2014 Evidence of Coverage Optional Supplemental Benefits Attachment OPTIONAL SUPPLEMENTAL BENEFITS YOU CAN BUY As explained in Chapter 4, Section 2.2 of this Evidence of Coverage, our plan offers some extra benefits that are not covered by Original Medicare and not included in your benefits package as a plan member. These extra benefits are called optional supplemental benefits. If you want these optional supplemental benefits, you must sign up for them and you will have to pay an additional premium for them. Amounts you spend on optional supplemental benefits do not count toward the plan s maximum outof-pocket amount. The optional supplmental benefits included in this section are subject to the same appeals process as any other benefits. This optional supplemental benefit and the additional monthly plan premium required to add to your PPO plan for 2014 is described below. Plan name Additional monthly plan premium $14.00 Optional Supplemental Benefits Coverage Guidelines Coverage of the optional supplemental benefits is provided only if furnished while an individual is a member. All the terms and conditions of the Evidence of Coverage will apply while you are covered by our plan. All plan premiums, fees, and charges are subject to change on an annual basis, as approved by the Centers for Medicare and Medicaid Services (CMS). You are eligible to elect an optional supplemental benefit if: You are currently enrolled in this Advantra Freedom PPO plan; You pay the required monthly plan premium fee for this optional supplemental coverage; and You reside in a county that offers this optional supplemental coverage. Enrollment and Effective Date of Coverage for Optional Supplemental Benefits You may enroll in optional supplemental benefit coverage as described below: At the time of initial enrollment in the Advantra Freedom PPO plan; During the Annual Election Period; or During a Special Enrollment Period. 1
If you do not enroll during these times, you may still choose to enroll in optional supplemental benefit coverage within 30-days of your Advantra Feedom PPO plan effective date. If you enroll during the 30-day period of your Advantra Advantage PPO effective date, your Dental plan will be effective the first of the month following the receipt of your dental application. Enrollment may be completed by submitting an application or calling Customer Service at the number on your ID card. The plan will determine if you are eligible for optional supplemental bneefit coverage and the effective date of coverage. Plan Premium There is an additional plan premium for the optional supplemental benefit. You will be billed by the plan on a monthly basis for all applicable plan premiums. You will be disenrolled from the optional supplemental benefit if you fail to pay the applicable plan premiums. However, prior to such action, Coventry will provide notice regarding the payment due and advise you that failure to pay the plan premiums within a 30-day grace period will result in termination of coverage from the optional supplemental benefit plan. Cancellation and termination of Optional Supplemental Benefit Coverage Optional supplemental benefit coverage shall terminate upon the date of termination, cancellation of your Advantra Freedom PPO plan, or if you fail to pay the additional premium for optional supplemental benefit coverage. If you wish to discontinue optional supplemental benefit coverage, please notify Customer Service in writing, or call the number on your ID card. Your optional supplemental benefit coverage will be discontinued on the first day of the month following our receipt of your request. Termination of optional supplemental benefit coverage will not affect your Coventry Advantra Freedom PPO medical coverage. However, cancellation or termination of your plan coverage will automatically cancel any optional supplemental benefit coverage you may have purchased. 2
Schedule of Benefits, Limitations & Exclusions Schedule of Benefits What you must pay when you get these Services that are covered for you services Non-Network Network Provider Provider Preventive & Diagnostic Services Oral Examinations - 2 per year with additional limitation of 1 comprehensive exam every 3 years Bitewing x-rays 1 per year Cleanings (Dental Prophylaxis) 2 per year Basic & Major Services Fillings (Amalgam and Composite) 2 per Member per year Simple & Surgical Extractions 2 per Member per year Crown or Bridge Recement one per Member per year Emergency Treatment for pain 2 per Member per year; will not be paid with any other service other than bitewing X-ray 0% Coinsurance, Deductible waived 50% Coinsurance, after $50 Deductible 30% Coinsurance**, Deductible waived 55% Coinsurance**, after $50 Deductible Annual Deductible $50 $50 Annual Benefit Maximum $1,000 **Payments for Covered Services rendered by Non-Participating Providers are based on the lesser of the Maximum Allowable Charge or the Provider s billed charges, as described below. Alternate Benefit Provision Many dental problems can be resolved in more than one way. If: 1) we determine that a less expensive alternative benefit could be provided for the resolution of a dental problem; and 2) that benefit would produce the same resolution of the diagnosed problem within professionally acceptable limits, we may use the less expensive alternative benefit to determine the amount payable under this plan. For example: When an amalgam filling and a composite filling are both professionally acceptable methods for filling a molar, we may base our benefit on the amalgam filling which is the less expensive alternative benefit. This is the case whether a Participating Provider or Nonparticipating Provider performs the service. 3
Out-of-Network Benefits You may receive Covered Services from Non-Participating Providers. Your cost for services from a Non-Network Provider are set forth in the Schedule of Benefits. Benefits are calculated using a Maximum Allowable Charge. Coverage for covered services provided by Non-Participating Providers is limited to the Maximum Allowable Charge less applicable Copayments, Coinsurance and Deductibles. The Maximum Allowable Charge is a rate established by us based upon our Participating contracted rates. You may call customer service at the telephone number listed on your Coventry Dental ID card to find out the Maximum Allowable Charge for a particular dental procedure code. If the amount you are charged for a service is equal to or less than the Maximum Allowable Charge, the charges should be completely covered by your out of Network Benefit, except for any Copayment, Deductible and Coinsurance payments you must make. However, if the amount you are charged is in excess of the Maximum Allowable Charge for a particular service, you must pay the excess. For example, assume your Coinsurance is 20%, the Provider's bill is $150 and the Maximum Allowable Charge is $100. In this example, Coventry would pay $80, you would pay Coinsurance of $20 plus the $50 in actual charges that exceeds the Out-of Network Rate. You are responsible for amounts charged by the Provider that exceed Benefits. You may also be required to remit payment at the time of service. Billing arrangements are between you and the Provider. If you obtain services from a Provider that is not part of the Network, You may be required to remit payment in full at the time services are rendered. You or the Provider can then submit a claim to Coventry Dental, PO Box 7402, London, KY 40742 (Payor ID CX049) for Out-of-Networks Benefits under the plan. Providers that are not part of the Network have not negotiated their fees with Coventry, or its dental benefit administrator, and will charge their usual and customary fees. Services Performed Outside the United States of America Any Claim submitted for procedures performed outside the U.S.A. is not covered. Predetermination of Benefits If the charge for any treatment is expected to exceed three hundred dollars ($300), we STRONGLY suggest that a dental treatment plan be submitted to us by your Provider for review before treatment begins by mailing X-rays, any applicable charting, and a predetermination request to Coventry Dental, PO Box 7402, London KY, 40742. This process is called predetermination and is separate and different from Pre-authorization. This may be helpful to estimate both the benefits available and your anticipated out of 4
pocket expense. Predetermination is optional and not a requirement for use of benefits. The proposed services will be reviewed and a predetermination of benefits statement will be issued to you or the Provider detailing the benefits that will be covered by Coventry. The predetermination is good for 180 calendar days. Payment will be subject to the plan benefits (e.g. Annual Maximums), limitations and exclusions in force at the time the claim is submitted. Predetermination of benefits is also subject to the Alternate Benefit Provision. Limitations & Exclusions (1) Coverage is limited to those services set forth in the Schedule of Covered Procedures. If a service is not listed, it is not included and is not covered. (2) Treatment to restore tooth structure lost due to attrition, erosion, abfraction or abrasion is not covered. (3) Where two or more professionally acceptable dental treatments for a dental condition exist, the Plan bases reimbursement on the least expensive alternative treatment (LEAT). (4) Services furnished solely for cosmetic reasons are not covered. (5) Any services related to implants including implant removal, repair, restoration or placement are not covered. (6) Fees related to broken appointments, preparing or copying dental reports, duplication of x-rays, itemized bills or claim forms are not covered. (7) Treatment for injuries or conditions covered by Workers Compensation or employer liability laws, and treatment provided without cost to you by any municipality, county, or other political subdivision is not covered. (8) Treatment as a result of, civil insurrection, duty as a member of the armed forces of any state or country, engaging in an act of declared or undeclared war, intentional or unintentional nuclear explosion or other release of nuclear energy, whether in peacetime or wartime is not covered. (9) Treatment of congenital or developmental malformations or the replacement of congenitally missing teeth is not covered. (10) Examination, evaluation and treatment of temporomandibular joint (TMJ) pain dysfunction is not covered. (11) Treatment of jaw fractures or orthognathic surgery is not covered 5
(12) Consultations and/or evaluation for non-covered services are not covered. (13) Services and/or appliances that alter the vertical dimension or alter, restore or maintain the occlusion including, but not limited to full mouth rehabilitation, splinting, appliances or any other method is not covered. (14) Removal and replacement of clinically acceptable material or restorations with alternative materials, for any reason except the pathological condition of the tooth or teeth, is not covered. (15) Replacement of fixed or removable bridges or orthodontic appliances that have been lost, stolen or damaged due to Member abuse or misuse is not covered. (16) Periodontal splinting of teeth by any method is not covered. (17) Analgesia, anxiolysis, inhalation of nitrous oxide or non-intravenous sedation is not covered. (18) Any procedure or treatment method which does not meet professionally recognized standards of dental practice or which is considered to be experimental in nature is not covered. (19) Any outpatient facility, surgicenter facility, or inpatient hospital facility and associated facility charges, services and supplies are not covered. (20) House, extended care facility calls, hospital calls, office visits for observation (during regularly scheduled hours) when no other services are provided, office visits after regularly scheduled hours or case presentations is not covered. (21) Drugs obtainable with or without a prescription are not covered. (22) Fees for equipment sterilization, OSHA or other regulatory agency requirements or mandates, infection control, and medical waste disposal is not covered. (23) Treatment that is not described by the most recent (current edition) of the American Dental Association (ADA) CDT (current dental terminology) book is not covered. (24) Any treatment covered under an individual or group medical plan, auto insurance, no fault auto insurance or uninsured motorist policy to the extent permitted by federal or state statute is not covered. 6
(25) Oral evaluation (comprehensive or periodic) and prophylaxis, including scaling and polishing is limited to twice per year. Comprehensive oral evaluation is limited to once per thirty six (36) months. (26) Bitewing x-rays are limited to one per year; vertical bitewings are not covered. (27) Amalgams and Composites are limited to two restorations allowed per Member per year. (28) Crowns and bridge recementation is limited to one per Member per year. (29) Extractions are limited to two per Member per year (30) Palliative treatment is covered as a separate benefit only if no other service other than exam and x-rays were done during the visit. Palliative treatment may only be rendered on an emergency basis for the relief of pain and cannot be billed as a separate charge if the underlying dental problem is corrected on the same date of service. Palliative treatment is limited to two per calendar year. 7