Dental Plan March 1, 2008 February 28, 2009 www.myfirstchoice.fchn.com In the event there is a discrepancy between information provided during open enrollment and the contents of this Benefits Summary, the contents herein shall prevail.
Table of contents Important Information 1 Contacting Customer Service 2 How to Obtain Health Services 3 Your ID Card 3 Choosing a Provider 3 Payment Provisions 4 Plan Year Dental Deductible 4 Annual Deductible and Maximum 4 Lifetime Orthodontia Maximum 4 Participant Reimbursement Liability 5 Summary of Dental Benefits 6 Dental Benefits 8 Dental Limitations and Exclusions 10 Dental Plan Definitions 12
Important Information This booklet describes how to use your benefits, and your coverage and payment levels offered under the RS Medical Employee Dental Plan as of March 1, 2008. For information on eligibility and enrollment, terminating and continuing coverage, administration, claim and appeal procedures, definitions and other details, see the Group Health Summary Plan Document. International Rehabilitative Sciences, Inc. dba RS Medical (RS Medical), the employer, Plan Sponsor and Plan Administrator of this self-funded Plan, delegates to First Choice Health Administrators (FCHA a division of First Choice Health Network, Inc.), a Third Party Administrator (TPA), to perform certain Plan services. The RS Medical Employee Dental Plan will be referred to within this document as the Plan. Please review this booklet carefully and share it with your family. If you have questions, contact RS Medical s Benefits Department (Plan Administrator) or FCHA. Coverage under this Plan will take effect for eligible employees and dependents when all eligibility requirements are satisfied. RS Medical fully intends to maintain this Plan indefinitely, but reserves the right to terminate, suspend, discontinue or amend the Plan at any time, for any reason. The Plan will pay benefits only for expenses incurred while this coverage is in force. No benefits are payable for expenses incurred before coverage began or after it terminated, even if the expenses result from an accident, injury or disease that occurred, began or existed while coverage was in force. An expense for a service or supply is incurred on the date the service or supply is furnished. If the Plan terminates, the rights of participants and beneficiaries are limited to charges incurred before termination. This Dental Benefit Summary booklet, combined with the Medical, Vision and Pharmacy Benefit summary booklet, and the Group Health Summary Plan Document, comprise the Plan document and summary plan document. These materials do not create a contract of employment or any rights to continued employment with RS Medical. First Choice Health One Union Square 600 University Street, Suite 1400 Seattle, WA 98101 1 of 14
Contacting Customer Service You may call FCHA Customer Service directly whenever you have questions or concerns at the number printed on your ID card or contact FCHA by mail, fax or Internet. First Choice Health Administrators Customer Service Department PO Box 12659 Seattle, WA 98111-4659 Toll-free: (888) 299-1045 Fax: (888) 206-3092 Medical pre-certification: (800) 808-0450 www.myfirstchoice.fchn.com FCHA s Customer Service Department business hours are Monday through Friday, 8:00 AM to 5:00 PM Pacific Standard Time (PST). The office is closed on New Year s Day, Memorial Day, Independence Day (4th of July), Labor Day, Thanksgiving, and the day after Thanksgiving, Christmas Eve and Christmas Day. FCHA offices close at 3:00 PM on the day before Thanksgiving and on December 23rd (or on the Friday before if the 23rd falls on a weekend). If the holiday falls on a Saturday, the office is closed on Friday; if the holiday falls on Sunday, the office is closed Monday (the holiday is recognized during the same calendar week in which the holiday falls). You can access benefit information or your specific claim and enrollment status anytime at www.myfirstchoice.fchn.com or by calling FCHA Customer Service s automated voice response system at (888) 299-1045. First Choice Health One Union Square 600 University Street, Suite 1400 Seattle, WA 98101 2 of 14
How to Obtain Health Services Your ID Card Your ID card identifies you as a Plan participant and contains important information about your coverage and benefits. We recommend presenting your ID card each time you receive care. If you lose your ID card, you may order a new one either through contacting FCHA Customer Service at (888) 299-1045, or logging into www.myfirstchoice.fchn.com. Under no circumstances should you give your ID card to another person for their use. Choosing a Provider This dental benefit does not utilize a participating dental provider network. You may select a licensed dental provider of your choice to be responsible for the quality of dental care you receive. First Choice Health One Union Square 600 University Street, Suite 1400 Seattle, WA 98101 3 of 14
Payment Provisions The benefits of this Plan are provided for covered services at the percentages specified within the Summary of Dental Benefits after the applicable deductible has been met. The dental benefit is a percentage of the usual, customary and reasonable (UCR) charges for those dental services and supplies that are listed in this section. To help you budget for more expensive treatments like crowns and bridges, we recommend that you have your dentist submit a pre-estimate any time charges are expected to exceed $500. Plan Year Dental Deductible The annual Plan year deductible is the amount you (or your family) must pay each Plan year before your employer is obligated to pay for covered services. Only covered services are applied towards the calculation of the deductible. The amount due to a provider remains your liability until your deductible is met. Annual Benefit Maximum The annual benefit maximum is the amount the Plan will pay for benefits in a Plan year. Lifetime Orthodontia Maximum The lifetime orthodontia maximum is the amount the Plan will pay for orthodontia benefits, per participant, while they are enrolled on this Plan. Annual Deductible and Maximum: Deductible and Maximum Deductible per Plan year Individual $25 Family $75 Annual Benefit Maximum $1,500 Lifetime Orthodontia Maximum $1,500 First Choice Health One Union Square 600 University Street, Suite 1400 Seattle, WA 98101 4 of 14
Participant Reimbursement Liability You are always responsible for the following costs associated with your health care: Annual Deductible, if applicable; Coinsurance, if applicable; The difference between a provider s charge for a service and the FCHA allowed amount for that service (See UCR in Definitions section.); Any costs for care you receive after your benefit limits have been exhausted; and Any costs for non-covered services. First Choice Health One Union Square 600 University Street, Suite 1400 Seattle, WA 98101 5 of 14
Summary of Dental Benefits Fluoride, topical application RS Medical Dental Plan Applies to Deductible Class I - Preventive and Diagnostic Dental Services For children through age 18; 2 per Plan year Oral evaluation of mouth, teeth and gums 2 per Plan year Prophylaxis (cleanings) 2 per Plan year Sealants For children through age 13; permanent molars only X-Rays Coverage N/A 100% N/A 100% N/A 100% N/A 100% -- Bitewings, twice per Plan year N/A 100% -- Full mouth set OR one Panorex, once every 36 months -- Other x-rays (periapical, occlusal, etc.), as needed Anesthesia (e.g., Novocaine) Class II - Basic Dental Services If dental procedure requires general anesthesia within hospital setting, coverage is provided under the medical plan: see Anesthesia in Medical, Vision and Pharmacy Benefit Summary booklet N/A 100% N/A 100% Consultations Emergency Treatment Endodontics (root canals) Extractions -- Simple extraction -- Surgical extraction Fillings/Restorations Occlusal guard For children through age 14. Oral surgery Periodontics Recementing of Bridge, Crown or Inlay/Onlay Re-line or Re-base of dentures First Choice Health One Union Square 600 University Street, Suite 1400 Seattle, WA 98101 6 of 14
Space maintainers For children through age 14. RS Medical Dental Plan Class II - Basic Dental Services Applies to Deductible Coverage Other Class II Services Class III - Major Dental Services Bridges (installation and repair) 50% Crowns (installation and repair) Benefit limitations apply; please see Dental Benefits for details. Dentures (installation and repair) Benefit limitations apply; please see Dental Benefits for details. Implants 50% Inlays/Onlays 50% Other Class III Services 50% Orthodontic Dental 50% 50% Lifetime Maximum of $1,500 on orthodontia. Children must be at least 6 years old to start treatment. Other benefit limitations apply; please see Dental Benefits for details. N/A 50% First Choice Health One Union Square 600 University Street, Suite 1400 Seattle, WA 98101 7 of 14
Dental Benefits Dental Expenses Dental expenses mean the charges for the dental services and supplies listed below which are provided by your dental professional and are in accordance with generally accepted standards of dental practice. Class I - Preventive and Diagnostic Dental Services Preventive and diagnostic dental expenses mean charges for the following services and supplies: Fluoride treatments for a child through age 18, limited to twice per Plan year. Take home fluoride is not covered. Oral evaluations of the mouth and teeth, limited to twice per Plan year. Prophylaxis, limited to twice per Plan year. Sealants: application of sealants, limited to permanent molars only, for a child through age 13. The following dental x-rays: -- -- -- One set of full mouth x-rays or one panorex x-ray in a 36 month period. One set of bitewing x-rays limited to twice per Plan year. Other x-rays, for example periapical or occlusal, as needed. Class II - Basic Dental Services Basic dental expenses mean charges for the following services and supplies: Anesthesia, such as novocaine (see Dental Plan exclusions for detail about excluded anesthetics.) Consultations Emergency treatment necessary to relieve the sudden onset of severe pain, fever, swelling, serious bleeding, severe discomfort or to prevent the imminent loss of teeth. Treatment limited to covered services offered by this Plan. Endodontic treatment, including pulpotomy, pulp capping, apicoectomy, retrograde filling, and root canal therapy. Extractions, simple or surgical extractions of one or more teeth are covered. Fillings/Restorations include the use of materials such as amalgam, silicate, acrylic and composite resin to restore teeth broken down by decay or injury. Silicate, acrylic and composite fillings are covered only for teeth in front of the first bicuspid. This benefit includes crown/core build-ups. First Choice Health One Union Square 600 University Street, Suite 1400 Seattle, WA 98101 8 of 14
Occlusal Guards are covered for children through the age of 14; it is a removable appliance designed to assist in habit-breaking. Oral surgery, for surgical treatment or procedures needed in and about the mouth and jaw. Periodontal services required for treatment of disease of the gums and supportive structures of the teeth. Periodontal Root Planing or Subgingival Curettage is covered. Recementing of bridges, onlays/inlays, and crowns. Re-line or re-base of dentures. Space maintainers are covered for children through the age of 14; they are designed to preserve the space between the teeth caused by premature loss of a primary tooth. Class III - Major Dental Services Replacement of an appliance or dental prosthesis must be at least five years old and no longer able to be repaired or restored to use. The replacement: i. Must be needed because a natural tooth, or an injury to a natural tooth, requires additional natural teeth to be pulled and be completed within 12 months of the extraction or injury; OR ii. Must be needed to replace an existing temporary appliance and be placed within 12 months after a temporary appliance was placed. If a member has a partial denture and a natural tooth adjacent to that denture is pulled, the addition of another tooth to the member s denture is covered. Major dental expenses are charges for the following services and supplies: Bridges: Installation and repair of one or more artificial teeth attached by crowns to adjacent teeth. It is used to maintain space and function for missing teeth. Crowns: Installation and repair of a crown (also known as cap ) made of porcelain and/or metal used to cover a decayed or damaged tooth are covered. Coverage is provided if the last placement was performed 5 or more years ago. Dentures: Initial placement or replacement of existing removable partial or complete dentures are covered, and any necessary repairs. Implants: Artificial device replacing tooth root; it may anchor an artificial tooth, bridge or denture. Inlays/Onlays: A gold, porcelain or composite custom-made filling cemented into the tooth. Orthodontia: Children must be at least 6 years of age on the date the treatment begins. Up to 35% of the total charge is allowed for the initial placement of braces and is payable during the first month of orthodontic treatment. After that benefits will be payable during each month of treatment. The monthly benefit will be the difference between the total benefit and the benefits determined for the first month of treatment divided by the number of months left in the treatment period. First Choice Health One Union Square 600 University Street, Suite 1400 Seattle, WA 98101 9 of 14
Dental Limitations and Exclusions No dental benefit will be paid for the following charges: Administrative fees, including but not limited to, telephone consultations, missed appointments, claim form completion, interest charges, legal services, obtaining and/or copying medical records, or provider travel and/or lodging expenses. Analgesics such as nitrous oxide, conscious sedations, or euphoric drugs. Any treatment resulting from an act of war, declared or undeclared, armed invasion, or aggression, national disaster, or from any illness or injury contracted or incurred during military service, including complications or recurrences thereof. Any condition for which the Veterans Administration or any of the armed services is responsible or to the extent benefits are provided or covered by any governmental agency, except as otherwise provided by law. Charges for experimental or investigational procedures as defined by the Plan. Charges for services or supplies other than the dental expenses listed in this group benefit. Charges which exceed the UCR for the services or supplies provided. Charges for services or supplies for which no charge would be made in the absence of insurance or for which you are not obligated to pay. Charges for services or supplies related to diagnosis or treatment of temporomandibular joint disorder or craniomandibular disorder. Charges for services or supplies for which you are entitled to benefits under any workers compensation or similar law, or charges for services or supplies received as a result of any dental condition caused or contributed to by an injury or sickness arising out of or in the course of any employment for wage or profit. Charges for dental expenses for which benefits are payable under any medical expense plan or under any liability policy including but not limited to, an automobile policy or a homeowners policy. Any benefits paid by the Employer contrary to this exclusion are provided solely to assist the participant in the form of an advance. By providing such benefits the Employer is not waiving any right to reimbursement or to subrogation as provided in this Plan. Charges for services that, to any extent, are payable under the medical expense benefit of the Plan. Charges for services not necessary for the diagnosis, prevention or care of dental disease, defect or injury. Complications from non-covered services. Crowns for teeth that are restorable by other means or for the purpose of periodontal splinting. First Choice Health One Union Square 600 University Street, Suite 1400 Seattle, WA 98101 10 of 14
Customized dental procedures. Dental appliances which have been lost, mislaid or stolen. Dental care provided for dietary planning for the control of dental disease or for plaque control or for oral hygiene instructions. Dental care that does not have ADA endorsement. Dental care that is cosmetic in nature. Dental care provided to correct any birth defect or developmental malformation which does not interfere with function. Fraudulent or misrepresented charges. Take-home fluoride solutions. First Choice Health One Union Square 600 University Street, Suite 1400 Seattle, WA 98101 11 of 14
Dental Plan Definitions Accidental Injury means physical harm caused by a sudden and unforeseen event at a specific time and place. Adverse Benefit Determination means a denial, decrease, or ending of a benefit. This includes a failure to provide or make payment (in whole or in part) for a benefit including claims based on medical necessity or experimental and investigational exclusions. Allowed Amount means the maximum amount paid by the Plan for a medically necessary covered service. Generally, this is an amount agreed to contractually by the Plan and participating providers. The allowable amount paid by the Plan for services from nonparticipating providers and for out-of-area providers is based on usual, customary and reasonable (UCR) rates. Authorized Representative means an individual acting on behalf of the claimant in obtaining or appealing a benefit claim. The authorized representative must have a signed form (specified by the plan) by the claimant except for urgent care benefits or appeals. Once an authorized representative is selected, all information and notifications should be directed to that representative until the claimant states otherwise. Benefit Administrator or Plan Administrator means the department designated by your employer group to administer the plan on behalf of the group s employees. Claim means any request for a plan benefit, made by you or your authorized representative. A participant making a claim for benefits is a claimant under ERISA regulations. Co-insurance means a cost-sharing requirement that requires a participant or dependent to pay a percentage of the cost of specified covered services. Concurrent claim means any claim that is reconsidered after an initial approval for ongoing course of treatment was made and results in a reduced or terminated benefit. Deductible means the amount the participant or dependant must pay each Plan year before your employer is obligated to pay for covered services. Only covered services are applied towards the calculation of the Plan year deductible. Dental Professional: means any of the following who is acting within the scope of the license A doctor of dental medicine (D.M.D.); A doctor of dental surgery (D.D.S.); A dental hygienist; or A denturist. First Choice Health One Union Square 600 University Street, Suite 1400 Seattle, WA 98101 12 of 14
Dental Services refer to services by any provider which are related to natural and unnatural teeth or structures and tissues contiguous to teeth (whether or not teeth are actually present). Dental services also include any associated service, such as, but not limited to anesthesia, laboratory, pathology, supplies, appliances, x-ray, or facility support. Dentist is a person who is properly trained and licensed to practice dentistry and who is practicing within the scope of such license. Emergency (Medical Emergency, Emergent) means the emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a prudent layperson acting reasonably to believe that a health condition exists that requires immediate medical attention, and that failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person s health in serious jeopardy. Experimental and Investigational Procedures means services which are determined to be either: Not in general use in the medical community in Washington State; Not approved by Medicare; Not proven safe & effective or to show a demonstrable benefit for a particular illness or disease; Under continued scientific testing and research; A significant risk to the health or safety of the patient; or Not proven to result in greater benefits for a particular illness or disease than other generally available services. FCHA means First Choice Health Administrators, a division of First Choice Health Network, Inc., the third party administrator for RS Medical. Incur, Incurs, Incurred and Incurred Date mean, with respect to a dental expense, the date the services or supplies are provided to you, except: Bridgework, a crown, or onlay work is incurred on the date the tooth or teeth are seated; Placement or modification of a full or partial denture is incurred on the date the impression is made; and Root canal therapy is incurred on the date the pulp chamber is opened. Lifetime is a reference to benefit maximums and limitations. Lifetime is understood to mean while covered under this Plan. Under no circumstances does lifetime mean during the lifetime of the participant or dependant. Periodontal Splint means any appliance designed to retain teeth in position, and includes multiple abutments for fixed bridgework. First Choice Health One Union Square 600 University Street, Suite 1400 Seattle, WA 98101 13 of 14
Plan Document means the instrument or instruments that set forth and govern the duties of Plan Sponsor and eligibility and benefit provisions of the Plan which provide for the payment or reimbursement of covered services. Plan Year means the twelve (12) month period beginning March 1 and ending the last day of February of the next year. Post-Service Claim means any claim for a plan benefit under the plan that is not a pre-service claim and is a request for payment or reimbursement for covered services already received. Precertification is the process of obtaining coverage determination from the Plan Administrator prior to obtaining certain inpatient and outpatient services, which are specifically indicated in this Summary Plan Document. Pre-Service Claim means any claim for a plan benefit for which the plan requires approval before medical care is obtained. Prosthetic devices are artificial substitutes which generally replace missing parts of the human body, such as a limb, bone, joint, eye, tooth, or other organ or part thereof, and materials which become ingredients or components of prostheses. Provider means any person, organization, health facility or institution licensed to deliver or furnish health care services. Summary Plan Description (SPD) means the ERISA required summary of benefit plan terms that must be furnished to participants and describes the terms and conditions under which the Plan operates and the requirements for eligibility and enrollment, covered services, limitations and exclusions, and other terms and conditions that apply to participation in the Plan. Temporomandibular Joint Disorders (TMJ) means those disorders which have one or more of the following characteristics: (i) pain in the musculature associated with the Temporomandibular Joint, (ii) internal derangement of the Temporomandibular Joint, (iii) arthritic problems with the Temporomandibular Joint, or (iv) an abnormal range of motion or limitation of motion of the Temporomandibular Joint. Third Party Administrator (TPA) is the organization providing services to this employer group in connection with the operation of this plan, as may be delegated to it, including processing and payment of claims. Usual, Customary and Reasonable (UCR) is the allowable paid by FCHA for services from non-participating providers and out-of-area providers as designated by an independent entity for the applicable geographical location. First Choice Health One Union Square 600 University Street, Suite 1400 Seattle, WA 98101 14 of 14