prominencehealthplan.com Small Group PPO Dental Plans (2-50)

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1 Small Group PPO Dental Plans (2-50) Sales and enrollment guide

2 Here for you Introducing dental plans from Prominence Health Plan Dental care is an integral part of overall good health. The ability to offer dental coverage is vital in attracting and retaining the best employees. Prominence Health Plan (formerly Saint Mary s Health Plans) is pleased to offer a variety of dental plan options that provide groups with choices in benefit levels and cost. Prominence Health Plan s PPO dental plans offer your employees access to quality care at discounted fees. Through the expansive DentalGuard Preferred Select Network, Prominence Health Plan members enrolled in a dental plan will appreciate the flexibility and freedom of choosing any dentist in the participating statewide and national network. A complete list of participating dental providers can be found at prominencehealthplans.com > Health Plan Members > Provider Directories. Several plans are available on a voluntary basis and can be ideal for businesses wanting to offer grouptype dental benefits while reducing company expenses. It is important to note that per Affordable Care Act (ACA) regulations, children under 19 years of age are not eligible for any dental services provided under Prominence Health Plan s small group dental plan. Dental coverage for children to age 19 is included within medical plan coverage. If you are interested in learning more about Prominence Health Plan dental plan options or to receive a quote, please contact your broker or Prominence Health Plan account executive or account manager. Prominence Health Plan Sales Office Reno: Las Vegas: Toll free:

3 Small Group PPO Dental Plans Children under 19 years of age are not eligible for any dental services provided under this dental plan. Plan CYD Single/Family Annual Maximum Diagnostic and Preventive Services (1) In-Network/ Out-of-Network Basic Restorative (2) In-Network/ Out-of-Network Major Restorative Procedures (2) Orthodontia (1) (3) Plan A $25 Single/3x Family $1, %/100% 80%/80% Not Covered Not Covered Plan B $50 Single/3x Family $1, %/80% 80%/60% 50%/50%* Not Covered Plan B Plus $50 Single/3x Family $1, %/80% 80%/60% 50%/50* 50%; up to $1,000 Lifetime Ortho max* Plan C $50 Single/3X Family $1, %/100% 80%/80% 50%/50%* Not Covered Plan C Plus $50 Single / 3x Family $1, % / 100% 80% / 80% 50% / 50%* 50%; up to $1,000 Plan C-1 $50 Single / 3x Family $1, % / 100% 80% / 80% 50% / 50%* Not Covered Plan C-1 Plus $50 Single / 3x Family $1, % / 100% 80% / 80% 50% / 50%* 50%; up to $1,000 Plan D $50 Single / 3x Family $1, % / 90% 90% / 80% 60% / 50%* Not Covered Plan D Plus $50 Single / 3x Family $1, % / 90% 90% / 80% 60% / 50%* 50%; up to $1,500 Plan D-1 $50 Single / 3x Family $2, % / 90% 90% / 80% 60% / 50%* Not Covered Plan D-1 Plus $50 Single / 3x Family $2, % / 90% 90% / 80% 60% / 50%* 50%; up to $1,500 (1) Not subject to deductible. (2) Subject to the deductible. (3) Plans featuring orthodontia benefits are not available to groups with less than 10 full-time eligible employees enrolled. * A 12-month waiting period applies. The waiting period is waived for initial enrollees with proof of this employer s prior plan being replaced by Prominence Health Plan. No waiting periods apply for qualified employer contributory plans when the employer group has a minimum of 10 or more enrolled employees. Covered Services Plan A Diagnostic and Preventive oral examinations, prophylaxis, X-rays Basic Restorative Procedures amalgam and composite restorations, basic oral surgery, emergency palliative treatment Covered Services Plans B & B Plus Diagnostic and Preventive oral examinations, prophylaxis, X-rays Basic Restorative Procedures amalgam and composite restorations, basic oral surgery, emergency palliative treatment Major Restorative Procedures complex oral surgery, anesthesia, endodontics, periodontics, fixed prosthodontics, removable prosthodontics, prosthodontic repair and replacement, benefits for implants are only available when no alternative form of therapy exists to treat the dental condition and only if approved by independent dental consultants Covered Services Plans C, C Plus, C-1, C-1 Plus, D, D Plus, D-1 & D-1 Plus Diagnostic and Preventive oral examinations, prophylaxis, X-rays Basic Restorative Procedures amalgam and composite restorations, periodontics, endodontics, basic oral surgery, complex oral surgery, anesthesia, emergency palliative treatment Major Restorative Procedures fixed prosthodontics, removable prosthodontics, prosthodontic repair and replacement, benefits for implants are only available when no alternative form of therapy exists to treat the dental condition and only if approved by independent dental consultants These covered services statements provide only a brief description of some important features of the dental policy. For a more complete description of the plans and any limitations, please refer to the summaries of benefits or certificate of coverage.

4 Dental Underwriting Guidelines Employer Paid (2-50 employees) Defined as a plan where the employer contributes, at a minimum, 50% of the employee cost for single coverage. Group must be headquartered in Nevada. Employer-paid plans are available for groups of two or more full-time eligible employees. Full-time is defined as 30 hours per week. Any change to the definition of a full-time employee is subject to underwriting approval. Dental offices/clinics are not eligible. 100 percent participation is required for groups with five or less full-time eligible employees; a 75 percent participation requirement, with a minimum of five enrolled, is required for groups with six or more full time eligible employees. Groups with 2 to 9 eligible employees may choose either dental plan A or B. Groups with 10 or more full-time eligible employees may select up to two dental plan options. Orthodontia services are only available as a selected optional group dental benefit for groups with 10 or more full-time eligible employees enrolled. If coverage is waived, a qualifying event must occur to gain coverage or the employee must wait until open enrollment to gain coverage. Groups with 50 percent or more of eligible employees residing outside of the state are subject to underwriting review. Coordination of benefits applies. Voluntary (3-50 employees) Defined as a plan where the employer contributes less than 50% of the employee cost for single coverage. Group must be headquartered in Nevada. Voluntary plans are available for groups of three or more full-time eligible employees. Groups with 3 to 9 enrolled employees may choose from plans A and B. Groups with more than 10 enrolled employees may choose from dental plans A, B and B Plus. Full-time is defined as 30 hours per week. Any change to the definition of a full-time employee is subject to underwriting approval. Dental offices/clinics are not eligible. Voluntary dental plans require a minimum of three employees enrolled or 25 percent participation of the eligible full-time employees, whichever is greater. Orthodontia services are only available as a selected optional group dental benefit for groups with 10 or more full-time eligible employees. If coverage is waived a qualifying event must occur to gain coverage or the employee must wait until open enrollment to gain coverage. Groups with 50 percent or more of eligible employees residing outside of the state are subject to underwriting review. Coordination of benefits applies. Prominence Health Plan allows the grandfathering of small groups currently enrolled in Prominence Health Plan dental riders to transition to a Prominence Health Plan dental product that is most similar in benefit design.

5 Prominence Health Plan Preferred Dental Plan Limitations & Exclusions The primary limitations and exclusions for each of the plans in this brochure are described below. Please take some time to review this information. Based upon dental services covered, no benefits are payable under this Policy for the procedures listed below. Additionally, the procedures listed below will not be recognized toward satisfaction of any deductible amount. Should there be any discrepancies between this brochure and the terms of your Certificate of Coverage, the terms of your Certificate of Coverage shall govern. 1. Procedures (including crowns, bridges, dentures and root canals) started prior to the date the member became eligible for such services under this Agreement. Retreatment of these procedures within one year of completion. 2. Any treatment which is elective or primarily cosmetic in nature and not generally recognized as a generally accepted dental practice by the American Dental Association. 3. Procedures, appliances or restorations to correct congenital or developmental malformations including, but not limited to, cleft palate, enamel hypoplasia, fluorosis, jaw malformations and anodontia (unless the procedure is performed on an Insured who was covered immediately following birth). 4. The replacement of lost, missing or stolen prosthesis or appliance. 5. Initial placement of any prosthetic appliance or fixed bridge unless such placement is necessitated by the extraction of one or more functioning natural teeth while insured under the Policy. 6. Replacement of prosthetic appliances (including full or partial dentures and bridges, crowns, inlays and onlays), unless the appliance is more than five years old and cannot be made serviceable. 7. Appliances, services or procedures relating to: the change or maintenance of vertical dimension; restoration of occlusion; splinting; correction of attrition or abrasion; bite registration or bite analysis; orthognathic surgery; treatment for jaw fracture; gnathological reporting, full mouth equilibration; and prosthodontic specialty services, including temporary processed functional crowns/appliances and realignment of teeth. 8. Services provided for any type of temporomandibular joint (TMJ) dysfunctions, muscular, skeletal deficiencies involving TMJ or related structures, myofascial pain. 9. Prescription drugs, premedication. 10. Any instruction for diet, plaque control, oral hygiene and behavior management. 11. Dental disease, defect or injury caused by a declared or undeclared war or any act of war. 12. Charges for implants of any type, and all related procedures, removal of implants, precision or semiprecision attachments, denture duplication, overdentures and any associated surgery, or other customized services or attachments; surgical grafting procedures and maxillofacial dental services, except as may be provided for within your Certificate of Coverage and Summary of Benefits. 13. Cast restorations and crowns for teeth that are not broken down by extensive decay or accidental injury or for teeth that can be restored by other means. 14. For treatment of malignancies, cysts and neoplasms. 15. For orthodontic treatment unless the employer elects the orthodontic rider (refer to Summary of Benefits). 16. Charges for failure to keep a scheduled visit or for the completion of any claim forms. 17. Procedures that are experimental or investigative in nature or that are not proven to be effective as determined by Prominence Health Plan. 18. Service or supply rendered by someone who is related to an Insured Person by blood (e.g., sibling, parent, grandparent, child, marriage (e.g. spouse or in-law,) or adoption or is normally a member of the Insured Person s household.

6 19. Any procedure, service or supplies which are included as covered medical or dental expenses under another group medical expense benefit plan, except as provided through the coordination of benefits provision within the policy. 20. Expenses compensable under Workers Compensation or Employers Liability Laws or by any coverage provided or required by law (including, but not limited to, group, group-type and individual automobile No-fault coverage), except as to charges which the person is legally obligated to pay. 21. Conditions caused by medical care of hospitalization. 22. Hospital expenses and services requiring treatment in a hospital (including emergency room). 23. Extractions of non-pathologic asymptomatic teeth, including extractions for orthodontic reasons. 24. Services for any dental treatment performed outside the United States or Canada except for emergency treatment. 25. Routine chest x-rays and medical exams prior to oral surgery. 26. Routine teeth cleaning (prophylaxis and scaling) more than once every six months. 27. Services that cannot be performed in the dental office because of patient physical, medical or behavioral limitations, unless medical necessity is determined by the Utilization Department and the Prominence Health Plan Medical Director. 28. Acrylic resin for restorations and crowns will not be covered on posterior teeth. 29. More than one set of full-mouth X-rays or its equivalent per insured person in a three (3) year period. 30. Bitewing X-rays in excess of two (2) series for standard or eight (8) vertical bitewing films twice per insured person, in a 12-month period. 31. Periapical and bitewing X-rays submitted individually will be combined and paid up to the amount of a full mouth series and are subject to the full mouth X-ray limitation. 32. Claims received after 12-months from the date service was rendered. 33. Fillings exceeding one (1) every five (5) years per surface per tooth, unless unserviceable. 34. Replacement of existing fillings for any purpose other than restoring active decay. 35. Periodontal scaling and root planing will be limited to once per quadrant in a three (3) year period. Polishing of all teeth is considered part of this treatment. 36. Periodontal surgery exceeding one (1) time per quadrant in a three (3) year period. 37. Gross debridement is allowed one time at the beginning of a periodontal treatment plan, prior to pocket depth charting. Subsequent requirement for debridement is considered patient neglect and would be the financial responsibility of the Insured. 38. Services for oral surgery, endodontics, periodontics, prosthodontics and orthodontics, if provided prior to the expiration of a specified plan waiting period for such services; or if not provided as available services under the benefits of your Summary of Benefits. Northern Nevada 1510 Meadow Wood Lane Reno, NV Southern Nevada 2475 Village View Drive, Suite 100 Henderson, NV REV_JULY 2014