Massachusetts State Health Care. Professionals Dental Fund. Summary Plan Description

Transcription

1 Massachusetts State Health Care Professionals Dental Fund Summary Plan Description Effective February 1, 2008

2 MASSACHUSETTS STATE HEALTH CARE PROFESSIONALS DENTAL FUND P.O. Box 9631, Boston, MA BOARD OF TRUSTEES Michele Heffernan Kevin R. Barrett Cheryl Malone Gary Spring Marilyn Tarmey Kevin M. Hayes Steven Robins Judy A. Locke Thomas P. Martin Patricia O Neill LEGAL COUNSEL Segal, Roitman, LLP FUND AUDITOR Michael P. Ross, CPA CONSULTANTS AND ACTUARIES The Segal Company FUND ADMINISTRATOR Alicare i

3 Dear Member: This booklet describes the dental and vision benefits that you and your eligible dependents are entitled to under the Massachusetts State Health Care Professionals Dental Fund. While the Board of Trustees is pleased to offer this Plan of Benefits, it reserves the right to amend, modify, discontinue or terminate all or part of this Plan whenever, in its judgment, conditions so warrant. Please read this booklet carefully and keep it with your important papers; it replaces previous booklets. You will see that the Trustees have adopted two significant improvements in Dental Expense Benefits. As of September 1, 2002, the DentalGuard Preferred Select Network was added to your dental benefits, as a way to minimize your out-of-pocket expenses. Additionally, in 2002 a High Option Dental Plan was offered to members employed by the University of Massachusetts Dartmouth, the University of Massachusetts Medical School and UMASS Memorial Medical Center. In 2003, the Trustees extended the High Option Dental Plan to members employed by the Commonwealth of Massachusetts, Unit 7, as well. Eligible members who elect the High Option Dental Plan make employee contributions each month to support the increased cost of that plan. The tax consequences of making employee contributions will vary from one employer to another, and contributing employees should check with their employer or accountant about the tax implications of their contributions. YOU SHOULD COMPLETE AN ENROLLMENT FORM if you have never completed an enrollment form or if you need to update the Fund s information about you (if you have a new address, change in name, or if you have a new dependent). No claims will be processed until a completed enrollment form is on file. The Fund s pre-treatment estimate program for dental benefits remains in effect. You should request a pre-treatment estimate from the Fund for any dental claim that you expect to be in excess of $ That way you will know before the dental work begins whether it is a covered procedure under the Plan and the exact amount, if any, that will be covered by the Fund. If you have any questions or need enrollment forms, claim forms or copies of this SPD, please call Alicare at , write to the Massachusetts State Health Care Professionals Dental Fund, c/o Alicare, P.O. Box 9631, Boston, MA or log on to Your Trustees worked diligently in reviewing various Plan options and believe that these Plans and these levels of benefits will provide quality dental and vision coverage for you and your family. We urge you to take full advantage of these important benefits. Sincerely, BOARD OF TRUSTEES ii

4 Table of Contents Dental Plans...2 Standard Dental Plan... 2 High Option Dental Plan... 3 Changing Your Coverage During the Year... 4 Schedules of Dental Benefits...6 Open Enrollment DentalGuard Preferred Select Network Dental Expense Benefits for You and Your Family...23 Exceptions and Limitations...23 Vision Benefits...24 Filing Dental and Vision Claims General Information...30 Employee Eligibility...30 Dependent Eligibility...30 Qualified Medical Child Support Orders (QMCSOs)...31 Coordination of Benefits...31 Subrogation...32 Termination of Coverage...34 Continuation of Coverage (COBRA)...34 Family and/or Medical Leave USERRA...43 Certificates of Coverage...43 Protected Health Information (PHI) Board of Trustees Policy Statements...46 Administrative Information...47 Statement of Rights Under The Employee Retirement Income Security Act of 1974 (ERISA)...49 Board of Trustees

5 Dental Plans Dental Plan Election Members employed by the University of Massachusetts Dartmouth, the University of Massachusetts Medical School or the Commonwealth of Massachusetts, Unit 7, may annually elect to enroll in one of the following dental plans: the Standard Plan or the High Option Dental Plan. Elections for members employed by the UMass Memorial Medical Center become effective each January 1 and remain in effect through each December 31. This twelve-month period is called the UMass Memorial Medical Center Plan Year. Elections for members employed by the Commonwealth of Massachusetts, Unit 7, the University of Massachusetts Dartmouth and the University of Massachusetts Medical School become effective each July 1 and remain in effect through each June 30. This twelve-month period is called the Commonwealth of Massachusetts, Unit 7, the University of Massachusetts Dartmouth and the University of Massachusetts Medical School Plan Year. During a Plan Year you are only able to change your Dental Plan election during the annual open enrollment period, except for qualifying changes-in-status as described on page 5. For open enrollment information, please see page 19. Covered Dental Services Benefits are payable only for services listed in the Schedules of Benefits and only for amounts up to the Maximum Payment. See page 7 through 18 for the Schedules of Benefits for the Standard and High Option Dental Plans. Standard Dental Plan Maximum Payment for the Standard Plan $1, each calendar year, for each covered person, excluding orthodontia. There is also a $ annual maximum for periodontia services which is included in this $1, maximum. There is an additional $1, lifetime maximum for each covered person for orthodontia. No Member Contributions for the Standard Plan Your employer makes a monthly contribution to the Fund on your behalf to support your dental benefits. Your employer makes the same level of contributions toward either the Standard Plan or the High Option Plan, if you are eligible to participate in either Plan. If you are in the Standard Plan, you are not required to contribute to the cost of the Plan. Your employer s monthly contribution to the Fund on your behalf supports your dental benefits. 2

6 High Option Dental Plan Maximum Payment for the High Option Plan $2, each calendar year, for each covered person, excluding orthodontia. There is also a $ annual maximum for periodontia services which is included in this $2, maximum. There is an additional $2, lifetime maximum for each covered person for orthodontia. Member Contributions for the High Option Dental Plan Your employer makes a monthly contribution to the Fund on your behalf to support your dental benefits. Your employer makes the same level of contributions toward either the Standard Plan or the High Option Plan, if you are eligible to participate in either Plan. If you enroll in the High Option Plan, you are required to make an employee contribution each month. The contribution amount is set by the Trustees and is subject to change from time to time at the Trustees discretion. Members employed by UMass Memorial Medical Center pay for these contributions via pre-tax payroll deduction. Members employed by the University of Massachusetts Dartmouth, the University of Massachusetts Medical School and the Commonwealth of Massachusetts, Unit 7 presently pay for these contributions via payroll deductions on an after-tax basis. The tax treatment of the contributions is determined by the particular employer, and is subject to change. You make member contributions in the month preceding the month for which dental coverage is provided. For example, deductions made in February provide you with High Option Benefits in March. Eligibility to Participate in the High Option Dental Plan You are eligible to participate in the High Option Dental Plan, i.e., make the required pre-tax or after tax payroll deductions, on the first day of the month following the date you return the required enrollment/deduction forms to Alicare. You must enroll in the High Option Dental Plan within thirty (30) days of being notified of your eligibility, or you forfeit the right to enroll in the High Option Dental Plan for the Plan Year. Missed Member Contributions (a) In General: If a member fails to make the monthly contribution to the High Option Dental Plan, the member will become covered under the Standard Plan beginning on the first day of the month following the month in which member contributions cease, provided the member is still eligible for Fund benefits. 3

7 (b) Exception for Sick Leave, Leave of Absence or Leave Without Pay that is a Non-Family Medical Leave Act (FMLA) Leave: If member contributions are not made because the member is on sick leave, leave of absence or leave without pay that is not considered FMLA leave, the member must notify Alicare of the occurrence of the leave. Upon notification, the member may self-pay the contributions if notification is made within 60 days of the commencement of the leave. The member will be required to pay all of the member contributions that have not been made during the Plan Year. Changing Your Coverage During The Year Government regulations generally require that your Plan coverage elections remain in effect throughout the Plan Year applicable to you, but you may be able to make some changes during the year if the Plan Administrator or its designee determines that you have a qualifying change in your status affecting your benefit needs (please refer to page 3 for the definition of your plan year). If, and only if, you have one of the following qualifying changes in status, you can change your dental coverage option and/or who is covered under the Plan during the Plan Year. Change in legal marital status, including marriage, divorce, legal separation, annulment or death of a spouse; Change in number of dependents, including birth, adoption, placement for adoption, or death of a dependent child; Change in employment status or work schedule, including the start or termination of employment by you, your spouse or any dependent child, or an increase in hours of employment by you, your spouse or any dependent child, including a switch between part-time and full-time employment, a strike or lockout, or the start of or return from an unpaid leave of absence; Change in dependent status under the terms of this Plan, including changes due to attainment of age, loss of student status or any other reason provided under the definition of dependent; Change of residence or worksite by you, your spouse or any dependent child; Change required under the terms of a Qualified Medical Child Support Order (QMCSO), including a change in your election to provide coverage for the child specified in the order, or to cancel coverage for the child if the order requires your former spouse to provide coverage. 4

8 You may also make a prospective election change that is on account of and corresponds with a change made under the plan of your spouse s, former spouse s, or dependent s employer if a plan of your spouse s, former spouse s, or dependent s employer (1) permits the participant to make an election change that would be permitted under federal regulations or (2) permits participants to make an election for a period of coverage that is different from the period of coverage under the Plan. A change of election during the Plan Year due to a change in family or employment status must be consistent with that change. For example, adding a dependent to your dental coverage would be consistent with the birth of the child. However, the birth of a child would not be consistent with a change to single coverage. An employee may also elect to increase payments under the Plan in order to pay for continuation coverage under the group health plan as provided in the Consolidated Omnibus Budget Reconciliation Act (COBRA) or any similar state law. A change in election must be made within 60 days after the qualifying change-instatus occurs, and will be effective for the balance of the Plan Year in which the election is made, beginning on the first day of the month following the month in which the election is made. However, in the event of birth, adoption or placement for adoption, the change in election will be effective as of the date of the birth, adoption or placement for adoption. The following schedules list the dental services and the Fund s payment for those services. All additional charges are an out-of-pocket cost to the member for any of these procedures. 5

9 I. DIAGNOSTIC SERVICES CODE Schedules of Dental Benefits DENTAL SERVICE MAXIMUM PAYMENT FOR STANDARD PLAN MAXIMUM PAYMENT FOR HIGH OPTION PLAN EXAMS, PROPHYLAXES AND X-RAYS *D0120 PERIODIC ORAL EVALUATION ESTABLISHED PT. $15.00 $28.00 *D0140 LIMITED ORAL EVALUATION PROBLEM $36.00 $70.00 FOCUSED... *D0150 COMPREHENSIVE ORAL EVALUATION NEW OR $33.00 $65.00 ESTABLISHED PATIENT **D0160 DETAILED & EXTENSIVE ORAL EVALUATION PROBLEM FOCUSED, BY REPORT. $33.00 $65.00 D0210 INTRAORAL-COMPLETE SERIES INCLUDING BITEWINGS (Once in 36 months)... $56.00 $ D0220 INTRAORAL-PERIAPICAL-FIRST FILM... $11.00 $21.00 D0230 INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM... $11.00 $21.00 D0240 INTRAORAL-OCCLUSAL FILM... $13.00 $25.00 D0270 BITEWING, 1 FILM... $10.00 $18.00 D0272 BITEWING, 2 FILMS... $17.00 $33.00 **D0273 BITEWING, 3 FILMS.. $22.00 $42.00 D0274 BITEWING, 4 FILMS... $27.00 $51.00 **D0277 VERTICAL BITEWINGS 7 TO 8 FILMS $41.50 $80.00 D0290 POSTERIOR-ANTERIOR OR LATERAL SKULL AND FACIAL BONE SURVEY FILM... $43.00 $84.00 D0321 OTHER TMJ FILMS, BY REPORT... $58.00 $ D0330 PANORAMIC FILM... $48.00 $93.00 D0340 CEPHALOMETRIC FILM... $45.00 $86.00 D0350 ORAL/FACIAL PHOTOGRAPHIC IMAGES $21.00 $40.00 D0415 COLLECTION OF MICROORGANISMS FOR CULTURE AND SENSITIVITY. $31.00 $60.00 D0470 DIAGNOSTIC CASTS... $47.00 $91.00 *Maximum of two cleanings and two oral evaluations per calendar year. ** New codes effective for services rendered on and after 2/1/08 6

10 CODE DENTAL SERVICE MAXIMUM PAYMENT FOR STANDARD PLAN MAXIMUM PAYMENT FOR HIGH OPTION PLAN *D1110 PROPHYLAXIS, ADULT $39.00 $75.00 *D1120 PROPHYLAXIS, CHILD. $28.00 $54.00 D1203 TOPICAL APPLICATION OF FLUORIDE, NO PROPHY, CHILD (Before age 19, once in 6 months)... $15.00 $30.00 D1204 TOPICAL APPLICATION OF FLUORIDE, NO PROPHY, ADULT (1 treatment per year)... $15.00 $28.00 D1351 DENTAL SEALANTS PER TOOTH (APPLIED TO 1 ST AND 2 ND MOLARS AND LIMITED TO CHILDREN UNDER AGE 16 AND ONCE IN FOUR YEARS). $21.00 $42.00 *Maximum of two cleanings and two oral evaluations per calendar year. SPACE MAINTAINERS D1510 SPACE MAINTAINER FIXED UNILATERAL (Before age 19)... $ $ D1515 SPACE MAINTAINER FIXED BILATERAL (Before age 19)... $ $ D1520 SPACE MAINTAINER REMOVABLE UNILATERAL. $ $ D1525 SPACE MAINTAINER REMOVABLE BILATERAL... $ $ D1550 RECEMENTATION OF SPACE MAINTAINER... $33.00 $

11 II. RESTORATIONS CODE DENTAL SERVICE MAXIMUM PAYMENT FOR STANDARD PLAN MAXIMUM PAYMENT FOR HIGH OPTION PLAN D2140 D2150 D2160 D2161 SILVER AMALGAM RESTORATIONS AMALGAM - ONE SURFACE, PRIMARY OR PERMANENT... $24.00 $59.00 AMALGAM -TWO SURFACES, PRIMARY OR PERMANENT... $32.00 $77.00 AMALGAM -THREE SUFACES, PRIMARY OR PERMANENT... $37.00 $90.00 AMALGAM -FOUR OR MORE SURFACES, PRIMARY OR PERMANENT... $48.00 $ COMPOSITE RESTORATIONS D2330 RESIN -ONE SURFACE, ANTERIOR... $33.00 $79.00 D2331 RESIN -TWO SURFACES, ANTERIOR... $38.00 $92.00 D2332 RESIN -THREE SURFACES, ANTERIOR... $49.00 $ D2335 RESIN - FOUR OR MORE SURFACES OR INCLUDING INCISAL ANGLE, ANTERIOR... $57.00 $ **D2390 RESIN-BASED COMPOSITE CROWN, ANTERIOR... $57.00 $ D2391 RESIN BASED COMPOSITE - ONE SURFACE POSTERIOR... $40.00 $84.00 D2392 RESIN BASED COMPOSITE TWO SURFACES, POSTERIOR. $55.00 $ D2393 RESIN BASED COMPOSITE THREE SURFACES, POSTERIOR. $72.00 $ D2394 RESIN BASED COMPOSITE, FOUR OR MORE SURFACES... $84.00 $ ** New codes effective for services rendered on and after 2/1/08 8

12 D3110 D3120 D3220 ENDODONTIA PULP CAPPING, DIRECT (excluding final restoration)... $14.00 $33.00 PULP CAPPING, INDIRECT (excluding final restoration)... $14.00 $33.00 THERAPEUTIC PULPOTOMY (excluding final restoration)... $37.00 $90.00 CODE DENTAL SERVICE MAXIMUM PAYMENT FOR STANDARD PLAN MAXIMUM PAYMENT FOR HIGH OPTION PLAN D3310 ROOT CANAL THERAPY, ANTERIOR (excluding final restoration)... $ $ D3320 ROOT CANAL THERAPY, BICUSPID (excluding final restoration)... $ $ D3330 ROOT CANAL THERAPY, MOLAR (excluding final restoration)... $ $ D3346 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY (anterior)... $ $ D3347 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY (bicuspid)... $ $ D3348 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY (molar)... $ $ D3410 APICOECTOMY/PERIRADICULAR SURGERY (Anterior)... $ $ D3421 APICOECTOMY/PERIRADICULAR SURGERY (Bicuspid, first root)... $ $ D3425 APICOECTOMY/PERIRADICULAR SURGERY (Molar, first root)... $ $ D3426 APICOECTOMY/PERIRADICULAR SURGERY (EACH ADDITIONAL ROOT). $ $ D3430 RETROGRADE FILLING, PER ROOT... $33.00 $

13 CODE DENTAL SERVICE MAXIMUM PAYMENT FOR STANDARD PLAN MAXIMUM PAYMENT FOR HIGH OPTION PLAN PERIODONTIA ANNUAL MAXIMUM FOR PERIODONTIA SERVICES... $ $ D4210 GINGIVECTOMY/GINGIVOPLASTY, FOUR OR MORE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER QUADRANT... $ $ **D4211 GINGIVECTOMY OR GINGIVOPLASTY ONE TO THREE CONTIBUOUS TEETH OR BOUNDED TEETH PER QUADRANT. $77.40 $ D4240 GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING, FOUR OR MORE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER QUADRANT $ $ **D4241 GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING ONE TO THREE CONTIGUOUS TEETH $78.00 $ OR BOUNDED TEETH SPACES PER QUADRANT **D4245 APICALLY POSITIONED FLAP $ $ D4249 CLINICAL CROWN LENGTHENING-HARD TISSUE... $ $ D4260 OSSEOUS SURGERY, (INCLUDING FLAP ENTRY AND CLOSURE) FOUR OR MORE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER QUADRANT... $ $ **D4261 OSSEOUS SURGERY (INCLUDING FLAP ENTRY AND CLOSURE) ONE TO THREE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER QUADRANT $ $ D4263 BONE REPLACEMENT GRAFT-FIRST SITE IN QUADRANT... $51.00 $ D4264 BONE REPLACEMENT GRAFT-EACH ADDITIONAL SITE IN QUADRANT... $61.00 $ D4270 PEDICLE SOFT TISSUE GRAFT PROCEDURE... $ $ D4271 FREE SOFT TISSUE GRAFT PROCEDURE (INCLUDING DONOR SITE SURGERY).. $ $ **D4273 SUBEPITHELIAL CONNECTIVE TISSUE GRAFT PROCEDURES, PER TOOTH. $ $ **D4275 SOFT TISSUE ALLOGRAFT.. $ $

14 **D4276 COMBINED CONNECTIVE TISSUE AND DOUBLE PEDICLE GRAFT, PER TOOTH $ $ D4320 PROVISIONAL SPLINTING-INTRACORONAL... $55.00 $ D4321 PROVISIONAL SPLINTING-EXTRACORONAL... $60.00 $ ** New codes effective for services rendered on and after 2/1/08 CODE DENTAL SERVICE MAXIMUM PAYMENT FOR STANDARD PLAN MAXIMUM PAYMENT FOR HIGH OPTION PLAN D4341 PERIODONTAL SCALING AND ROOT PLANING FOUR OR MORE TEETH PER QUADRANT $57.00 $ D4342 PERIODONTAL SCALING AND ROOT PLANING ONE TO THREE TEETH PER QUADRANT. $58.00 $ D4910 PERIODONTAL MAINTENANCE (FOLLOWING ACTIVE THERAPY, 2 PER YEAR IN ADDITION TO $77.00 STANDARD PROPHYLAXIS)... $32.00 **D4920 UNSCHEDULED DRESSING CHANGE (BY SOMEONE OTHER THAN TREATING DENTIST). $21.00 $53.00 ** New codes effective for services rendered on and after 2/1/08 III. PROSTHODONTICS INLAY & ONLAY RESTORATIONS **D2510 INLAY METALLIC, ONE SURFACE... $ $ **D2520 INLAY METALLIC, TWO SURFACES. $ $ **D2530 INLAY METALLIC, THREE OF MORE SURFACES... $ $ **D2542 ONLAY METALLIC, TWO SURFACES $ $ **D2543 ONLAY METALLIC, THREE SURFACES... $ $ **D2544 ONLAY METALLIC, FOUR OR MORE SURFACES $ $ D2610 INLAY PORCELAIN/CERAMIC, ONE SURFACE... $ $ D2620 INLAY PORCELAIN/CERAMIC, TWO SURFACES... $ $ D2630 INLAY PORCELAIN/CERAMIC, THREE OR MORE SURFACES... $ $ **D2642 ONLAY PORCELAIN/CERAMIC, TWO OR MORE SURFACES... $ $

15 **D2643 ONLAY PORCELAIN/CERAMIC, THREE SURFACES... $ $ D2644 ONLAY PORCELAIN/CERAMIC, FOUR OR MORE SURFACES... $ $ D2650 INLAY RESIN-BASED COMPOSITE, ONE SURFACE. $ $ D2651 INLAY RESIN-BASED COMPOSITE, TWO SURFACES... $ $ D2652 INLAY RESIN-BASED COMPOSTIE, THREE OR MORE SURFACES... $ $ ** New codes effective for services rendered on and after 2/1/08 CODE DENTAL SERVICE MAXIMUM PAYMENT FOR STANDARD PLAN MAXIMUM PAYMENT FOR HIGH OPTION PLAN **D2662 ONLAY RESIN-BASED COMPOSITE, TWO SURFACES... $ $ **D2663 ONLAY RESIN-BASED, THREE SURFACES... $ $ **D2664 ONLAY RESIN BASED, FOUR OR MORE SURFACES... $ $ CROWNS AND BRIDGES (SINGLE RESTORATIONS) D2710 CROWN RESIN-BASED COMPOSITE (INDIRECT)... $ $ **D2712 CROWN ¾ RESIN-BASED COMPOSITE (INDIRECT) $ $ D2720 CROWN RESIN WITH HIGH NOBLE METAL... $ $ D2721 CROWN RESIN WITH PREDOMINATELY BASE METAL... $ $ D2722 CROWN RESIN WITH NOBLE METAL... $ $ D2740 CROWN PORCELAIN/CERAMIC SUBSTRATE... $ $ D2750 CROWN PORCELAIN FUSED TO HIGH NOBLE METAL... $ $ D2751 CROWN PORCELAIN FUSED TO PREDOMINATELY BASE METAL... $ $ D2752 CROWN PORCELAIN FUSED TO NOBLE METAL... $ $ D2780 CROWN ¾ CAST HIGH NOBLE METAL... $ $ D2781 CROWN ¾ CAST PREDOMINATELY BASE METAL... $ $ D2782 CROWN ¾ CAST NOBLE METAL... $ $

16 ** New codes effective for services rendered on and after 2/1/08 13

17 CODE DENTAL SERVICE MAXIMUM PAYMENT FOR STANDARD PLAN MAXIMUM PAYMENT FOR HIGH OPTION PLAN D2783 CROWN ¾ PORCELAIN/CERAMIC... $ $ D2790 CROWN FULL CAST HIGH NOBLE METAL... $ $ D2791 CROWN FULL CAST PREDOMINATELY BASE METAL... $ $ D2792 CROWN FULL CAST NOBLE METAL... $ $ **D2794 CROWN TITANIUM $ $ D2799 PROVISIONAL CROWN... $ $ OTHER RESTORATIVE SERVICES D2910 RECEMENT INLAY, ONLAY OR PARTIAL COVERAGE RESTORATION... $18.00 $44.00 D2920 RECEMENT CROWN... $20.00 $48.00 D2930 PREFABRICATED STAINLESS STEEL CROWN (primary tooth)... $61.00 $ D2940 SEDATIVE FILLINGS... $22.00 $55.00 D2950 CORE BUILDUP, INCLUDING ANY PINS... $41.00 $ D2951 PIN RETENTION, PER TOOTH (in addition to restoration)... $10.00 $22.00 D2952 POST AND CORE IN ADDITION TO CROWN, INDIR- ECTLY FABRICATED... $95.00 $ D2953 EACH ADDITIONAL INDIRECTLY FABRICATED POST SAME TOOTH $59.00 $ D2954 PREFABRICATED POST & CORE IN ADDITION TO CROWN... $74.00 $ D2960 LABIAL VENEER (RESIN LAMINATE), CHAIRSIDE... $ $ D2961 LABIAL VENEER (RESIN LAMINATE), LAB... $ $ D2962 LABIAL VENEER (PORCELAIN LAMINATE), LAB... $ $ ** New codes effective for services rendered on and after 2/1/08 FULL AND PARTIAL DENTURES D5110 COMPLETE DENTURE, UPPER (MAXILLARY)... $ $ D5120 COMPLETE DENTURE, LOWER (MANDIBULAR)... $ $

18 D5130 IMMEDIATE DENTURE, UPPER (MAXILLARY)... $ $ D5140 IMMEDIATE DENTURE, LOWER (MANDIBULAR)... $ $

19 CODE D5211 D5212 D5213 D5214 **D5225 **D5226 DENTAL SERVICE MAXIMUM PAYMENT FOR STANDARD PLAN MAXIMUM PAYMENT FOR HIGH OPTION PLAN MAXILLARY PARTIAL DENTURE RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)... $ $ MANDIBULAR PARTIAL DENTURE RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)... $ $ MAXILLARY PARTIAL DENTURE CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)... $ $ MANDIBULAR PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)... $ $ MAXILLARY PARTIAL DENTURE FLEXIBLE BASE (INCLUDING ANY CLASPS, RESTS AND TEETH). $ $ MANDIBULAR PARTIAL DENTURE FLEXIBLE BASE (INCLUDING ANY CLASPS, RESTS AND TEETH). $ $ ** New codes effective for services rendered on and after 2/1/08 REPAIR AND ADJUSTMENTS TO PROSTHETIC APPLIANCES DENTURES D5410 ADJUST COMPLETE DENTURE (MAXILLARY)... $16.00 $40.00 D5411 ADJUST COMPLETE DENTURE (MANDIBULAR)... $19.00 $46.00 D5421 ADJUST PARTIAL DENTURE (MAXILLARY)... $18.00 $44.00 D5422 ADJUST PARTIAL DENTURE (MANDIBULAR)... $21.00 $51.00 D5510 REPAIR BROKEN COMPLETE DENTURE BASE... $33.00 $79.00 D5520 REPLACE MISSING OR BROKEN TEETH-COMPLETE DENTURE (EACH TOOTH)... $22.00 $55.00 D5610 REPAIR RESIN DENTURE BASE... $28.00 $68.00 D5620 REPAIR CAST FRAMEWORK... $31.00 $75.00 D5630 REPAIR OR REPLACE BROKEN CLASP... $33.00 $81.00 D5640 REPLACE BROKEN TEETH, PER TOOTH... $24.00 $

20 17

21 CODE DENTAL SERVICE MAXIMUM PAYMENT FOR STANDARD PLAN MAXIMUM PAYMENT FOR HIGH OPTION PLAN D5650 ADD TOOTH TO EXISTING PARTIAL DENTURE... $28.00 $68.00 D5660 ADD CLASP TO EXISTING PARTIAL DENTURE... $37.00 $90.00 **D5670 REPLACE ALL TEETH AND ACRYLIC ON CAST METAL FRAMEWORK (MAXILLARY).. $ $ **D5671 REPLACE ALL TEETH AND ACRYLIC ON CAST METAL FRAMEWORK (MANDIBULAR)... $ $ D5710 REBASE COMPLETE MAXILLARY DENTURE (ONCE IN 3 YEARS)... $87.00 $ D5711 REBASE COMPLETE MANDIBULAR DENTURE (ONCE IN 3 YEARS)... $87.00 $ D5720 REBASE MAXILLARY PARTIAL DENTURE (ONCE IN 3 YEARS)... $93.00 $ D5721 REBASE MANDIBULAR PARTIAL LOWER DENTURE (ONCE IN 3 YEARS)... $93.00 $ D5730 RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE)... $57.00 $ D5731 RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE)... $46.00 $ D5740 RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE)... $54.00 $ D5741 RELINE MANDIBULAR PARTIAL DENTURE (CHAIRSIDE)... $46.00 $ D5750 RELINE COMPLETE MAXILLARY DENTURE, LAB... $68.00 $ D5751 RELINE COMPLETE MANDIBULAR DENTURE, LAB... $81.00 $ D5760 RELINE MAXILLARY PARTIAL DENTURE, LAB... $82.00 $ D5761 RELINE MANDIBULAR PARTIAL DENTURE, LAB... $82.00 $ **D5860 OVERDENTURE COMPLETE, BY REPORT $ $ **D5861 OVERDENTURE PARTIAL, BY REPORT $ $ **D5862 PRECISION ATTACHMENT, BY REPORT INCLUDES MALE AND FEMALE PAIR.. $ $ ** New codes effective for services rendered on and after 2/1/08 18

22 CODE **D6053 **D6054 **D6058 **D6059 **D6060 **D6061 **D6062 **D6063 **D6064 DENTAL SERVICE MAXIMUM PAYMENT FOR STANDARD PLAN MAXIMUM PAYMENT FOR HIGH OPTION PLAN IMPLANT SERVICES IMPLANT/ABUTMENT, BY REPORT INCLUDES MALE AND FEMALE PAID IMPLANT/ABUTMENT SUPPORTED REMOVABLE DENTURE FOR COMPLETELY EDENTULOUS ARCH. $ $ IMPLANT/ABUTMENT SUPPORTED REMOVABLE DENTURE FOR PARTIALLY EDENTULOUS ARCH. $ $ ABUTMENT SUPPORTED PORCELAIN/CERAMIC CROWN $ $ ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (HIGH NOBLE METAL).. $ $ ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (PREDOMINANTLY BASE METAL). $ $ ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (NOBLE METAL). $ $ ABUTMENT SUPPORTED CAST METAL CROWN (HIGH NOBLE METAL). $ $ ABUTMENT SUPPORTED CAST METAL CROWN (PREDOMINANTLY BASE METAL) $ $ ABUTMENT SUPPORTED CAST METAL CROWN (NOBLE METAL) $ $ D6065 IMPLANT SUPPORTED PORCELAIN/CERAMIC CROWN $ $ D6066 IMPLANT SUPPORTED PORCELAIN FUSED TO METAL CROWN... $ $ D6067 IMPLANT SUPPORTED METAL CROWN... $ $ **D6092 RECEMENT IMPLANT/ABUTMENT SUPPORTED CROWN $20.00 $48.00 **D6094 ABUTMENT SUPPORTED CROWN TITANIUM. $ $ **New codes effective for services rendered on and after 2/1/08 19

23 CODE DENTAL SERVICE MAXIMUM PAYMENT FOR STANDARD PLAN MAXIMUM PAYMENT FOR HIGH OPTION PLAN BRIDGEWORK: **D6210 PONTIC CAST HIGH NOBLE METAL.. $ $ D6211 PONTIC CAST PREDOMINATELY BASE METAL... $ $ **D6212 PONTIC CAST NOBLE METAL. $ $ **D6214 PONTIC TITANIUM. $ $ D6240 PONTIC PORCELAIN FUSED TO HIGH NOBLE METAL... $ $ D6241 PONTIC PORCELAIN FUSED TO PREDOMINATELY BASE METAL... $ $ D6242 PONTIC PORCELAIN FUSED TO NOBLE METAL... $ $ **D6245 PONTIC PORCELAIN/CERAMIC... $ $ **D6250 PONTIC RESIN WITH HIGH NOBLE METAL. $ $ D6251 PONTIC RESIN WITH PREDOMINATELY BASE METAL. $ $ **D6252 PONTIC RESIN WITH NOBLE METAL... $ $ **D6608 ONLAY PORCELAIN/CERAMIC, TWO SURFACES... $ $ **D6609 ONLAY PORCELAIN/CERAMIC, THREE OR MORE SURFACES... $ $ **D6610 ONLAY CAST HIGH NOBLE METAL, TWO SURFACES... $ $ **D6611 ONLAY CAST HIGH NOBLE METAL, THREE OR MORE SURFACES.. $ $ **D6612 ONLAY CAST PREDOMINANTLY BASE METAL, TWO SURFACES. $ $ **D6613 ONLAY CAST PREDOMINANTLY BASE METAL, THREE OR MORE SURFACES.. $ $ **D6614 ONLAY CAST NOBLE METAL, TWO SURFACES. $ $ **D6615 ONLAY CAST NOBLE METAL, THREE OR MORE SURFACES... $ $ **D6634 ONLAY TITANIUM. $ $ **D6720 CROWN RESIN WITH HIGH NOBLE METAL. $ $ D6721 CROWN RESIN WITH PREDOMINATELY BASE METAL... $ $

24 ** New codes effective for services rendered on and after 2/1/08 21

25 CODE DENTAL SERVICE MAXIMUM PAYMENT FOR STANDARD PLAN MAXIMUM PAYMENT FOR HIGH OPTION PLAN **D6722 CROWN RESIN WITH NOBLE METAL $ $ **D6740 CROWN PORCELAIN/CERAMIC.. $ $ D6750 CROWN PORCELAIN FUSED TO HIGH NOBLE METAL... $ $ D6751 CROWN PORCELAIN FUSED TO PREDOMINATELY BASE METAL... $ $ D6752 CROWN PORCELAIN FUSED TO NOBLE METAL... $ $ **D6780 CROWN ¾ CAST HIGH NOBLE METAL.. $ $ **D6781 CROWN ¾ CAST PREDOMINANTLY BASE METAL $ $ **D6782 CROWN ¾ CAST NOBLE METAL. $ $ **D6783 CROWN ¾ PORCELAIN/CERAMIC.. $ $ D6790 CROWN FULL CAST HIGH NOBLE METAL... $ $ D6791 CROWN FULL CAST PREDOMINATELY BASE METAL... $ $ **D6792 CROWN FULL CAST NOBLE METAL.. $ $ **D6794 CROWN TITANIUM $ $ D6930 RECEMENT FIXED PARTIAL DENTURE... $24.00 $59.00 D6940 STRESS BREAKER... $63.00 $ D6950 PRECISION ATTACHMENT... $ $ **D6970 CAST POST AND CORE IN ADDITION TO FIXED PARTIAL DENTURE RETAINER, INDIRECTLY FABRICATED.. $95.00 $ **D6972 PREFABRICATED POST AND CORE IN ADDITION TO FIXED PARTIAL DENTURE RETAINER.. $74.00 $ **D6973 CORE BUILD UP FOR RETAINER, INCLUDING ANY PINS.. $41.00 $ D6980 FIXED PARTIAL DENTURE REPAIR, BY REPORT... $47.00 $ ** New codes effective for services rendered on and after 2/1/08 22

26 IV. ORAL SURGERY/EXTRACTIONS CODE DENTAL SERVICE MAXIMUM PAYMENT FOR STANDARD PLAN MAXIMUM PAYMENT FOR HIGH OPTION PLAN D7111 EXTRACTION, CORONAL REMNANTS DECIDUOUS TEETH.. $37.00 $77.00 D7140 EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPS REMOVAL).. $38.00 $79.00 D7210 SURGICAL REMOVAL OF ERUPTED TOOTH... $65.00 $ D7220 REMOVAL OF IMPACTED TOOTH SOFT TISSUE... $78.00 $ D7230 REMOVAL OF IMPACTED TOOTH PARTIAL BONY.. $ $ D7240 REMOVAL OF IMPACTED TOOTH COMPLETELY BONY... $ $ D7241 REMOVAL OF IMPACTED TOOTH COMPLETELY BONY, WITH UNUSUAL SURGICAL COMPLICATIONS $ $ D7250 SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (cutting procedure demonstrable by x-ray)... $64.00 $ D7280 SURGICAL ACCESS OF AN UNERUPTED TOOTH... $ $ D7285 BIOPSY OF ORAL TISSUE HARD (BONE, TOOTH)... $65.00 $ D7286 BIOPSY OF ORAL TISSUE SOFT... $49.00 $ D7310 ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS, 4 OR MORE TEETH OR TOOTH SPACES, PER QUADRANT... $46.00 $ **D7311 ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS, ONE TO THREE TEETH OR TOOTH SPACES, PER QUADRANT... $27.60 $66.00 D7320 ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS, 4 OR MORE TEETH OR TOOTH SPACES, PER QUADRANT... $82.00 $ **D7321 ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS, ONE TO THREE TEETH OR TOOTH SPACES, PER QUADRANT... $49.20 $ D7510 INCISION AND DRAINAGE OF ABSCESS INTRAORAL SOFT TISSUE... $40.00 $99.00 D7520 INCISION AND DRAINAGE OF ABSCESS EXTRAORAL SOFT TISSUE... $45.00 $ ** New codes effective for services rendered on and after 2/1/08 23

27 CODE DENTAL SERVICE MAXIMUM PAYMENT FOR STANDARD PLAN MAXIMUM PAYMENT FOR HIGH OPTION PLAN MINOR TREATMENT TO CONTROL HARMFUL HABITS D8210 REMOVABLE APPLIANCE THERAPY... $90.00 $ D8220 FIXED APPLIANCE THERAPY... $90.00 $ UNCLASSIFIED TREATMENT D9110 PALLIATIVE (EMERGENCY) TREATMENT OF DENTAL PAIN, MINOR PROCEDURE... $21.00 $53.00 D9951 OCCLUSAL ADJUSTMENT LIMITED.. $46.00 $ D9952 OCCLUSAL ADJUSTMENT COMPLETE. $65.00 $ D9973 EXTERNAL BLEACHING, PER TOOTH. $90.00 $ D9974 INTERNAL BLEACHING, PER TOOTH.. $90.00 $ V. ORTHODONTIA DENTAL SERVICE LIFETIME MAXIMUM FOR ORTHODONTIA BENEFITS... MAXIMUM PAYMENT FOR STANDARD PLAN MAXIMUM PAYMENT FOR HIGH OPTION PLAN $1, $2, ANNUAL PLAN MAXIMUM (EXCLUDING ORTHODONTIA)... $1, $2, ALL VALID ORTHODONTIA CDT CODES ARE REIMBURSABLE. THE REIMBURSMENT AMOUNT WILL DEPEND UPON WHICH CDT CODE IS BILLED AND REIMBURSEMENTS ARE SUBJECT TO THE MAXIMUMS DENOTED IN THE CHART ABOVE ($1,000 LIFETIME MAXIMUM PAYABLE UNDER THE STANDARD PLAN, $2,000 LIFETIME MAXIMUM PAYABLE UNDER THE HIGH OPTION PLAN). PLAN ALLOWANCE FOR ORTHODONTIA IS LIMITED TO THE GUARDIAN RATE WHEN A PARTICIPATING DENTIST PROVIDES SERVICES. PLAN ALLOWANCE FOR SERVICES RENDERED BY A NON-PARTICIPATING DENTIST IS LIMITED TO THE ACTUAL CHARGE. IN NO CASE WILL THE TOTAL BENEFITS ISSUED EXCEED THE PLAN S LIFETIME MAXIMUMS. NOTE: CURRENT DENTAL TERMINOLOGY 2007 AMERICAN DENTAL ASSOCIATION. ALL RIGHTS RESERVED. 24

28 Open Enrollment Open Enrollment is the period of time each year to be designated by the Fund during which eligible employees may make changes in their dental elections. Enrollment forms will be sent to you. Elections Available During Open Enrollment During the Open Enrollment period, you may elect for yourself and your eligible dependents who are enrolled for coverage, to: enroll in the Standard or High Option Dental Plan; or add eligible dependents for dental and vision coverage; or discontinue coverage under the Standard or High Option Dental Plan for yourself and/or any of your eligible dependents. Restrictions on Elections During Open Enrollment No dependent may be covered unless you are covered. You and all your covered eligible dependents must be enrolled in the same dental program. All relevant parts of the enrollment form must be completed and the form must be submitted before the end of the Open Enrollment period. Changes to Coverage Following Open Enrollment All changes in or discontinuance of coverage will become effective on the first day of the Plan Year following Open Enrollment. Failure to Make a New Election During Open Enrollment If you have been enrolled for coverage and you fail to make a new election during the Open Enrollment period, you will be considered to have made an election to retain the same dental coverage you had during the preceding Plan Year. Failure to Enroll During Open Enrollment - Very Important Information If you fail to enroll yourself and/or any of your eligible dependents during Open Enrollment, you and they will be required to wait until the next Open Enrollment period to enroll in the Plan, except if a qualifying change in status occurs. See page 5 for a description of qualifying changes in status. 25

29 DentalGuard Preferred Select Network As of September 1, 2002, the DentalGuard Preferred Select Network was added to your dental benefits as a way to minimize your out-of-pocket dental expenses. This Network may be used in conjunction with either the Standard Plan or the High Option Plan. What is the DentalGuard Preferred Select Network? Whenever you or a covered family member needs dental care, you are free to visit any dentist or specialist you wish and be reimbursed according to the Fund s schedules of benefits. But you have a choice when you need dental care. If you visit a dentist from the DentalGuard Preferred Select Network, you can minimize your out-of-pocket dental expenses. The DentalGuard Preferred Select Network is a network of dentists who have agreed to fees that are up to 30% less than what dentists normally charge. This means that instead of being responsible for the difference between the Fund s current schedules and the dentists usual charges, you will only be responsible for the difference between the Fund s scheduled amounts and the discounted amounts on the DentalGuard Preferred Select schedule. Most often this will result in out-of-pocket savings for you and your family. In order to receive these out-of-pocket savings, there are no forms for you to complete and no special enrollment is necessary. You present the DentalGuard Preferred Select ID Card to your dentist at the time of service. If your dentist is a participating dentist, your ID card will signify that you are eligible for the discounted fee. As one of the industry s largest Dental Preferred Provider networks, DentalGuard Preferred Select has dentists at over 43,000 locations across the country, with approximately 2,400 dentists in Massachusetts as of January There are also dentists available in surrounding states. You may locate a participating dentist through the on-line provider listing at The on-line directory is updated with new providers on a monthly basis; you can access the web site to see if your provider is listed. If your dentist is not currently participating in the network, he or she may be added at a future date. The Fund in no way selects, employs or controls the dentists in the network. To access the DentalGuard Preferred Select Network: Under Resources (extreme right side of screen) select Provider Online Search Select Find a Dentist Under PPO Networks Select DentalGuard Preferred Select Click on GO 26

30 A directory of the participating Massachusetts dentists will also be furnished to you, upon request, without charge, in a separate document. Obtain a directory of the participating DentalGuard Massachusetts dentists from Alicare by calling or writing to Massachusetts State Health Care Professionals Dental Fund, c/o Alicare, P.O. Box 1477, New York, NY Dental Expense Benefits For You and Your Family If you or an eligible member of your family incurs covered dental charges, this Plan will pay for the expenses actually incurred up to the amount specified in the Schedules of Dental Benefits, but not to exceed in the aggregate the Maximum Payment as shown in those Schedules. Benefits are payable only for services listed in the Schedules of Benefits when performed by a legally qualified dentist or dental hygienist for oral examinations and treatment of accidentally injured or diseased teeth or supporting bone or tissue. THIS PLAN DOES NOT COVER: Exceptions and Limitations 1. Treatment on or to the teeth or gums for cosmetic purposes, including charges for personalization s or characterizations of dentures. 2. Any dental conditions for which the person on whom the claim is presented has received, or is entitled to receive, compensation for that particular dental condition under any worker s compensation or occupational disease law. 3. Charges for any dental services and supplies which are included as covered medical expenses under a comprehensive or major medical expense benefit. 4. Dental treatment provided by or paid for by the United States Government or any instrumentality thereof. 5. Any loss caused by war or act of war, except as specifically covered by the Plan. 6. Loss incurred while engaged in military, naval or air service, except as specifically covered by the Plan. 7. Rebase or reline of a denture in less than six (6) months from initial date of placement, not more often than once in any three (3) year period. 8. Replacement of lost or stolen prosthetics. 9. Sealants (except as provided under the Dental Schedules). 10. Services and supplies for which you or your dependents are not required to pay, or charges that would not be made if no Fund coverage were available. 11. Services not expressly included in the Schedules of Dental Benefits set forth in this Summary Plan Description. 27

31 VISION BENEFITS No Member Contributions for Vision Benefits Your employer makes a monthly contribution to the Fund on your behalf to support your vision benefits. You are not required to contribute to the cost of vision benefits. Benefits The vision benefit may be used only for the following: 1. Purchase one pair of eyeglasses (lenses and frames); 2. Replace or repair lost or broken eyeglasses; and/or 3. Purchase contact lenses during the applicable time period referenced below. Maximum Payment The maximum payment is $100 per twenty-four month period for each covered person age 14 and older. The maximum payment is $100 per twelve-month period for eligible dependents under the age of 14. Benefits Period The first benefits period began on June 1, The next twenty-four month benefit period began on June 1, 2001, and the next twelve-month benefit period began on June 1, Subsequent benefits periods begin each succeeding twenty-four and twelve-month periods. Immediately after an eligible dependent attains age 14, the benefit month period becomes twenty-four months and begins with the next twenty-four month period. Exclusions There are no benefits for professional services or materials connected with: 1. Orthoptics or vision training and any associated supplemental testing. 2. Plano lenses i.e., plain non-prescription lenses or non-prescription sunglasses. 3. Medical or surgical treatment of the eyes. (These services may be covered by your medical plan.) 4. Any eye examination. (These services may be covered by your medical plan.) 5. Any eye examination, or any corrective eye-wear, required by your employer as a condition of employment, e.g., safety-wear. 6. Eye-wear for sports. 7. Lenses not prescribed by an optometrist or an ophthalmologist. 28

32 8. Materials or services purchased from a non-licensed provider. 9. Warranties or replacement cost insurance. 29

33 Filing Dental and Vision Claims The Department of Labor (DOL) issued new claims and appeals regulations that became applicable to the Plan on January 1, The new procedures create maximum time periods for acting on claims and appeals. These new procedures supersede the language set forth in previous versions of this Summary Plan Description. Claims and Appeals Procedures This section describes the procedures for filing claims for benefits from the Plan. It also describes the procedure for you to follow if your claim is denied in whole or in part and you wish to appeal the decision. How to File a Claim A claim for benefits is a request for Plan benefits made in accordance with the Plan s reasonable claims procedures. In order to file a claim for benefits offered under this Plan, you or your provider must complete, sign and submit a dental or vision claim form, as appropriate. Simple inquiries about the Plan s provisions that are unrelated to any specific benefit claim will not be treated as a claim for benefits. In addition, a request for prior approval of a benefit that does not require prior approval by the Plan is not a claim for benefits. A dental or vision claim form may be obtained from Alicare by calling: (617) The following information must be completed on the claim form in order for your request for benefits to be a claim, and for Alicare to be able to decide your claim. Member s name and social security number Member s address and telephone number Member s date of birth Member s marital status Spouse s name and social security number (if applicable) Spouse s date of birth and employment status (if applicable) Name address and telephone number for spouse s employer Patient name and address (if different from member) Patient s relationship to insured Patient Date of Birth Patient s Sex Student status Date of Service CDT code (the code for dental services found in the Current Dental Terminology, as maintained and distributed by the American Dental Association) Billed charge, amount paid and balance due Federal taxpayer identification number (TIN) of the provider Billing name and address If treatment is due to accident, accident details 30

34 WHEN CLAIMS MUST BE FILED Claims must be filed within 12 months following the date the charges were incurred. Failure to file claims within the time required shall invalidate or reduce any claim. WHERE TO FILE CLAIMS Your claim will be considered to have been filed as soon as it is received and date stamped at Alicare. Claims should be filed with Alicare at the following address: Massachusetts State Health Care Professionals Dental Fund c/o Alicare PO Box 1477 New York, NY Tel. (800) Fax. (212) AUTHORIZED REPRESENTATIVES An authorized representative, such as your spouse, may complete the claim form for you if you are unable to complete the form yourself and have previously designated the individual to act on your behalf. A form can be obtained from Alicare to designate an authorized representative. The Plan may request additional information to verify that this person is authorized to act on your behalf. CLAIMS PROCEDURES Post-Service Dental And Vision Claims The following procedure applies to Post-Service Dental and Vision Claims. A Post-Service Claim is a claim for services that have already been provided, for example, a dental claim submitted for payment, or any claim for vision benefits. Dental Benefits 1. Obtain a claim form from Alicare and complete the employee s portion of the claim form and sign your name on the line specified. Failure to complete the form could delay processing of your claim. 2. Have your dentist complete his/her portion of the claim form and mail the claim form to Alicare. 3. In order to receive benefits you must submit your claims within 12 months of the date of dental service. 31

35 Vision Benefits 1. Obtain a claim form from Alicare and complete the employee s portion of the claim form and sign your name on the line specified. Failure to complete the form could delay processing of your claim. 2. Submit your paid bills. (a) Be sure to separate the original itemized statement from the provider for each person, listing all services received, the charge for each service, and the dates(s) the services were received. (b) Provide verification of payment (e.g., an original receipt, an (c) original charge slip or a cancelled check). Submit the claim form, the itemized bill, and the verification of payment to Alicare. 3. In order to receive benefits you must submit your claims within 12 months of the date of vision service. Check the claim form to be certain that all applicable portions of the form are completed and that you have submitted all itemized bills. By doing so, you will expedite the processing of your claim. If the claim forms have to be returned to you for information, delays in payment will result. Ordinarily, you will be notified of the decision on your Post-Service claim within 30 days from the Plan s receipt of the claim. This period may be extended one time by the Plan for up to 15 days if the extension is necessary due to matters beyond the control of the Plan. If an extension is necessary, you will be notified before the end of the initial 30-day period of the circumstances requiring the extension of time and the date by which the Plan expects to render a decision. If an extension is needed because the Plan needs additional information from you, the extension notice will specify the information needed. In that case you will have 45 days from receipt of the notification to supply the additional information. If the information is not provided within that time, your claim will be denied. During the period in which you are allowed to supply additional information, the normal period for making a decision on the claim will be suspended. The deadline is suspended from the date of the extension notice until either 45 days or until the date you respond to the request (whichever is earlier). The Plan then has 15 days to make a decision on a Post-Service Claim and notify you of the determination. NOTICE OF DECISION You will be provided with written notice of a denial of a claim (whether denied in whole or in part). This notice will include: The specific reason(s) for the determination Reference to the specific Plan provision(s) on which the determination is based A description of any additional material or information necessary to perfect the claim, and an explanation of why the material or information is necessary A description of the appeal procedures (including voluntary appeals, if any) and applicable time limits 32

36 A statement of your right to bring a civil action under ERISA Section 502(a) following an adverse benefit determination on review. If an internal rule, guideline or protocol was relied upon in deciding your claim, you will receive either a copy of the rule or a statement that it is available upon request at no charge. If the determination was based on a medical necessity, or because the treatment was experimental or investigational, or other similar exclusion, you will receive an explanation of the scientific or clinical judgment for the determination applying the terms of the Plan to your claim, or a statement that it is available upon request at no charge. You and your Plan may have other voluntary alternate dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency. REQUEST FOR REVIEW OF DENIED CLAIM If your claim is denied in whole or in part, or if you disagree with the decision made on a claim, you may ask for a review. Your request for review must be made in writing to Alicare within 180 days after you receive notice of the denial. REVIEW PROCESS The review process works as follows: You have the right to review documents relevant to your claim. A document, record or other information is relevant if it was relied upon by the Plan in making the decision; it was submitted, considered or generated (regardless of whether it was relied upon); it demonstrates compliance with the Plan s administrative processes for ensuring consistent decision making; or it constitutes a statement of plan policy regarding the denied treatment or service. Upon request, you will be provided with the identification of medical experts, if any, that gave advice to the Plan on your claim, without regard to whether their advice was relied upon in deciding your claim. A different person will review your claim than the one who originally denied the claim. The reviewer will not give deference to the initial adverse benefit determination. The decision will be made on the basis of the record, including such additional documents and comments that may be submitted by you. If your claim was denied on the basis of a medical judgment (such as a determination that the treatment or service was not medically necessary, or was investigational or experimental), a health care professional who has appropriate training and experience in a relevant field of medicine will be consulted. 33