Enhanced Dental Benefit Program

Transcription

1 Cleveland Clinic Enhanced Dental Benefit Program Summary Plan Description

2 Table of Contents CLEVELAND CLINIC ENHANCED DENTAL BENEFIT PROGRAM About the Enhanced Dental Benefit Program Introduction Eligibility Provisions Coverage Options Coverage for Dependents Dependent Verification Enrollment Process Newly Hired Employees Current Employees Employee Contributions Changes in Coverage Life Event Changes Highlights of Coverage Benefit Program Details Deductible Co-insurance Covered Services Preventive Services Fillings and Extractions Major Restorative Services Orthodontia Non-Covered Services Alternate Benefit Provision Predetermination of Benefits Emergency Treatment Coordination of Benefits (COB) Process for Determining Which Dental Program Is Primary How Cigna Pays as Primary How Cigna Pays as Secondary Enforcement of Coordination of Benefits (COB) Provision Facility of Payment Right of Recovery Coordination Disputes General Administrative Provisions Claims Services Provided by Cleveland Clinic Dentistry Dental Benefit Program Identification Cards Quick Reference Guide Appeal Process Claim Appeals Appeals Procedure Level One Appeal Level Two Appeal iii

3 Facility of Payment Right of Recovery Subrogation Provider Status and Direction of Payment Continuation of Coverage Consolidated Omnibus Budget Reconciliation Act (COBRA) Coverage Qualifying Events: Who, When, and for How Long When Continued Coverage Ends How to Obtain Coverage Veteran Reemployment Retirement Medical Leave/Disability Status Leave of Absence Termination of Coverage A Statement of Your Rights Under ERISA Receive Information about Your Plan and Benefits Continue Group Health Plan Coverage Prudent Actions by Plan Fiduciaries Enforce Your Right Assistance with Your Questions ERISA Required Information iv

4 Cleveland Clinic Enhanced Dental Benefit Program About the Enhanced Dental Benefit Program The Cleveland Clinic Enhanced Dental Benefit Program (the Benefit Program ) is available to help defray the cost of dental care. This Summary Plan Description (SPD) describes how the Benefit Program works and what it covers. A chart summarizing coverage is located on page 5 of this booklet. Please contact the ONE HR Service Center, at with any questions. 1

5 Introduction This booklet describes the benefits provided by the Cleveland Clinic Enhanced Dental Benefit Program (the Benefit Program ). The Benefit Program is self-insured by Cleveland Clinic. Cleveland Clinic is the Benefit Program Administrator. The Third-Party Administrator is Cigna. Eligibility Provisions You are eligible to participate in the Enhanced Dental Benefit Program if you are a regular full-time or part-time staff member or employee of Cleveland Clinic. A member of the contract staff is eligible to enroll if his or her contract includes participation in the Enhanced Dental Benefit Program. Coverage Options The levels of coverage available are: Employee Only Employee + 1 Dependent Employee + Family Coverage for Dependents Eligible dependents include: Your lawful spouse (not divorced or legally separated) Your children are eligible for coverage under the Benefit Program until they attain age 26. Eligible children include: A natural child A legally adopted child A child placed for adoption with you or your spouse A child for whom you or your spouse has been appointed by a court as the legal guardian A child for whom you or your spouse is required to provide coverage under a qualified medical child support order (as defined in Section 609 of ERISA) In addition, if a child is covered under the Enhanced Dental Benefit Program at the time he or she attains age 26, the child shall continue to be eligible for coverage under the Benefit Program after attaining age 26, if all of the following requirements are met: Prior to age 26, you provide to the Benefit Program s Administrative Committee evidence that the child is physically or mentally incapable of self-support, The child is receiving principal financial support from you and/or your spouse, and The Benefit Program s Administrative Committee determines that the child is physically or mentally incapable of self-support. An extension of coverage for a child past age 26 shall apply only for so long as the foregoing requirements continue to be met. Note: If you and your spouse are both employed at Cleveland Clinic, you cannot cover any family member twice. Dependents are covered under the Benefit Program only if coverage is elected for them by you and acceptable documentation is provided to verify dependent eligibility (see dependent verification below). The following are not eligible for coverage under the Benefit Program: your parents, parents-in-law, grandchildren, nieces, nephews, former spouses, common-law marriage partners, and foster children who have not been legally adopted. 2

6 Dependent Verification All newly hired and/or existing staff members and employees enrolling themselves and/or their dependents for the first time must provide documentation to verify dependent eligibility under the Enhanced Dental Benefit Program. Documentation must be returned to the Total Rewards Department within 31 days of employment or alife event, along with the enrollment form, in order for dependents to be enrolled in the Benefit Program. Acceptable documentation for verification of eligibility is as follows: Spouse Copy of marriage license, or Copy of page one of most recent tax return (wage information may be crossed out) Children under age 26 Natural-born children: Copy of birth certificate or one of the following: Copy of page one of most recent tax return (wage information may be crossed out) Copy of court-issued qualified medical child support order (QMCSO) (if applicable) Copy of divorce decree (if applicable) Stepchildren/Custodial: Copy of birth certificate and one of the following: Marriage license Copy of court-ordered qualified medical child support order (QMCSO) (if applicable) Copy of divorce decree (if applicable) Custodial papers Adopted children: Adoption papers Enrollment Process Newly Hired Employees When you begin working at a Cleveland Clinic facility, you are given an opportunity to sign up for dental benefits. You must elect a Dental Benefit Program within 31 days of your start date in order for your coverage to become effective. If you DO NOT elect coverage for yourself and your dependents, you will not receive dental coverage. You will not be entitled to dental coverage until the next annual open enrollment period unless you experience a Life Event Change, as described on page 4. If an employee begins employment at Cleveland Clinic between October and December, near the open enrollment period, he/she will have the opportunity to elect benefits for the current year and will also be given information about making benefit election changes for the new calendar year. If you have further questions on how to apply for coverage, contact the Total Rewards Department. Current Employees Current employees have the opportunity each year to enroll for dental coverage during the Benefits Open Enrollment period. Through this process, you can choose to keep the same coverage you have or make changes for the next calendar year. If you did not previously elect coverage through the Cleveland Clinic Dental Benefit Program, you have the chance to do so at this time and your coverage will become effective on the first day of the new calendar year. 3

7 Employee Contributions You pay a portion of the cost of coverage under the Benefit Program (through payroll deduction). The amount (which is determined annually) is based on the level of coverage elected (i.e., Employee Only vs. Employee + Family) and percent of time worked (full-time vs. part-time). You are notified of the cost when they enroll in the Benefit Program and at the time of any change. Changes in Coverage A change in coverage, such as upgrade, downgrade, or cancellation of coverage, may be made only during the annual open enrollment period for the new calendar year, unless the change in coverage is due to and corresponds with a certain life event change. (See Life Event Changes below.) If you wish to enroll or change the level of coverage due to a life event change, a completed enrollment form must be returned to the Total Rewards Department (see the Quick Reference Guide on page 11), along with documentation verifying such event, within 31 days of the event. In general, the change in coverage will then be applied retroactively to the date of the qualifying life event. If an enrollment form is not filed within 31 days, coverage cannot be changed until the next open enrollment period. Life Event Changes You or a dependent may experience an event during the Benefit Program Year (January 1 through December 31) which results in the need to make changes in benefit elections. Under the Internal Revenue Service guidelines, the following occurrences meet the definition of a Life Event Change and, therefore, permit a change in certain elections during the Benefit Program Year: 1. A change in legal marital status including marriage, death of a spouse, divorce, legal separation or annulment. 2. A change in number of dependents, including birth, adoption, placement for adoption, attainment of legal guardianship, or death of a dependent. 3. A dependent satisfies or ceases to satisfy the Benefit Program requirements for eligible dependents because of age, job status or other circumstances. 4. A change in employment status, which means a commencement or termination of employment by you, your spouse, or your dependent. 5. A change in work schedule, meaning a reduction or increase in hours of employment by you, your spouse or dependent, including a switch between part-time and full-time, a strike or lockout, or commencement or end of an unpaid leave of absence. 6. A change in work location, meaning a change in the place of residence or work of you, your spouse or dependent. 7. A qualified medical child support order (QMCSO), or other similar order, that requires coverage for your child. 8. You, your spouse or dependent becomes qualified for Medicare or Medicaid (Health coverage may be cancelled for that person). If one of these events occurs, you must contact the Total Rewards Department (see the Quick Reference Guide on page 11) within 31 days of the qualified life event and provide documentation of that event. Any changes in elections must be consistent with the life event change. You/your dependents covered under another dental program who lose that coverage as a result of one of the life events listed above are eligible to participate in the Cleveland Clinic Enhanced Dental Benefit Program. 4

8 Highlights of Coverage The chart below summarizes benefits under the Cleveland Clinic Enhanced Dental Benefit Program. Annual Program Benefit Maximum Deductible Ind./Family (Percentage of 1 Allowed Amount) 1 Benefit (Per Person) Preventive Care (two visits per calendar year) $0 100% Fillings and Extractions 180% $1,500 per year Major Restorative Care $50/$ % Orthodontia 180% $2,500 lifetime 1 If a dentist participates in the Cigna DPPO, the Allowed Amount is a fee schedule negotiated with network providers. In-network providers agree to accept the Allowed Amount. For covered services, the Benefit Program member pays the deductible and co-insurance amounts, but is not responsible to pay charges in excess of the Allowed Amount. 1 If a dentist does not participate in the Cigna DPPO, the Allowed Amount is the Usual and Customary (U&C) charge for similar services provided in the community in which care is received, and is determined by Cigna. If the dentist s charge exceeds the U&C amount, the Benefit Program member is responsible to pay the amount in excess of the U&C amount (in addition to the deductible and co-insurance). 1 See Benefits Covered Under the Benefit Program and for definition of Allowed Amount below. Benefit Program Details The Cleveland Clinic Enhanced Dental Benefit Program (the Benefit Program ) is available to assist you with dental expenses. The Benefit Program pays a percentage of Allowed Amount for covered dental services. Covered dental services are described on pages 6 and 7. Non-covered services are described on pages 8 and 9. The Allowed Amount is determined by Cigna, and depends on whether a dentist participates in the Cigna Dental Preferred Provider Organization (DPPO) network. If a dentist participates in the Cigna DPPO, the Allowed Amount is a fee schedule negotiated with network providers. In-network providers agree to accept the Allowed Amount. For covered services, the Benefit Program member pays the deductible and co-insurance amounts (described below and on page 6), but is not responsible to pay charges in excess of the Allowed Amount. If a dentist does not participate in the Cigna DPPO, the Allowed Amount is the Usual and Customary (U&C) charge for similar services provided in the community in which care is received, and is determined by Cigna. If the dentist s charge exceeds the U&C amount, the Benefit Program member is responsible to pay charges in excess of the U&C amount (in addition to the deductible and co-insurance). Dental services must be performed by licensed dentists or physicians (or by individuals who are under their employment and supervision) within the range of their authorized fields. For a directory of Cigna DPPO dentists, see Deductible The deductible is an amount that each covered person must pay in a calendar year before the Benefit Program provides any benefits. There is no deductible for preventive services. The $50 deductible applies to fillings and extractions, major restorative care, and orthodontia. The Benefit Program member pays the first $50 per year of covered dental expenses (other than preventive services) up to a maximum of $150 per year per family. 5

9 Co-insurance Benefit Program members pay a portion of all covered dental services other than preventive services. This is called co-insurance. The amount of co-insurance is as follows: Fillings and Extractions Major Restorative Services Orthodontia Individual s Dental Program Pays Co-insurance 80% of 20% of Allowed Amount Allowed Amount 60% of 40% of Allowed Amount Allowed Amount 80% of 20% of Allowed Amount Allowed Amount If a dentist does not participate in the Cigna DPPO the Benefit Program member is responsible to pay any charges in excess of the Allowed Amount (i.e., the amount in excess of the U&C charges determined by Cigna). In addition to the co-insurance described above, the Benefit Program member is responsible to pay any amount in excess of the Benefit Program s maximum benefit. The Benefit Program s maximum benefit for restorative services for each covered person is $1,500 per year; the maximum benefit for orthodontia for each covered person is $2,500 lifetime. Covered Services The Benefit Program pays a percentage of the Allowed Amount, subject to deductible and co-insurance amounts described on page 7, to a maximum annual benefit of $1,500 per year (other than orthodontia) 2 for each covered person, for the following: Preventive Services The Benefit Program pays 100% of the Allowed Amount (deductible is not applicable) for preventive services, such as: Routine oral examination two per calendar year Prophylaxis (cleaning) two per calendar year Bitewing x-rays two per calendar year Full mouth x-rays one complete set every 24 months Panoramic (Panorex) x-rays one every 24 months Topical application of fluoride (excluding prophylaxis) one per calendar year, to age 19 Palliative (emergency) treatment of dental pain, minor procedures, when no other definitive dental services are performed. (Any x-ray taken in connection with such treatment is a separate dental service.) Topical application of sealant on a posterior tooth one treatment per tooth every three calendar years Fillings and Extractions The Benefit Program pays 80% of the Allowed Amount (deductible is applicable) for: Amalgam filling Composite/resin filling anterior teeth only Cone beam imaging Routine dental extraction Surgical extraction of erupted tooth 2 $1,500 maximum annual benefit per covered person; $2,500 maximum lifetime benefit per covered person for orthodontia. 6

10 Major Restorative Services The Benefit Program pays 60% of the Allowed Amount (deductible is applicable) for major restorative services, such as: Oral surgery (other than removal of impacted wisdom teeth or tumors in the mouth; these are covered by the Professional Staff Health Benefit Program, please refer to the Professional Staff Health Benefit Program SPD for details regarding dental surgery benefits) Crowns 3 Bridge pontics 3 Retainer crowns 3 Removable prosthesis Complete (full) dentures, upper or lower Upper or lower removable partial denture, cast metal base with resin saddles (including any conventional clasps, rests and teeth) Adjustments for complete denture Any adjustment or repair to a denture within six months of installation is not a separate dental service Root canal therapy Any x-ray, test, laboratory, exam or follow-up care is part of the allowance for root canal therapy and not a separate dental service Osseous surgery Flap entry and closure is part of the allowance for osseous surgery and not a separate dental service Periodontal scaling and root planing The Benefit Program covers a maximum of four periodontal cleanings per year; any routine cleanings that were paid under Preventive Care shall be combined and included in the four per-year limit. Dental implants Prosthesis over implant A prosthetic device supported by an implant or implant abutment is covered. Replacement of any type of prosthesis with a prosthesis supported by an implant or implant abutment is only payable if the existing prosthesis is at least five years old, is not serviceable, and cannot be repaired. Space maintainers, fixed unilateral Recement bridge Anesthetics, antibiotic injections, or intravenous sedation Local anesthetic, analgesic and routine postoperative care for extractions and other oral surgery procedures are not separately reimbursed but are considered as part of the submitted fee for the global surgical procedure. General anesthesia or intravenous sedation is paid as a separate benefit only when clinically appropriate, as determined by Cigna, and when administered in conjunction with complex oral surgical procedures which are covered under the Benefit Program. 3 Crown restorations are covered only when the tooth, as a result of extensive caries or fracture, cannot be restored with amalgam, composite/resin, silicate, acrylic or plastic restoration. 7

11 Orthodontia The Benefit Program pays 80% of the Allowed Amount (deductible is applicable) for covered orthodontic treatment with a lifetime maximum benefit of $2,500 per person (including adults). Covered orthodontic treatments are necessary services for realignment of natural teeth or corrective positioning of teeth. Included are charges for guidance and evaluation before orthodontic treatment begins, if those services are performed by or under the direction of a qualified dentist. The dentist should submit to Cigna a complete outline of the orthodontic problem, the proposed treatment, the charges for the treatment and the length of time for completion of the treatment. Subject to the Benefit Program limits stated above, orthodontic charges are paid as follows: up to 25% of the total orthodontia fee is considered as being incurred on the date the initial appliance is placed, and the remainder of the total orthodontia fee is divided by the number of months for the total treatment plan; the resulting portion is considered to be incurred on a monthly basis until the Benefit Program maximum is paid, treatment is completed, or eligibility ends. Non-Covered Services The following services are not covered under the Benefit Program: Surgical extraction of impacted teeth (this is covered by the Health Benefit Program) Removal of tumors in the mouth (this is covered by the Health Benefit Program) Incision and drainage of an abscess in the mouth (this is covered by the Health Benefit Program) Services performed solely for cosmetic reasons Replacement of a lost or stolen appliance Replacement of a bridge, crown or denture within five years after the date it was originally installed unless: The replacement is made necessary by the placement of an original opposing full denture or the necessary extraction of natural teeth, or The bridge, crown or denture, while in the mouth, has been damaged beyond repair as a result of an injury received while an individual is covered by this Benefit Program. Any replacement of a bridge, crown or denture which is or can be made usable according to common dental standards Procedures, appliances or restorations (except full dentures) whose main purpose is to: Change vertical dimension, or Diagnose or treat conditions or dysfunction of the temporomandibular joint, or Stabilize periodontally involved teeth, or Restore occlusion. Bite registrations, precision or semiprecision attachments, or splinting Treatment provided as a result of severe trauma to sound natural teeth (this is covered by the Health Benefit Program for treatment provided within one year of an accident or injury) Treatment that was disallowed due to an alternate procedure evaluation (see page 9 regarding Alternate Benefit Provision ) Instruction for plaque control, oral hygiene and diet Charges in excess of the Benefit Program s Allowed Amount (see Benefit Program Details on page 5 for definition of Allowed Amount) Charges made after coverage ends, except for devices which were fitted and ordered but not delivered before the coverage ended (these devices must be delivered within 30 days after coverage ends) Services performed before the member becomes covered by this Benefit Program Dental services that do not meet common dental standards Services that are deemed to be medical services 8

12 Services and supplies received from a hospital Charges which the Benefit Program member would not normally be required to pay, such as those which would not have been billed if the patient had no coverage by this Benefit Program Services for or in connection with an injury arising out of, or in the course of, any employment for wage or profit Services for or in connection with a sickness which is covered under any workers compensation or similar law Charges made by a hospital owned or operated by, or which performs care or performs services for, the United States government, if such charges are directly related to a military-service-connected condition Services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared Charges which the person is not legally required to pay Charges for unnecessary care, treatment or surgery Charges to the extent that payment is unlawful where the person resides at the time the services are received Charges to the extent that a Benefit Program member is paid or entitled to payment for those expenses by or through a public program, other than Medicaid Charges for or in connection with experimental procedures or treatment methods not approved by the American Dental Association or the appropriate dental specialty society Alternate Benefit Provision Often there is an element of choice in the use of dental services, such as two or more appropriate methods of treatment. In the event dental care can be provided through more than one appropriate method of treatment, the amount paid by the Benefit Program may be based upon the least expensive treatment to correct the condition. In that event, if the Benefit Program member prefers a more expensive or extensive treatment, he or she would pay the difference in cost. Predetermination of Benefits A dentist may request a predetermination/preauthorization of benefits from Cigna. If a predetermination of benefits is requested, an Explanation of Benefits (EOB) is returned to the dentist indicating what portion of the cost will be paid by the Benefit Program. A request for predetermination of benefits is particularly important if the dentist recommends one type of treatment, and Cigna determines that an alternate treatment will be paid by the Benefit Program. Emergency Treatment Emergency treatment is subject to the same payment limitations as any other dental services. Coordination of Benefits (COB) Coordination of Benefits (COB) is the process used to pay dental expenses when an individual is covered by more than one dental program. Coordination of Benefits helps achieve cost savings for all Cleveland Clinic Enhanced Dental Benefit Program (the Benefit Program ) members because it eliminates duplication of payments. If a Benefit Program member is covered by more than one dental program, the Benefit Program s Third-Party Administrator (TPA) follows rules established by Ohio law to decide which dental program pays first (primary plan) and how much the other dental program (secondary plan) must pay. A Benefit Program member must provide the TPA with COB facts and information necessary to apply order-of-benefit determination provisions of the Benefit Program. The combined payments of all dental programs will not exceed the actual amount billed for services. 9

13 Process for Determining Which Dental Program Is Primary To determine which dental plan is primary, Cigna has to consider both the coordination of benefit provision of the other dental program and which family member is involved in a claim. The primary dental program is determined by the first of the following that applies: 1. Non-Coordinating Program: If covered by another group program that does not coordinate benefits, that program will always be primary. 2. Employee: The program covering an active employee is always primary and pays before a program covering the person as a dependent, laid-off employee or retiree. 3. Children: Birthday Rule When children s dental care expenses are involved, Cigna follows the birthday rule. The birthday rule states that the dental program of the parent with the first birthday in the calendar year is always primary for the children. For example, if your birthday is in January and your spouse s birthday is in March, your dental program is primary for the children. Gender Rule and other Dental Program Rules Sometimes a spouse s dental program has some other coordination of benefits rule, such as a gender rule, which states that the father s dental program is always primary. In cases of the gender rule or other specific dental program coordination of benefits rules for children, Cigna will follow the rules of that dental program. 4. Children (Parents Divorced or Separated): If the court decree makes one parent responsible for dental expenses, that parent s program is primary. If the court decree gives joint custody and does not mention dental care, Cigna follows the birthday rule. If neither of those rules applies, the order will be determined in accordance with the Ohio Department of Insurance rule on coordination of benefits. 5. Other Situations: For all other situations not described previously, the order of benefits will be determined in accordance with the Ohio Department of Insurance rule on coordination of benefits. How Cigna Pays as Primary As primary, Cigna pays the full benefit provided by the Benefit Program as though there were no other coverage, as long as the service is covered by the Benefit Program. How Cigna Pays as Secondary As secondary payor, Cigna s payments are based on the balance left after the primary dental program has paid. A copy of the Explanation of Benefits (EOB) from the primary dental program must be submitted to Cigna. In no event will Cigna pay more than it would have paid had it been primary. Cigna will pay no more than the allowable expense for the dental care involved. Enforcement of Coordination of Benefits (COB) Provision Cigna will coordinate benefits, provided it is informed by the Benefit Program member (or some other person or organization) of coverage under another dental program. In order to apply and enforce this provision or any provision of similar purpose of any other dental care program, it is agreed that: Any person claiming benefits described under this Benefit Program will furnish Cigna with any information it needs; and Cigna may, without the consent of or notice to any person, release or obtain from any source any necessary information needed to complete the claims adjudication process. 10

14 Facility of Payment If payment is made by another dental program that Cigna should have made under this provision, then Cigna has the right to pay whoever paid under such other dental program; Cigna will determine the necessary amount under this provision. Amounts so paid are benefits under this dental program and Cigna is discharged from liability to the extent of such amounts paid for covered services. Right of Recovery If Cigna pays more for covered services than this provision requires, then it has the right to recover the excess from anyone to or for whom the payment was made. The Benefit Program member agrees to do whatever is necessary to secure Cigna s right to recover the excess payment. Coordination Disputes If a Benefit Program member disagrees with the way Cigna has paid a claim, the first attempt to resolve the problem should be to contact Cigna toll-free at Cigna s appeal process must be followed (see page 12). If still not satisfied, the Benefit Program member may file a consumer complaint with the Ohio Department of Insurance at General Administrative Provisions Claims Claims must be filed with Cigna within 365 days after the services are provided. A dentist may file electronically with Cigna or send a paper claim form to Cigna. Claim forms can be obtained from Cigna s website at or from the Total Rewards Department (see the Quick Reference Guide below). Services Provided by Cleveland Clinic Dentistry When dental services are received at Cleveland Clinic (Ohio), the Section of Dentistry files a claim with Cigna, and Cigna directs any payment from the Benefit Program to the Section of Dentistry. Dentistry sends a billing statement to the Benefit Program member, and the member is responsible to pay any amount in excess of the Benefit Program benefit. Since Cleveland Clinic s Section of Dentistry participates in the Cigna DPPO, the Benefit Program member is not responsible for charges in excess of the contracted DPPO rates. Dental Benefit Program Identification Cards Cigna issues ID cards to Benefit Program members. If a dental ID card is lost or stolen, contact Cigna Customer Service to request a replacement (see the Quick Reference Guide below) or go to Quick Reference Guide Cigna Dental Questions Customer Service, Claims and Benefits Inquiries: toll-free: (800.Cigna24 toll-free: ( Plan I.D. Number: Claims address: Cigna Dental P.O. Box Chattanooga, TN Web: Cleveland Clinic ONE HR Service Center Questions General Dental Benefit Program, Eligibility Verification Phone: toll-free: Science Park Drive / AC341 Beachwood, OH Total Rewards Department For Additional Benefit Information (including forms and direct links to the websites listed above): go to 11

15 Appeal Process Claim Appeals Members may contact Cigna by phone or in writing with any concerns regarding Enhanced Dental Benefit Program benefits (see the Quick Reference Guide on page 11). Cigna will resolve the issue within 30 days If the issue is not resolved to the member s satisfaction he or she can start the appeals procedure. Appeals Procedure The Enhanced Dental Benefit Program has a two-step appeals process. To initiate the process, a request for appeal must be submitted in writing to Cigna within 365 days of a denial notice. The member should state the reason why he or she feels the appeal should be approved and include any applicable supporting documentation. If the member is unable to provide a written appeal he or she should ask Cigna to register the appeal by telephone. See the Quick Reference Guide on page 11 for Cigna s address and phone number. Level One Appeal The appeal will be reviewed and a decision made by someone not involved in the initial determination. Appeals involving medical necessity or clinical appropriateness will be considered by a healthcare professional. For level one appeals, Cigna will provide a written decision within 30 calendar days after receiving an appeal for a post-service coverage determination. If more time or information is needed to make a determination, Cigna will notify the member in writing to request an extension of up to 15 calendar days and specify any additional information needed to complete the review. Level Two Appeal If a member is dissatisfied with the level one appeal decision he or she may request a second review. To initiate a level two appeal a written appeal must be directed to: Cleveland Clinic Total Rewards Department 3050 Science Park Drive / AC341 Beachwood, OH The appeal must be resolved within 45 days of the request as long as the required documents to conduct the appeal are submitted. Facility of Payment If payment is made under any other dental program, which Cigna should have made under this provision, then Cigna has the right to pay whoever paid under the other dental program; Cigna will determine the necessary amount under this provision. Amounts so paid are benefits under this Program and Cigna is discharged from liability to the extent of such amounts paid for covered expenses. Right of Recovery If an overpayment is made by Cigna, Cigna has the right to (a) recover that overpayment from the person to whom or on whose behalf it was made; or (b) offset the amount of that overpayment from a future claim payment. Subrogation If Cigna provides benefits for covered expenses and you have the right to recover from another person, organization or insurer as a result of a negligent or wrongful act, Cigna assumes your legal rights to any recovery of incurred expenses. For the purposes of this section, insurer shall include, but is not limited to, (1) any insurer of any third party, (2) any insurer providing uninsured or under-insured motorist coverage, and (3) your own insurer other than Cigna. 12

16 To the extent Cigna provides benefits for covered expenses, you must repay Cigna amounts recovered by suit, settlement or otherwise from any person, organization or insurer. You have the legal obligation to help Cigna in all possible ways when Cigna tries to recover these amounts. You must give Cigna Dental information and assistance and sign the necessary documents to help enforce Cigna s rights. You must not do anything that might limit Cigna s rights. Provider Status and Direction of Payment Cigna has agreed to make payment directly to providers. You and your eligible covered dependents can choose any dental provider for your services. You are not required to use a network of dental providers. However, if you use a Cigna network provider, you may experience lower out-of-pocket costs because of the discounted rates the providers have agreed to accept. You authorize Cigna to make payments directly to certain providers who have performed services for you. Cigna also reserves the right to make payment directly to you. When this occurs, you must pay the provider and Cigna is not legally obligated to pay any additional amounts. You cannot assign your right to receive payment to anyone else, nor can you authorize someone else to receive your payments for you. If Cigna has incorrectly paid for services or it is later discovered that payment was made for services that are not considered covered expenses, then Cigna has the right to recover payment, and you must repay this amount when requested. Continuation of Coverage Consolidated Omnibus Budget Reconciliation Act (COBRA) Coverage The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) may require that a covered employee and/or his or her covered dependents be provided with the opportunity to continue group healthcare coverage on a contributory basis under certain circumstances. The extension of coverage applies to almost all employee health plans providing medical, dental, prescription drug, vision, or hearing benefits. Coverage can be continued through COBRA by paying all of the costs of the health plan elected, including any portion formerly paid for by Cleveland Clinic. Qualifying Events: Who, When, and for How Long When an employee s Cleveland Clinic Enhanced Dental Benefit Program (the Benefit Program ) coverage terminates, coverage can be continued (including for covered dependents) for up to 18 months: If the covered employee terminates employment for any reason, including retirement, other than gross misconduct; or If the covered employee loses coverage due to a reduction in hours of employment; or If a covered employee or dependent becomes disabled within the first 60 days of COBRA continuation, coverage may be continued for an additional 11 months (29 months total). Covered dependents may continue coverage under the Benefit Program for up to 36 months: If the employee dies while covered by the Benefit Program; or If the covered employee and spouse become divorced, legally separated, or their marriage is annulled; or If the covered employee becomes eligible for Medicare; or If a covered employee s dependent child is no longer eligible for coverage under the Benefit Program. If a covered employee is entitled to Medicare benefits at the time coverage terminates due to termination of employment or reduction in hours, the continuation period for covered dependents will be the longer of: 18 months from the date coverage terminates due to termination of employment or reduction of hours; or 36 months from the date of Medicare eligibility. 13

17 When Continued Coverage Ends The continued coverage ends for any qualified person when: The cost of continued coverage is not paid on or before the date it is due; or That person becomes eligible for Medicare, if later than the date of the COBRA election; or That person becomes covered under another group health plan unless that other plan contains an exclusion or limitation with respect to any pre-existing health condition; or The Benefit Program terminates for all staff member; or The covered employee or dependent is no longer deemed disabled during the additional 11-month extended period; or The last day of the applicable 18, 29 or 36 month time limit. How to Obtain Coverage When coverage terminates, the Total Rewards Department notifies the COBRA Administrator (PayFlex). PayFlex then notifies the Benefit Program member of election rights. The Benefit Program member must elect continued coverage within 60 days of the event. For questions regarding COBRA, contact PayFlex at or the Total Rewards Department (see the Quick Reference Guide on page 11). There is generally a1-2 week lag time between the time PayFlex processes the first paid premium and the time Cigna is updated. Covered services can be received during this lag time. However, the COBRA continuant should be prepared to either provide proof of insurance or resubmit the claim if it is initially denied. If an individual elects to continue any benefits under COBRA, the first payment must be made within 45 days of the election to continue coverage. The first payment covers the period beginning with the date the qualifying event occurred through the date the continuation coverage was elected. Thereafter, monthly payments are due on the first of the month and must be paid within the 31 day grace period following the due date. COBRA regulations may change from time to time. The extension of coverage will be provided in accordance with current law. COBRA rules are complicated; contact the Total Rewards Department (see the Quick Reference Guide on page 11) with any questions regarding eligibility. Veteran Reemployment Cleveland Clinic will also comply with the provisions of the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA). This law enables employees who take leaves of absence to serve in the armed forces to continue their medical coverage in a manner similar to COBRA. Retirement Dental benefits cease at the end of the month in which you retire. You may elect to continue coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA). Staff members who were enrolled may be eligible to elect to continue coverage under the Retiree Dental Benefit Program. Medical Leave/Disability Status If you are on an approved medical leave of absence for more than six months, he or she may be eligible for medical leave/disability status. If approved for medical leave/disability status, coverage may be extended. Arrangements for continuation of coverage must be made directly with the Total Rewards Department (see the Quick Reference Guide on page 11). 14

18 Leave of Absence Coverage may continue during an approved leave of absence. Continuation of coverage must be arranged directly with the Total Rewards Department (see the Quick Reference Guide on page 11). Termination of Coverage Coverage under the Benefit Program terminates the last day of the month in which: You transfer to a non-benefits eligible position; or You terminate employment; or You or your dependent(s) are no longer eligible plan participants. You may have your opportunity to continue coverage under COBRA as described on page 13. A Statement of Your Rights Under ERISA As a participant in the Cleveland Clinic Welfare Benefits Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA) which are described on page 16. Receive Information about Your Plan and Benefits ERISA provides that all plan participants shall be entitled to: Examine, without charge, at the Plan Administrator's office and at other specified locations, such as worksites, all documents governing the Plan and/or this Benefit Program including insurance contracts and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Pension and Welfare Benefit Administration. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the plan, including insurance contracts, and copies of the latest annual report (Form 5500 Series) and updated Summary Plan Description. The Plan Administrator may make a reasonable charge for the copies. Receive a summary of the plan s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report. Continue Group Health Plan Coverage You may continue dental care coverage for yourself, spouse or dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this Summary Plan Description and the documents governing the plan on the rules governing your COBRA continuation coverage rights. Prudent Actions by Plan Fiduciaries In addition to creating rights for plan participants ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called fiduciaries of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights under ERISA. 15

19 Enforce Your Rights If your claim for benefits is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and do not receive them within thirty (30) days, you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the plan s decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court. If it should happen that plan fiduciaries misuse the plan s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. Assistance with Your Questions If you have any questions about your plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration. ERISA Required Information This information is provided in compliance with the Employee Retirement Income Security Act of 1974 (ERISA), as amended. While you should not need these details on a regular basis, the information may be useful if you have specific questions about the Plan. This following provides information specific to the Cleveland Clinic Welfare Benefit Plan (the Plan ), and the Cleveland Clinic Enhanced Dental Benefit Program (the Benefit Program ) which is a component of the Plan and provides dental benefits to eligible employees and staff members. Official Plan Name Cleveland Clinic Welfare Benefits Plan Official Benefit Program Name... Cleveland Clinic Enhanced Dental Benefit Program Plan Number Type of Administration Benefits are provided solely under the terms and conditions of a contract between Cleveland Clinic and Cigna Dental. The Insurer acts on behalf of Cleveland Clinic or the Plan Administrator of the Plan Cigna Dental P.O. Box Chattanooga, TN

20 Contributions to the Benefit Programs The Cleveland Clinic Enhanced Dental Benefit Program is a Cigna Dental PPO Plan, which is a self-insured benefit plan offering dental benefits. Benefits from the Benefit Program are paid from employee contributions, as applicable, and from the general assets of Cleveland Clinic, as needed. Cleveland Clinic has contracted with Cigna, a thirdparty administrator to administer the Benefit Program. The Plan Sponsor shall from time to time determine the amount of contributions payable by Participants. Funding Medium The Benefit Program is funded by employer and employee contributions. Benefits provided by this Benefit Program are provided solely through Cigna. Cleveland Clinic does not directly provide any benefits. Plan Sponsor, Plan Administrator and Plan Fiduciary Cleveland Clinic 3050 Science Park Drive / AC341 Beachwood, OH The administration of the Plan, including the Benefit Program, will be under the supervision of the Plan Administrator. To the fullest extent permitted by law, the Plan Administrator will have the discretion to determine all matters relating to eligibility, coverage and benefits under the Plan. The Plan Administrator will also have the discretion to determine all matters relating to the interpretation and operation of the Plan including any portion thereof. Any determination by the Plan Administrator, or any authorized delegate, shall be final and binding. Agent for Service of Legal Process Cleveland Clinic Law Department / AC Science Park Drive Beachwood, OH Service of legal process may also be made on the Plan Administrator. Plan Year January 1 December Records and reports for the Plan, including Benefit Programs contained therein, are kept on a calendar year (January 1 December 31). The Plan Year is also the Fiscal Year. Employer Identification Number of Plan Sponsor Dental Benefit Program Effective Date The Plan is effective January 1, 2013 and the provisions of the Benefit Program are effective January 1, Plan Documentation If there are any discrepancies between this summary plan description and the provisions of the Plan document, including the contract, the Plan document will prevail. No oral interpretations can change this Plan. The Plan Sponsor also reserves the right to interpret the Plan s coverage and meaning in the exercise of its sole discretion. 17

21 Future of the Plan: The Plan Sponsor reserves the right to amend, modify or terminate the Plan, including this Benefit Program, in whole or in part, at any time, without notice, in such manner as it shall determine regardless of a participant s health or treatment status, which may result in the termination or modification of a staff member s coverage. If the Plan is amended, modified, or terminated, the rights of staff members are limited to services and percentages of Allowed Amounts incurred prior to the Plan s amendment, modification or termination. However, this will not affect any claim for covered expenses incurred prior to the modification or termination of the Plan Since premiums are paid on a monthly basis, if the Plan, or any of the components are terminated, any premium paid but not applied to provide coverage for a month, in whole or in part, will be returned to the participant This SPD does not create any contractual rights to employment nor does it guarantee the right to receive benefits under the Plan. Benefits are payable under the Plan only to individuals who have satisfied all of the conditions under the Plan document for receiving benefits. No Employment Contract This SPD does not create any contractual rights to employment nor does it guarantee the right to receive benefits under the Plan or Benefit Program. Benefits are payable under the Plan or Benefit Program only to individuals who have satisfied all of the conditions under the Plan document for receiving benefits. Delegation of Responsibility The Plan Administrator may delegate to other persons responsibilities for performing certain duties of the Plan Administrator under the terms of the Plan. The Plan Administrator, Claims Administrator, and/or Appeals Administrator, as applicable, may seek such expert advice as reasonably necessary with respect to the Plan or Benefit Program. The Plan Administrator, Claims Administrator, and/or Appeals Administrator, as applicable, shall be entitled to rely upon the information and advice furnished by such delegates and experts, unless actually knowing such information and advice to be inaccurate or unlawful. The Plan Administrator may adopt uniform rules for the administration of the Plan from time to time, as it deems necessary or appropriate. 18

22 Cleveland Clinic Every life deserves world class care Euclid Avenue, Cleveland, OH Cleveland Clinic is a top-ranked nonprofit academic medical center founded in With more than 1,300 staffed beds, as well as research and education institutes, the organization is dedicated to providing expert inpatient and hospital care through innovation, quality, teamwork and service. The Cleveland Clinic Foundation /2015