or identification card number, to establish residency you must provide copies of two other forms of documentation that contain your name and residential address with this completed application. Examples include home mortgage statement; lease or loan agreement; homeowner s, renter s, or car insurance policy; or current bank statements (within the last 60 days). These documents must contain the applicant s name and residential address. Dependent Information List all eligible dependents you wish to enroll, including any child who is under the age of 26 or who is medically certified as disabled and dependent upon you for support (copy of certification required). If you have more dependents to include, make a copy of this page and attach. List all eligible dependents you wish to enroll, including any child who is under the age of 26; or who is medically certified as disabled and dependent on parent for support (copy of certification required). Gender: Male Female Dependent 1: Legal Name (first, middle initial, last) Relationship: Legal spouse Child Step-child Other Social Security Number (required) Date of Birth (mm/dd/yy) Does dependent 1 live at the same address as you? Yes No Gender: Male Female Dependent 2: Legal Name (first, middle initial, last) Relationship: Legal spouse Child Step-child Other Social Security Number (required) Date of Birth (mm/dd/yy) Does dependent 2 live at the same address as you? Yes No Gender: Male Female Dependent 3: Legal Name (first, middle initial, last) Relationship: Legal spouse Child Step-child Other Social Security Number (required) Date of Birth (mm/dd/yy) Does dependent 3 live at the same address as you? Yes No Gender: Male Female Dependent 4: Legal Name (first, middle initial, last) Relationship: Legal spouse Child Step-child Other Social Security Number (required) Date of Birth (mm/dd/yy) Does dependent 4 live at the same address as you? Yes No Premium Calculation 1st month s premium required with application. Total premium is calculated on a per-person basis. Premiums for dependents under age 19 are capped at a 3-child rate with Applicant coverage. See Premium Chart for applicable rates. Requested Effective date: / / (Earliest effective date will be the 1st of the month following receipt of application and premium payment) Plan Selected: o Dental Choice o Dental Choice Plus NOTE: For enrollees over age 19, both plans have a six-month waiting period for Basic Dental Services and 12-month waiting period for Major Dental Services. For enrollees under age 19, both plans have a 24-month waiting period for medically-necessary Orthodontia, which also requires preauthorization. Applicant Premium based on age; see Premium Chart (write in N/A if you are responsible party only) $ Dependent 1 Premium based on age; see Premium Chart $ Dependent 2 Premium based on age; see Premium Chart $ Dependent 3 Premium based on age; see Premium Chart $ Dependent 4 Premium based on age; see Premium Chart $ Total monthly premium $ 3000 E. Pine Ave. Meridian, Idaho Mailing Address: P.O. Box 7408 Boise, ID Form No A (09-15) 2015 by Blue Cross of Idaho, an independent licensee of the Blue Cross and Blue Shield Association

3 Dental Choice and Dental Choice Plus No matter if you are at home or on the road, your Blue Cross of Idaho dental plan provides you access to quality dental care. Our network includes 86 percent of Idaho dentists and more than 236,000 dental providers across the United States. Locating a participating provider is easy: just visit bcidaho.com/ findaprovider to find a dentist near you.

4 Benefit Details DENTAL CHOICE (Under Age 19) In-Network Out-of-Network Individual Deductible Annual Out-of- Pocket Maximum Benefit Period Maximum Preventive Dental Services (No waiting period; Includes exams, cleanings, X-rays and fluoride) Basic Dental Services (Includes sealants, fillings, extractions, periodontal maintenance) Major Dental Services (Root canals, periodontics, crowns, bridges, dentures and dental implants) $50 per member, $350 Individual/ $700 Two or more You pay $50 copayment. $100 per member, $10,000 Orthodontia Benefit Details you pay 80% of the 24-month waiting period for members under age 19; medically-necessary,non-cosmetic treatment. Prior authorization required. DENTAL CHOICE PLUS(Under Age 19) In-Network Out-of-Network Individual Deductible Annual Out-of- Pocket Maximum Benefit Period Maximum Preventive Dental Services (No waiting period; Includes exams, cleanings, X-rays and fluoride) Basic Dental Services (Includes sealants, fillings, extractions, periodontal maintenance) $50 per member, $350 Individual/ $700 Two or more You pay $40 copayment. you pay 20% of the allowed amount $100 per member, $10,000 you pay 50%. of the allowed amount Major Dental Services (Root canals, periodontics, crowns, bridges, dentures and dental implants) Orthodontia you pay 50%. you pay 50%. you pay 80% of the 24-month waiting period for members under age 19; medically-necessary,non-cosmetic treatment. Prior authorization required.

5 Benefit Details Individual Deductible Annual Out-of- Pocket Maximum Benefit Period Maximum Preventive Dental Services (No waiting period; Includes exams, cleanings, X-rays and fluoride) Basic Dental Services (Includes sealants, fillings, extractions, periodontal maintenance) Major Dental Services (Root canals, periodontics, crowns, bridges, dentures and dental implants) DENTAL CHOICE (Age 19 and Over) In-Network Out-of-Network $50 per member, You pay $25 copayment. $1,000 $100 per member, you pay 50%. of the allowed amount 6-month waiting period for members age 19 and over 12-month waiting period for members age 19 and over Orthodontia No Benefit No Benefit Benefit Details Individual Deductible Annual Out-of- Pocket Maximum Benefit Period Maximum Preventive Dental Services (No waiting period; Includes exams, cleanings, X-rays and fluoride) Basic Dental Services (Includes sealants, fillings, extractions, periodontal maintenance) Major Dental Services (Root canals, periodontics, crowns, bridges, dentures and dental implants) DENTAL CHOICE PLUS(Age 19 and Over) In-Network Out-of-Network $50 per member, $100 per member, $1,000 $1,000 You pay $10 copayment. you pay 20% of the your deductible, allowed amount 6-month waiting period for members age 19 and over you pay 50%. you pay 50%. 12-month waiting period for members age 19 and over Orthodontia No Benefit No Benefit

6 MONTHLY PREMIUM RATES FOR 2016 Age Dental Choice Dental Choice Plus 0-20 $29.46 $

7 MONTHLY PREMIUM RATES FOR 2016 Age Dental Choice Dental Choice Plus and over

8 GENERAL EXCLUSIONS AND LIMITATIONS Procedures that are not included in the Closed List of Dental Covered Services; or that are not Medically Necessary for the care of an Insured s covered dental condition; or that do not have uniform professional endorsement. Charges for services that were started prior to the Insured s Effective Date. The following guidelines will be used to determine the date when a service is deemed to have been started: o For full dentures or partial dentures: on the date the final impression is taken. o For fixed bridges, crowns, inlays or onlays: on the date the teeth are first prepared. o For root canal therapy: on the later of the date the pulp chamber is opened or the date canals are explored to the apex. o For periodontal Surgery: on the date the Surgery is actually performed. o For all other services: on the date the service is performed. o For orthodontic services, if benefits are available under this Policy: on the date any bands or other appliances are first inserted. Cast restorations (crowns, inlays or onlays) for teeth that are restorable by other means (i.e., by amalgam or composite fillings). Replacement of an existing crown, inlay or onlay that was installed within the preceding five (5) years or replacement of an existing crown, inlay or onlay that can be repaired. Appliances, restorations or other services provided or performed solely to change, maintain or restore vertical dimension or occlusion. A service for cosmetic purposes, unless necessitated as a result of Accidental Injuries received while the Insured was covered by Blue Cross of Idaho. In excess of the Maximum Allowance. A partial or full removable denture for fixed bridgework, or the addition of teeth thereto, if involving a replacement or modification of a denture or bridgework that was installed during the preceding five (5) years. Orthodontic services and supplies unless otherwise specifically listed in the Closed List of Dental Covered Services. Replacement of lost or stolen appliances. Ridge augmentation procedures. Any procedure, service or supply other than vestibuloplasty, alveoloplasty or alveolectomy required to prepare the alveolus, maxilla or mandible for a prosthetic appliance. Excluded services include, but are not limited to stomatoplasty and synthetic bone grafts to the alveolars, maxilla or mandible. Any procedure, service or supply required directly or indirectly to treat a muscular, neural, orthopedic or skeletal disorder, dysfunction or Disease of the temporomandibular joint (jaw hinge) and its associated structures including, but not limited to, myofascial pain dysfunction syndrome. Orthognathic Surgery, including, but not limited to, osteotomy, ostectomy and other services or supplies to augment or

9 reduce the upper or lower jaw. Temporary dental services. Charges for temporary services are considered an integral part of the final dental services and are not separately payable. Any service, procedure or supply for which the prognosis for success is not reasonably favorable as determined by Blue Cross of Idaho. Myofunctional therapy and biofeedback procedures. For hospital Inpatient or Outpatient care for extraction of teeth or other dental procedures. Occlusal adjustments. Not prescribed by or upon the direction of a Provider. Investigational in nature. Provided for any condition, Disease, Illness or Accidental Injury to the extent that the Insured is entitled to benefits under occupational coverage, obtained or provided by or through the employer under state or federal Workers Compensation Acts or under Employer Liability Acts or other laws providing compensation for work-related injuries or conditions. This exclusion applies whether or not the Insured claims such benefits or compensation or recovers losses from a third party; Provided or paid for by any federal governmental entity or unit except when payment under this Policy is expressly required by federal law, or provided or paid for by any state or local governmental entity or unit where its charges therefor would vary, or are or would be affected by the existence of coverage under this Policy; or o For which payment has been made under Medicare Part A and/or Part B. Provided for any condition, Accidental Injury, Disease or Illness suffered as a result of any act of war or any war, declared or undeclared. Furnished by a Provider who is related to the Insured by blood or marriage and who ordinarily dwells in the Insured s household. Received from a dental, vision or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trust or similar person or group. For personal hygiene, comfort, beautification or convenience items even if prescribed by a Dentist, including but not limited to, air conditioners, air purifiers, humidifiers, physical fitness equipment or programs. For telephone consultations; for failure to keep a scheduled visit or appointment; for completion of a claim form; or for personal mileage, transportation, food or lodging expenses, or for mileage, transportation, food or lodging expenses billed by a Dentist or other Provider. For Congenital Anomalies, or for developmental malformations, unless the patient is an Eligible Dependent child. For the treatment of injuries sustained while committing a felony, voluntarily taking part in a riot, or while engaging in an illegal act or occupation, unless such injuries are a result of a medical condition or domestic violence.

10 For treatment or other health care of any Insured in connection with an Illness, Disease, Accidental Injury or other condition which would otherwise entitle the Insured to Covered Services under this Policy, if and to the extent those benefits are payable to or due the Insured under any medical payments provision, no fault provision, uninsured motorist provision, underinsured motorist provision, or other first party or no fault provision of any automobile, homeowner s or other similar policy of insurance, contract or underwriting plan. o In the event Blue Cross of Idaho for any reason makes payment for or otherwise provides benefits excluded by this provision, it shall succeed to the rights of payment or reimbursement of the compensated Provider, the Insured, and the Insured s heirs and personal representative against all insurers, underwriters, self-insurers or other such obligors contractually liable or obliged to the Insured or his or her estate for such services, supplies, drugs or other charges so provided by Blue Cross of Idaho in connection with such Illness, Disease, Accidental Injury or other condition. Any services or supplies for which an Insured would have no legal obligation to pay in the absence of coverage under this Policy or any similar coverage; or for which no charge or a different charge is usually made in the absence of insurance coverage or for which reimbursement or payment is contemplated under an agreement entered into with a third party. Provided to persons who were enrolled as Eligible Dependents after they cease to qualify as Eligible Dependents due to a change in eligibility status which occurs during the Policy term. Provided outside the United States, which if had been provided in the United States, would not be Covered Services under this Policy. Not directly related to the care and treatment of an actual condition, Illness, Disease or Accidental Injury. For acupuncture or hypnosis. Repair, removal, cleansing or reinsertion of Implants. Precision or semi-precision attachments (including Implants placed to support a fixed or removable denture). Denture duplication. Oral hygiene instruction. Treatment of jaw fractures. Charges for acid etching. Charges for oral cancer screening which are included in a regular oral examination. No benefits are available for replacement and/or repair of orthodontic appliances. This includes removable and/or fixed retainer. Blue Cross of Idaho does not discriminate on the basis of basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.