DENTAL INSURANCE
SUMMARY PLAN DESCRIPTION
January 2010
SUMMARY PLAN DESCRIPTION
Dental Insurance
Oak Ridge Associated Universities Sponsored Plan
Administered by Delta Dental Plan of Tennessee
240 Venture Circle
Nashville, TN 37228
Phone (615) 255-3175 Fax (615) 244-8108
(800) 223-3104
www.deltadentaltn.com
Notice to Members
The Health Insurance Portability and Accountability Act (HIPAA) of 1966, subsequent changes, and its implementing regulations restrict ORAU’s employees who have access to individually identifiable health information from disclosing Protected Health Information (PHI). ORAU requires that employees comply fully with the HIPAA requirements. Please refer to ORAU policy HR-654 for more details.
This Summary Plan Description (SPD) is a guide to your dental insurance benefits under the Delta Dental Premier plan. It is not the contract between Delta Dental Plan of Tennessee (DDPT) and ORAU or any member of the plan. Should there be any conflict between the SPD and the contract, the contract will prevail.
Please read this SPD carefully and keep it in a safe place for future reference. It explains your benefits as administered by Delta Dental of Tennessee. If you have questions about this SPD or any matter related to your membership in the plan, please write or call a Human Resources (HR) staff member or contact Delta Dental at the above address or phone numbers.
The agent for service of legal process is:
Director
Compensation, Benefits, and HRIS
Oak Ridge Associated Universities, Mail Stop 32
P. O. Box 117
Oak Ridge, TN 37831-0117
Telephone: (865) 576-3167
TABLE OF CONTENTS
ACRONYMS/DEFINITIONS 3
Eligibility and Enrollment of Employees and Dependents 5
Application for Coverage 5
Termination of Coverage 6
Payment for Services 6
Choosing a Dentist 6
General Provisions 7
Benefits 8
Schedule A - Diagnostic and Preventive Benefits 8
Schedule B – Basic Benefits 8
Schedule C – Major Benefits 9
Schedule D – Orthodontic Benefits 9
Implants 9
General Limitations and Exclusions 9
Limitations and Exclusions on Diagnostic and Preventive Benefits (Schedule A) 9
Limitations and Exclusions on Basic Benefits (Schedule B) 10
Limitations and Exclusions on Major Benefits (Schedule C) 10
Limitations and Exclusions on Orthodontic Benefits 11
Limitations and Exclusions on Implant Benefits 11
ACRONYMS/DEFINITIONS
Amalgams - silver fillings and prefabricated stainless steel crown restorations used for the treatment of tooth decay.
Cast restorations – crowns and on-lays for the treatment of visible decay and fractures of hard tooth structure when teeth are so badly damaged that they cannot be restored with amalgam or composite restorations.
Composites – white fillings used for the treatment of tooth decay.
Denture Repair – services to repair complete or partial dentures.
DDPT – Delta Dental Plan of Tennessee
Diagnostic Services – oral examination and x-rays that aid the dentist in planning required dental treatment.
Endodontia – treatment of the dental pulp (root canal procedures including charges for x-rays and temporary restorations).
Explanation of Benefits (EOB) – a form that will be sent to the subscriber by DDPT that gives the amount of benefits provided and, if applicable, services that were denied.
HIPAA – Health Insurance Portability and Accountability Act.
HR – Human Resources
Implant – artificial materials implanted into or on bone or gums.
Mandibular Teeth – lower teeth.
Maxillary Teeth – upper teeth.
Non-Participating Dentist – a dentist who has not contracted with Delta Dental to provide services at negotiated fees.
Optional Services – services which are not normally covered under the plan.
Oral Surgery – extractions and other surgical procedures.
ORAU – Oak Ridge Associated Universities
Participating Dentist – an independent contracting dentist who has agreed to accept DDPT negotiated fees for the service they provide.
Periodontia – treatment of the gums and bones that surround the tooth.
PHI – Protected Health Information
Predetermination – an estimate, given by DDPT, of the cost of certain dental procedures before they are done.
Preventive Maintenance – prophylaxis (cleaning), topical application of fluoride for members up to age 19. Space maintainers for members age 14 and under.
Prophylaxis – cleaning.
Prosthodonics – procedures for construction of fixed bridges, partial or complete dentures, and repair of fixed bridges.
Sealants – resin filling used to seal grooves and pits on the chewing surface of permanent molar teeth.
Standard Denture – a removable appliance that replaces missing natural or permanent teeth and is made by conventional means from acceptable materials.
SPD – Summary Plan Description
Eligibility and Enrollment of Employees and Dependents
The group health insurance plan consists for four plans. They are: medical and prescription drug (BlueCross BlueShield of Tennessee), dental (Delta Dental of Tennessee), and vision (Vision Service Plan Insurance). You must participate in all plans or none of the plans.
Employees are eligible to begin participation in the dental plan on the date of hire in an eligible classification or when changed to an eligible classification. Dependents are eligible to begin participation when the employee elects coverage. Eligible dependents may be covered through age 24.
Application for Coverage
The initial application by an employee shall be made by completing an application form and filing it with an HR staff member. HR staff shall submit the application to Delta Dental as a condition to coverage for the employee and eligible dependents. The names and other information of the employee and, if applicable, dependents for whom application for coverage is made must be listed on the form.
A dependent must be:
· The subscriber’s lawful husband or wife.
· The unmarried, natural, legally adopted, foster or step-child(ren) of the subscriber or the subscriber’s spouse who is under the age limit of 25 and is dependent upon the subscriber or subscriber’s spouse for at least 50% of his/her support. In addition, eligible dependents shall include children placed for adoption or a child in the subscriber’s legal custody.
· An unmarried child who is above age 24, as defined above, may continue to be eligible provided he/she continues to meet the support, maintenance and marriage requirements if the child is not able to support him/herself because of mental incapacity or physical handicap that began before reaching age 25. Proof of such incapacity and dependency must be furnished within 31 days of the child’s attainment of the applicable limiting age, and subsequently as required by Delta Dental.
If you did not have a dependent when you enrolled and later acquire a dependent, you may elect dependent coverage at any time if you are not participating in the 125 Premium Conversion Plan. Coverage for the new dependent will begin as of the date of enrollment.
Employees who are participating in the Section 125 Premium Conversion Plan must enroll a new dependent or drop a dependent within 31 days of the qualifying event or must wait for an open enrollment period.
Coverage began or will begin on the date of eligibility or anytime election is made after the date of eligibility as follows:
· If election to participate in the plan is made between the first (1st) and fifteenth (15th) day of the month, full coverage will be provided as of the date of enrollment. A full premium must be paid for that month.
· If election to participate in the plan is made on the 16th to the end of the month, full coverage as of the date of enrollment will be provided. No monthly premium will be due for that portion of the month.
· Payments for coverage are due in advance. It may be necessary for a double deduction to be taken from your first paycheck (i.e., premium taken in July would be for August coverage).
· Normally, premiums are taken from the first paycheck in the month.
· An individual cannot be enrolled as both an employee and dependent.
· An employee who enrolls in the plan, then voluntarily drops out of the plan, must wait one full year or until an open enrollment period to re-enter the plan unless he/she has a qualifying event (e.g., spouse loses medical coverage, etc.).
Please see the Medical Prescription Drug Insurance Summary Plan Description for information on continuation of coverage during:
· Leave of Absence.
· Retirement.
· Total Disability.
· Active Uniformed Service Duty.
· Following death of an employee.
Termination of Coverage
Coverage for any subscriber or dependent terminates when they are no longer eligible for benefits. Specific state and federal laws, such as COBRA, may allow an extension of membership for a limited time.
Payment for Services
Delta Dental will not pay for services received by a patient who is not enrolled or is not eligible for benefits at the time of treatment.
Choosing a Dentist
DDPT does not directly provide dental services. It has contracted with “participating” dentists who have agreed to accept negotiated fees for the service they provide to you. DDPT is not liable for a dentist’s refusal to provide services.
Dentists who have not contracted with DDPT are referred to as non-participating dentists. The fact that a dentist has or has not chosen to participate with DDPT should not be viewed as a statement about their qualifications.
Although you are free to choose any dentist, your out-of-pocket expenses may be less if you choose a participating dentist. Ask your dentist if he/she is a participating dentist or verify with DDPT prior to receiving services.
DDPT is not responsible for any injuries or damages suffered due to the actions of any dentist. DDPT shares your concern over the spread of infectious disease, but cannot require a dentist to be tested for them. If you have questions about clinical precautions, your dentist’s health status or use of recommended clinical precautions, you should discuss them with your dentist.
General Provisions
· Dental services must be necessary and must be provided in accordance with generally accepted dental practice standards.
· The dentist or provider must be licensed to perform services.
· Participating dentists have claim forms in their offices and will file your claim with DDPT.
· Non-participating dentists do not have claims forms. Forms may be obtained from HR staff, or by going to the Delta Dental website, www.deltadentaltn.com, first screen, under “Featured Subscriber Information”.
· A claim must be filed within 15 months of the date of service in order to be considered for benefits.
· You may get an estimate, called predetermination, of the cost of certain dental procedures before the work is done. Ask your dentist to send a claim form to DDPT that details the projected treatment and DDPT will give an estimate of the benefits to be paid. A predetermination is not a guarantee of payment. Actual benefit payment will be subject to continued eligibility along with plan limitations and maximums.
· If you or a covered dependent receives an injury that requires dental treatment because of the action or fault of another person, and if DDPT is unaware of other coverage, DDPT may pay benefits but would assume the rights to recover from the other person. You and the covered dependent would be required to help in making the recovery.
· The dental plan does not replace any workers’ compensation coverage.
· When subscribers and dependents have two dental plans, DDPT will coordinate benefits as follows:
o The plan covering the patient as an employee is primary over a plan covering the patient as a dependent.
o When the patient is a dependent child, primary dental coverage will be determined by the date of birth of the parents. The coverage of the parent whose date of birth occurs earlier in the calendar year will be primary. For a dependent child of legally separated or divorced parents, the coverage of the parent with legal custody, or the coverage of the custodial parent’s spouse (i.e. stepparent) will be primary.
o When there is a court decree stating that one parent has financial responsibility for a child’s dental expenses that parent’s coverage will be primary.
· Services chosen that are more expensive than those DDPT pays for will be limited to the amount that would normally be paid. The subscriber would be responsible for the remainder of the fee.
· Should a member transfer from one dentist to another during the course of treatment, payment will be limited to the amount that would have been paid had only one dentist rendered the service.
· An Explanation of Benefits (EOB) will be sent to the subscriber after a claim is processed that will outline benefits that were paid and, if applicable, those denied.
· Not every dental procedure is covered under this plan.
· Not every dental procedure is covered under the same level of co-payment, deductibles or maximums.
· A review, in writing, should be requested immediately if you question denial of the claim. A decision will be sent by DDPT to the subscriber within 30 days after DDPT receives the request unless unusual circumstances arise.
· If the subscriber does not agree with the review decision, an appeal to the Appeals Committee of DDPT may be made in writing and received by DDPT no later than 60 days after receipt of the initial EOB.
Benefits
Calendar Year Deductible Network Provider Non-Network Provider
Amount per person $ 25 $ 25
Maximum amount per family 75 75
Deductible exclusions: Diagnostic, preventive, and orthodontics
Annual Maximums excluding Orthodontics
Benefit charges for preventative maintenance services (cleanings) do not count against the $1,500 individual maximum per year);
Per person $ 1,500 $ 1,500
Lifetime Maximum for Orthodontics (No age limit)
Per person $ 1,500 $ 1,500
Lifetime Maximum for Implants
Per person $ 2,000 $ 2,000
Schedule A - Diagnostic and Preventive Benefits
Diagnostic and Preventive Benefits 100% 100%
Two oral exams and cleanings, including periodontal maintenance, in any 12-month period.
Benefit charges for preventative maintenance services do not count against yearly maximum.
Full mouth x-rays once within 3 years unless there is a special need.
One set of bite-wing x-rays in a 12-month period.
Topical application of fluoride – up to age 19.
Space maintainers, for members under 15 years of age.
Members with high risk health conditions may receive a total of four cleanings (including periodontal maintenance cleanings) in any 12 month period. Eligible members include:
Diabetics with periodontal disease
Pregnant women with periodontal disease
Individuals with renal failure/dialysis
Individuals with suppressed immune systems (such as those undergoing chemotherapy or radiation treatment, HIV positive, organ transplant patients, stem cell/bone marrow transplant patients)
Schedule B – Basic Benefits
Basic Benefits 80% 80%
Oral surgery
General Anesthesia & Intravenous Sedation – only when administered by a licensed dentist in