Pediatric Benefits. Affordable Care Act Plans. Dental Coverage Vision Coverage

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1 Pediatric Benefits Affordable Care Act Plans Dental Coverage Vision Coverage

2 Pediatric Coverage The Affordable Care Act requires vision and dental coverage for children (dependents) 18 years and younger. It is important to review your Summary of Benefits and Coverage provided by health insurance carriers to determine if your plan is meeting these requirements for your children (dependents). Who is eligible for pediatric benefits? In order to be eligible you need to be on an ACA individual or small group plan with Avera Health Plans. Self-funded, large group, transitional and grandfathered plans, do not have this benefit. The benefits listed are for individuals who are 18 years or younger and have a health insurance plan with Avera Health Plans. If the member turns 19 in the middle of a plan year, coverage is provided until the end of the month of his or her 19th birthday. When will coverage start? Pediatric coverage will be effective the same date as your health insurance coverage becomes effective other than orthodontia, which has a 24-month waiting period. Can I go to any dentist? With these benefits, you may choose any dental provider in the nation that accepts insurance. Please present your Avera Health Plans member ID card at the time of service. is recommended for any treatment or services with an anticipated cost of $300 or more providers will complete preauthorizations, not members. is required for such services as (but not limited to) orthodontia and periodontal services, crowns, bridges, inlays/onlays, veneers, implants, and overdentures. Routine orthodontia is not covered. To identify what is not covered for pediatric dental, a detailed listing is provided with your plan s Certificate of Coverage Pediatric Coverage addendum. Members can access this 24/7 by logging in at AveraHealthPlans.com. Can I go to any eye doctor? Your child s eyes deserve the best care to keep them healthy year after year. Plus, with VSP, you ll get a great value on eye care and eyewear for your child. That s it! We ll handle the rest there are no claim forms to complete when your child sees a VSP doctor. Please present your Avera Health Plans member ID card at the time of service and mention you re a VSP member. With these benefits, it is important to find a VSP doctor who s right for your child and one who carries children s frames from their exclusive Otis & Piper Eyewear Collection. Visit vsp.com and enter your ZIP code to search in your area.

3 Pediatric Dental Plan Dental benefits fall into three categories, which will determine the amount of your responsibility for covered services: Basic - Intermediate - Major BASIC COVERAGE BENEFIT DESCRIPTION Coinsurance Diagnostic and Treatment Dental examinations, visits and consultation 1 examination every 6 months Preventive Services Cleanings 0% 1 cleaning every 6 months Fluoride treatment (topical) Bitewing X-rays No preauthorization required. 2 applications every 12 months 1 set every 6 months Sealants 1 sealant per tooth every 36 months INTERMEDIATE COVERAGE BENEFIT DESCRIPTION Coinsurance Minor Restorative Services Endodontic Services Periodontic Services Prosthodontic Services Oral Surgery Anesthesia Services Resin based anterior composites (alternate benefit of amalgam for molar teeth) Prefabricated stainless steel crowns Therapeutic pulpotomy (exclusions apply) Peridontal scaling and root planing - 4 or more teeth, per quadrant Rebase of complete maxillary dentures; 6 months after initial installation Removal of an impacted tooth Surgical access of an un-erupted tooth Sedation (not including anesthesia or oral) 30% is recommended for any treatment or services with an anticipated cost of $300 or more. is required to such services (but not limited to) orthodontia and periodontal services, crowns, bridges, inlays/ onlays, veneers, implants, and overdentures. 1 per tooth in 60 months 1 every 24 months 1 in 36-month period

4 Pediatric Dental Plan (cont.) Dental benefits are not subject to your medical health plan deductible. You will be responsible for a certain percentage of the cost of covered services, called coinsurance. Depending on the provider, you may have to pay at the time of service. MAJOR COVERAGE BENEFIT DESCRIPTION Coinsurancee Major Restorative Services Metallic Onlays Porcelain or ceramic crown substrate 1 per tooth every 60 months 1 per tooth every 60 months Endodontic Services Anterior, bicuspid and molar root canal (exclusions apply) Retreatment of anterior, bicuspid and molar root canal therapy (exclusions apply) 50% Periodontic Services Prosthodontic Services Implant Services Orthodontic Services * Gingivectomy or Gingivoplasty 1 to 3 teeth, per quadrant Porcelain, ceramic and cast metal retainers for resin bonded fixed prosthesis Services are subject to medical health plan guidelines Orthodontia procedures which help restore oral structures to health and function and to treat serious medical conditions such as cleft palate and cleft lip; maxillary/mandibular micrognathia (underdeveloped upper and lower jaw); extreme mandibular prognathism or severe asymmetry (craniofacial anomalies) * ORTHODONTIC WAITING PERIOD Unless medically necessary, there is a waiting period to receive orthodontic services. To meet this requirement, the member receiving orthodontia services must be enrolled in the same plan for an entire and continuous 24-month waiting period to receive orthodontic coverage in the same plan option. Re-enrollment after returning from another dental carrier plan, will require the member to satisfy a new 24-month orthodontia waiting period for the elected plan option. is recommended for any treatment or services with an anticipated cost of $300 or more. is required to such services (but not limited to) orthodontia and periodontal services, crowns, bridges, inlays/ onlays, veneers, implants, and overdentures. 1 every 36 months 1 every 60 months

5 Pediatric Vision Plan What is included with pediatric vision benefits? Your child is covered-in-full for an eye exam and glasses or contacts every year. Review your child s benefit information. You will have access to the highest quality vision care from a VSP doctor you can trust. When making the appointment, mention you re a VSP member. Vision benefits are not subject to your medical health plan deductible. You will be responsible for a certain percentage of the cost of covered services, called coinsurance. Depending on the service, you may have to pay at the time of service. BENEFIT DESCRIPTION CO-PAY Your coverage with a VSP Advantage Doctor WellVision Exam Prescription glasses Frames A thorough eye exam that tests for childhood eye health and vision issues, like nearsightedness, amblyopia (lazy eye), and strabismus. Frames covered in full from our exclusive Otis & Piper Eyewear Collection $0 Every 12 months $0 Every 12 months Lenses Single vision, lined bifocal, lined trifocal or lenticular lenses Polycarbonate, scratch-resistant coating and UV protection $0 Included in Prescription Glasses Every 12 months Lens Options percent off other lens options N/A Every 12 months Contacts (Instead of glasses) Contact lens exam and minimum three-month s supply of contact lenses are covered in full. Ask your VSP doctor which contacts qualify for your child s plan $0 Every 12 months Extra Savings and Discounts Glasses and Sunglasses 20 percent off additional glasses and sunglasses, including lens options, from any VSP doctor within 12 months of your last WellVision Exam Laser Vision Correction Average 15 percent off the regular price or 5 percent off the promotional price; discounts only available from contracted facilities VSP guarantees coverage for VSP doctors only. Coverage information is subject to change. CONTACT VSP vsp.com

6 Discrimination is Against the Law Avera Health Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Avera Health Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Avera Health Plans: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as: qualified interpreters and information written in other languages. If you need these services, contact the Avera Health Plans Service Center at , (TTY 711), 8 a.m. to 5 p.m. CST, Monday through Friday. If you believe that Avera Health Plans has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: You can file a grievance in person or by mail, fax, or . You may also contact the Complaint and Appeals Coordinator if you need assistance with filing a complaint. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or call or (TDD). Or mail: US Department of Health and Human Services, 200 Independence Avenue SW Room 509F, HHH Building, Washington, D.C Complaint forms are available at Complaint and Appeals Coordinator Avera Health Plans 3816 S. Elmwood, Suite 100, Sioux Falls, SD Fax Getting Help in other Languages Language assistance services are available free of charge. Our Service Center is available 8 a.m. to 5 p.m. CST, Monday Friday, toll-free at (TTY: ). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). Hmoob (TTY: ). CHÚ Ý: N u b n nói Ti ng Vi t, có các d ch v h tr ngôn ng mi n phí dành cho b n. G i s (TTY: ). XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (TTY: ) (TTY: ). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: ) (TTY: ) , (TTY: ) (TTY: ). ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (TTY: ). :, (TTY: ). : ( : ) (TTY- Telefon za osob govorom ili sluhom: ), (TTY: ) Form PS (Rev. 2/17)

7 AveraHealthPlans.com Toll-Free: MyAvera 15-AVHP-6341

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