3. Explains when and how you or your provider may ask for an exception to the limits.

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1 April 1, 2012 Dear Valued UPMC for You Member: UPMC for You will be making some changes to your dental benefits. These changes will begin May 1, The enclosure explains the changes to your benefits. Please read the enclosure carefully. The enclosure: 1. Lists services that are no longer covered. 2. Explains which services may have limits. 3. Explains when and how you or your provider may ask for an exception to the limits. 4. Explains your rights to appeal. Not all members will notice a change. Limits do not apply: If you are under the age of 21 or If you live in a nursing home or an intermediate care facility (ICF). We want to assure you that these changes will not affect how we serve you. You will get the same highquality care, customer service, and respect you have come to know and expect as a UPMC for You member. We encourage you to keep going to your dental provider to help coordinate your dental care. If you have any questions, please call UPMC for You Member Service at for Southwest or for Lehigh Capital (Lehigh Valley and Capital Region). TTY users should call toll-free at Representatives will be happy to explain the changes to you. They are available Monday, Tuesday, Thursday and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m. and Saturday from 8 a.m. to 3 p.m. Wishing you good health, UPMC for You Enclosure 1

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3 IMPORTANT INFORMATION ABOUT YOUR UPMC for You DENTAL BENEFITS Please read this notice carefully to see how these changes affect your UPMC for You dental benefits. These changes start May 1, Do these changes apply to you? These changes do not apply to you if you are under 21 years of age; or you live in a nursing home or an intermediate care facility (ICF). What are the changes? Starting May 1, 2012 members with full dental benefits (who are 21 years of age and older and do not live in a nursing home or intermediate care facility) will be eligible for the following: Every 180 days you can get: One dental exam (oral evaluation) and cleaning (prophylaxis). o Additional oral evaluations and prophylaxis will require special approval called a benefit limit exception (BLE). In your lifetime you can get: One partial upper denture or one full upper denture; and One partial lower denture or one full lower denture. o Additional dentures will require a BLE. o Note: If UPMC for You paid for a partial or full upper denture since March 1, 2004, you can get another partial or full upper denture only if you get a BLE. o Note: If UPMC for You paid for a partial or full lower denture since March 1, 2004, you can get another partial or full lower denture only if you get a BLE. You can get the following services only if you get a BLE: Crowns and adjunctive services. Root canals and other endodontic services. Periodontal services. *SEE THE ATTACHED CHART FOR A COMPLETE LIST OF SERVICES* 3

4 What if you need dental services that require a benefit limit exception? UPMC for You can grant a Benefit Limit Exception if: You have a serious chronic illness or health condition and without the additional services, your life would be in danger; or You have a serious chronic illness or health condition and without the additional services, your health would get much worse; or You would need more expensive services if the exception is not granted; or, It would be against federal law for UPMC for You to deny the exception. IF YOU HAVE ANY QUESTIONS ABOUT THE DENTAL BENEFIT CHANGES, PLEASE CALL MEMBER SERVICES AT: UPMC for You Member Services at for Southwest or for Lehigh Capital (Lehigh Valley and Capital Region). TTY users should call toll-free at Representatives are available to help you Monday, Tuesday, Thursday, Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m. and Saturday from 8 a.m. to 3 p.m. How do you get a benefit limit exception? Your dentist must ask for the exception. This can happen before the services start or after they are finished. Your dentist can ask for an exception up to 60 days after your dental services are finished. Your dentist must mail a written request to: Avesis UPMC for You P.O. Box 7777 Phoenix, AZ ATTN: Benefit Limit Exceptions The benefit limit exception submitted by your dentist must include: A completed Avesis Dental BLE request form. The dental service that is needed. The reason the exception is needed. The dentist s name and phone number. An American Dental Association (ADA) claim form completed in its entirety. If your dentist asks for a benefit limit exception before the dental service begins, you and your dentist will get an answer within 21 days. If you dentist asks for a quick response because you have an urgent need before the dental services begins, you and your dentist will get an answer within 48 hours. If your dentist asks after the dental service is finished, you and your dentist will get an answer within 30 days. What if your benefit limit exception request is denied? You can file a complaint or grievance with UPMC for You or ask for a Fair Hearing with the Department of Public Welfare if your request for a benefit limit exception is denied. 4

5 Your Right to Appeal What are your rights to appeal? Because these changes are caused by changes in state law, you cannot appeal the changes. If you think these changes do not apply to you or if you think we do not have, the right facts about you, such as your age or where you live, and the changes should not apply to you, you may file an appeal and ask for a fair hearing by June 1, See the instructions on the next page on how to file an appeal. If you want to talk to a lawyer about these changes, call: In Central Pennsylvania MidPenn Legal Services In Northwestern Pennsylvania Northwestern Legal Services In Southwest Pennsylvania Laurel Legal Services Southwestern PA Legal Services Neighborhood Legal Services State wide Pennsylvania Health Law Project Pennsylvania Legal Aid Network How do you file an appeal? If you think these changes do not apply to you or if you think we do not have the right facts about you, such as your age or where you live, and the changes should not apply to you, you may file an appeal and ask for a hearing by June 1, If you want to have a hearing, you may call your caseworker, but you must also fill out and sign the form included with this letter. After you have filled out the form, mail it or take it to your county assistance office. If your request is not postmarked or received by June 1, 2012 your appeal will be dismissed without a hearing. Because these changes are caused by State law, you will not be granted a hearing unless you are appealing the correctness of your case information. If you are only appealing the changes, your appeal will be dismissed. Whether or not you file an appeal now, you can always ask your caseworker to see if these changes should apply to you. At the hearing, you can tell the hearing official why you think the facts that we have about you are wrong. You may present evidence and bring witnesses. You may represent yourself or have someone else represent you. You can get free legal help by calling one of the phone numbers listed on the notice. 5

6 If you speak a language other than English and need an interpreter, and you ask in advance, we will help you get an interpreter at no charge to you. If you or your representative would like to meet with us to discuss the issue under appeal informally or to give us information which might change the decision on your benefit, please call your caseworker. This informal meeting will not delay or cancel your hearing. A hearing will be scheduled for you either over the telephone or in person, whichever you choose. If you ask to appear in person for the hearing, it will be held in the city listed below for the county in which you live. HEARING LOCATIONS Erie for: Crawford, Mercer Harrisburg for: Adams, Cumberland, Dauphin, Lancaster, Lebanon, Perry, York. Pittsburgh for: Allegheny, Armstrong, Beaver, Bedford, Butler, Clearfield, Fayette, Greene, Indiana, Lawrence, Washington, Westmoreland. Reading for: Berks, Lehigh, Northampton. To file a complaint: You can also file a complaint with UPMC for You within 45 days from the date of this notice. Call UPMC for You Member Services at for Southwest or for Lehigh Capital (Lehigh Valley and Capital Region). TTY users should call toll-free at Send your complaint to UPMC for You at: UPMC for You Complaints, Grievance and Appeals P.O. Box 2939 Pittsburgh, PA If you have any questions about the dental benefit changes, please call UPMC for You Member Services at for Southwest or for Lehigh Capital (Lehigh Valley and Capital Region). TTY users should call toll-free at Representatives are available to help you Monday, Tuesday, Thursday, Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m. and Saturday from 8 a.m. to 3 p.m. These changes are authorized by 62 P.S. section 443.6, as amended by Act If you wish to file a request for a fair hearing, please fill out the form below and mail or take it to your county assistance office by June 1,

7 I WANT A HEARING BECAUSE: (attach additional pages, if necessary) DO YOU WANT A TELEPHONE HEARING, OR AN IN-PERSON HEARING? (circle one) TELEPHONE IN-PERSON DO YOU NEED AN INTERPRETER? (circle one) YES NO If you circled YES, what language? Date Recipient ID Number Representative s Signature Representative s Telephone Number Your Signature Your Telephone Number YOUR ADDRESS COUNTY CASE RECORD NUMBER Mail or take this form to your caseworker at the county assistance office. 7

8 Dental services The following dental benefits and limits apply to members 21 years of age and older, including members 21 years of age and older who reside in personal care homes and assisted living facilities. The dental limits do not apply to members under 21 years of age or to adults who reside in a nursing home or an intermediate care facility (ICF). Services beyond a member s benefit limits are not covered, unless you or your provider request and receive approval for a Benefit Limit Exception (BLE). Full Dental Benefits Description Age 21 and over Age 21 and over (Residing in a Nursing Home or Intermediate Care Facility) Anesthesia Checkups - (Routine exam including x-rays) Cleanings - (Prophylaxis) Crowns and adjunctive services Dentures -(One partial upper denture or one full upper denture and one partial lower denture or one full lower denture) Dental surgical procedures May require prior authorization - 1 per 180 days Additional exams require a BLE - 1 per 180 days Additional cleanings require a BLE Not Unless a BLE is approved - once per lifetime May require prior authorization 1 per 5 years Additional dentures require a BLE Dental emergencies - (Emergency care) Extractions -(Impacted tooth removal) Extractions - (Simple tooth removals) Fillings - (Restorations) Orthodontics - (Braces)* Not * * *If braces were put on before the age of 21, services will be covered until they are completed or until age 23, whichever comes first, as long as the member remains eligible for Medical Assistance. Palliative Care -(Emergency treatment of dental pain) Periodontal & Endodontic services ** Not covered** Unless a BLE is approved ** Exceptions to the periodontal limits will be granted for individuals who have special needs or are disabled, pregnant women, individuals with coronary artery disease or individuals with diabetes. Root canals Not Unless a BLE is approved X-rays Inpatient Hospital/Short procedure unit (SPU)/Ambulatory Surgical Center (ASC) dental care *** *** May require prior authorization *** May require prior authorization ***Dental care such as, but not limited to, oral surgery and impacted teeth removal for members with conditions that cause undue risk if performed on an outpatient basis or teeth extractions and dental restorative services performed for a member who is unmanageable because of severe physical and/or mental conditions that necessitates the use of general anesthesia by an anesthesiologist, not the dentist. 8