Summary Plan Description for the Dental Coverage Base and Buy-Up Options under the Campbell Clinic Health and Welfare Plan The information in this summary plan description is effective as of January 1, 2016.
General Information About the Plan This document, together with the Delta Dental of Tennessee Certificate of Coverage, including the Benefit Summary Page for the option you elect (Base/Standard or Buy-Up option), collectively referred to as the certificate, constitutes your summary plan description (SPD) for your dental coverage under the Campbell Clinic Health and Welfare Plan (Plan). These documents should be read together and kept together. Plan Name Campbell Clinic Health and Welfare Plan Name and Address of Plan Administrator Campbell Clinic, P.C. 1400 South Germantown Road Germantown, TN 38138 Telephone No. of Plan Administrator (901) 759-3105 The Plan Administrator has the sole discretionary authority and responsibility to control and administer the Plan in accordance with its terms and has, without limitation, the discretionary authority to interpret the Plan or its terms. The Plan Administrator s powers include making and enforcing rules it deems necessary or proper for the efficient administration of the Plan, deciding all questions concerning the Plan, including determining eligibility for benefits under the Plan, and allocating its responsibilities under the Plan to other persons. The Plan Administrator has delegated to Delta Dental of Tennessee (DDTN) the discretionary authority to make determinations on dental claims and appeals hereunder. Refer to the certificate to which this is attached for information. Claim Administrator/Insurer Group Contract Number 7069 Delta Dental of Tennessee 240 Venture Circle Nashville, TN 37228 Telephone: (800) 223-3104 The Plan Administrator keeps the records for the Plan, and will also answer any questions you may have about the Plan. If you have general questions about the Plan or your eligibility for benefits, you may contact Human Resources, which acts on behalf of the Plan Administrator with respect to day-to-day matters, and whose contact information is provided below. Plan Contact Information Name and Address of Plan Sponsor Participating Employer(s) Plan Sponsor s Tax ID Number (EIN) 62-0811256 Plan Number 505 Agent for Service of Legal Process Campbell Clinic, P.C. Attention: Human Resources 1400 South Germantown Road Germantown, TN 38138 Telephone: (901) 759-3105 Campbell Clinic, P.C. 1400 South Germantown Road Germantown, TN 38138 Campbell Clinic Surgery Center, L.L.C. and the Campbell Foundation also participate in this Plan. Campbell Clinic, P.C. Attention: HR Director 1400 South Germantown Road
Plan Year End Type of Plan Type of Funding/Administration Amendment or Termination of the Plan Effect of Plan Document Germantown, TN 38138 Service may also be made on the Plan Administrator. December 31 the Plan is operated on calendar (January 1 through December 31) year, referred to as the plan year. The Plan is an employee welfare benefit plan, and provides the dental coverage described in this SPD (among other welfare benefits). The portion of the Plan described in this SPD is insured and is administered in accordance with the provisions of the group dental contract issued by DDTN. Plan benefits are provided pursuant to the group dental contract, the premiums for which are paid from the employer s general assets. The insurer, not the Plan Sponsor, is responsible for paying claims under this dental coverage of the Plan. Participants are required to contribute the full cost of this coverage for the option they elect (Base/Standard or Buy-Up). The Plan may, at any time, in the Employer s sole discretion, be amended or terminated, without advance notice to any person (except as otherwise required by the group dental contract or applicable law). Any amendment or termination of the Plan will not affect any proper entitlement to benefits incurred prior to the effective date of such amendment or termination. No person shall have any vested right to continue benefits under the Plan. This SPD provides a summary of the terms, conditions, and benefits under the Plan for eligible employees (as described in the attached certificate). It does not give the details on all the terms of the official Plan document (including the group dental contract). If there is any conflict between the information in this SPD and the provisions of the Plan document, the Plan document will always control. Your Rights Under ERISA and Other Applicable Law This statement of ERISA rights is required by federal law and regulation. As a participant in the Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all Plan participants shall be entitled to: Receive Information About Your Plan and Benefits Examine, without charge, at the office of the Plan Administrator and at other specified locations, such as worksites, all documents governing the Plan, including insurance contracts, and a copy of the latest annual report (Form 5500 Series) filed by the Plan (if applicable) with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts, and copies of the latest annual report (Form 5500 Series), if applicable, and updated summary plan description. The Plan Administrator may make a reasonable charge for the copies. Receive a summary of the Plan s annual financial report (if applicable). If applicable, the Plan Administrator is required by law to furnish each participant with a copy of this summary annual report. Continue Group Health Plan Coverage Continue health care coverage for yourself, spouse, or dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the Plan for the rules governing your COBRA continuation coverage rights.
Prudent Actions by Plan Fiduciaries In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate the Plan, called fiduciaries of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your employer or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. Enforce Your Rights If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal court. In addition, if you disagree with the Plan s decision (or lack thereof) concerning the qualified status of a medical child support order, you may file suit in federal court. If it should happen that Plan fiduciaries misuse the Plan s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U. S. Department of Labor, or may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. Assistance with Your Questions If you have any questions about your Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U. S. Department of Labor, listed in your telephone directory, or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue NW, Washington, DC 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration. Qualified Medical Child Support Orders The Plan will comply with the terms of a qualified medical child support order (QMCSO). A QMCSO is an order or a judgment from a court or administrative body (including a National Medical Support Notice) directing the Plan to cover a child of a participant under the group health plan coverage provided through the Plan. Federal law provides that a medical child support order must meet certain form and content requirements in order to be a QMCSO. Coverage under the applicable coverage(s) of the Plan pursuant to a QMCSO will not become effective until the Plan Administrator determines that the order is a QMCSO. If you have any questions or would like to receive, without charge, a copy of the Plan s written procedure for determining whether an order is a QMCSO, contact the Plan Administrator (contact information is provided under General Information About the Plan above). Continuation Coverage Rights Under COBRA If coverage for you, your eligible spouse, or your eligible dependents ceases because of certain qualifying events (for example, termination of employment, reduction in hours, divorce, death, child's ceasing to meet the plan's definition of dependent) specified in a federal law called COBRA, then you, your eligible spouse, or your eligible dependents may have the right to purchase continuing coverage under the Plan for a limited period of time. For more information about COBRA rights, see the Continuation Coverage Rights Under COBRA notice, a copy of which was previously furnished to you and your spouse (if covered under the Plan). Please contact the contact the Plan
Administrator (contact information is provided under General Information About the Plan above) if you need another copy. Your Coverage and Benefits You are generally eligible for the health and welfare benefits of the Plan, including the dental coverage described in this booklet, if you are classified by the employer as regularly working a minimum of 32 hours per week. You may also enroll your eligible dependents in the dental coverage described in this booklet. Your eligible dependents include your legal spouse, your child(ren) to age 26, or your disabled child(ren) over age 26, provided all applicable eligibility requirements are met. Refer to the attached certificate for details. The dental benefits for the option you elect (Base or Buy-Up), and the terms and conditions of such benefits (including, for example, when such benefits terminate), are described in the attached certificate. Certificate Attached: Benefit Summary Page for Base option (no Orthodontic Services coverage) Benefit Summary Page for Buy-Up option (includes Orthodontic Services coverage, to age 19) Certificate of Coverage 16777944.4
Delta Dental of Tennessee Certificate of Coverage Benefit Summary Page Group Name: Campbell Clinic Group Number: 7069 Provider Network: Delta Dental PPO (Point-of-Service) Benefit Year: January 1 through December 31 Deductible $50 Deductible per person total per Benefit Year limited to a maximum Deductible of $100 per family per Benefit Year. The deductible does not apply to oral exams, preventive, x-rays, sealants, periodontal maintenance, full mouth debridement, and cephalometric films. Covered Services Delta Dental PPO Dentist Customer Service Toll-Free Number: 800-223-3104 www.deltadentaltn.com December 22, 2014 Delta Dental Premier Dentist Nonparticipating Dentist Plan Pays Plan Pays Plan Pays* Diagnostic & Preventive Diagnostic and Preventive Services - exams, cleanings, fluoride, and space maintainers 100% 100% 100% Sealants - to prevent decay of permanent teeth 100% 100% 100% Brush Biopsy - to detect oral cancer 100% 100% 100% Radiographs - X-rays 100% 100% 100% Periodontal Maintenance - cleanings following periodontal therapy 100% 100% 100% Basic Services Emergency Palliative Treatment - to temporarily relieve pain 80% 70% 70% Minor Restorative Services - fillings 80% 70% 70% Endodontic Services - root canals 80% 70% 70% Periodontic Services - to treat gum disease 80% 70% 70% Oral Surgery Services - extractions and dental surgery 80% 70% 70% Other Basic Services - misc. services 80% 70% 70% Adjustments and Repairs - to bridges and dentures 80% 70% 70% Major Services Crown Repair - to individual crowns 50% 40% 40% Major Restorative Services - crowns 50% 40% 40% Implant Repair - implant maintenance, repair, and removal 50% 40% 40%
Relines and Rebase - to dentures 50% 40% 40% Prosthodontic Services - bridges, implants, and dentures 50% 40% 40% * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. The Nonparticipating Dentist Fee may be less than what your dentist charges and you are responsible for that difference. Oral exams (including evaluations by a specialist) are payable twice in any period of 12 consecutive months. Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months. People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment. Fluoride treatments are payable twice in any period of 12 consecutive months for people up to age 19. Space maintainers are payable once per area per lifetime for people up to age 15. Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any three-year period, whether provided by a general dentist or specialist. Sealants are payable once per tooth per lifetime for the occlusal surface of first and second permanent molars up to age 16. The surface must be free from decay and restorations. Composite resin (white) restorations are Covered Services on posterior teeth. Implants and implant related services are payable once per tooth in any five-year period. Maximum Payment $1,000 per person total per Benefit Year on all services. Special Enrollment Notations Employees are eligible on the first of the month following 1 month of employment. Fellows, Administration, and Physicians are eligible date of hire. Dependent Age Limit 26 Customer Service Toll-Free Number: 800-223-3104 www.deltadentaltn.com December 22, 2014
Delta Dental of Tennessee Certificate of Coverage Benefit Summary Page Group Name: Campbell Clinic Group Number: 7069 Provider Network: Delta Dental PPO (Point-of-Service) Benefit Year: January 1 through December 31 Deductible $50 Deductible per person total per Benefit Year limited to a maximum Deductible of $100 per family per Benefit Year. The deductible does not apply to oral exams, preventive, x-rays, sealants, periodontal maintenance, full mouth debridement, cephalometric films, diagnostic casts, photos, and orthodontics. Covered Services Delta Dental PPO Dentist Customer Service Toll-Free Number: 800-223-3104 www.deltadentaltn.com December 22, 2014 Delta Dental Premier Dentist Nonparticipating Dentist Plan Pays Plan Pays Plan Pays* Diagnostic & Preventive Diagnostic and Preventive Services - exams, cleanings, fluoride, and space maintainers 100% 100% 100% Sealants - to prevent decay of permanent teeth 100% 100% 100% Brush Biopsy - to detect oral cancer 100% 100% 100% Radiographs - X-rays 100% 100% 100% Periodontal Maintenance - cleanings following periodontal therapy 100% 100% 100% Basic Services Emergency Palliative Treatment - to temporarily relieve pain 80% 70% 70% Minor Restorative Services - fillings 80% 70% 70% Endodontic Services - root canals 80% 70% 70% Periodontic Services - to treat gum disease 80% 70% 70% Oral Surgery Services - extractions and dental surgery 80% 70% 70% Other Basic Services - misc. services 80% 70% 70% Adjustments and Repairs - to bridges and dentures 80% 70% 70% Major Services Crown Repair - to individual crowns 50% 40% 40% Major Restorative Services - crowns 50% 40% 40% Relines and Rebase - to dentures 50% 40% 40%
Implant Repair - implant maintenance, repair, and removal 50% 40% 40% Prosthodontic Services - bridges, implants, and dentures 50% 40% 40% Orthodontic Services Orthodontic Services - braces 50% 50% 50% Orthodontic Age Limit - Up to age 19 Up to age 19 Up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. The Nonparticipating Dentist Fee may be less than what your dentist charges and you are responsible for that difference. Oral exams (including evaluations by a specialist) are payable twice in any period of 12 consecutive months. Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months. People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment. Fluoride treatments are payable twice in any period of 12 consecutive months for people up to age 19. Space maintainers are payable once per area per lifetime for people up to age 15. Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any three-year period, whether provided by a general dentist or specialist. Sealants are payable once per tooth per lifetime for the occlusal surface of first and second permanent molars up to age 16. The surface must be free from decay and restorations. Composite resin (white) restorations are Covered Services on posterior teeth. Implants and implant related services are payable once per tooth in any five-year period. Maximum Payment $1,000 per person total per Benefit Year on all services, except cephalometric film, photos, diagnostic casts, and orthodontics. $2,500 per person total per lifetime on cephalometric film, photos, diagnostic casts, and orthodontic services. Special Enrollment Notations Employees are eligible on the first of the month following 1 month of employment. Fellows, Administration, and Physicians are eligible date of hire. Dependent Age Limit 26 Customer Service Toll-Free Number: 800-223-3104 www.deltadentaltn.com December 22, 2014
Delta Dental of Tennessee 240 Venture Circle Nashville, TN 37228 Phone (800) 223-3104 Fax (615) 244-8108 www.deltadentaltn.com Certificate of Coverage Table of Contents Benefit Summary Page... i Introduction... 1 I. Eligibility and Enrollment of Subscribers and Dependents... 1 II. Choosing a Dentist... 1 III. General Provisions... 2 IV. Benefits... 3 V. Optional Services... 3 VI. Schedule of Benefits... 3 Introduction This Certificate of Coverage (COC) is a guide to your dental plan. It is not the contract between Delta Dental of Tennessee (DDTN) and your group or any member of the plan. Should there be any conflict between the COC and the contract, the contract will prevail. I. Eligibility and Enrollment of Subscribers and Dependents Subscribers who have enrolled in this dental plan through their employer or other group sponsoring this plan may also enroll their dependents. Dependents are defined as a lawful husband or wife or child(ren) from birth to the Dependent Age Limit listed on the Benefit Summary Page. "Child" includes a natural child, step-child, adopted child, foster child or child in the subscriber s legal custody. A child over the Dependent Age Limit may continue to be eligible provided they continue to meet the support, maintenance and marriage requirements. In addition, the child must not be able to support themself because of mental incapacity or physical handicap. Such disabling condition must have begun before reaching the Dependent Age Limit. Proof of these facts must be given to DDTN or group within 31 days if requested. Proof will not be required more than once a year. Dependents in military service are not eligible. Dependents must enroll along with the subscriber or as soon as they become dependents. If dependents do not enroll at this time, they must wait until the next open enrollment period to enroll. Dependents may not be enrolled without the enrollment of the subscriber, but the subscriber may drop dependent coverage and maintain their coverage. A subscriber or dependent who drops their coverage but who still meets all requirements of the plan, may re-enroll during the first open enrollment period after having been out of the plan for 12 consecutive months except in the event of a qualified life status change. Coverage for any subscriber or dependent terminates when they are no longer eligible for benefits as a member of the group. Specific state and federal laws or group policies may allow an extension of membership for a limited time. You should speak to the administrator of your group to see if an extension is available and for how long the benefits could be extended. DDTN will not pay for any services received by a patient who is not eligible at the time of treatment. Coverage for subscribers and dependents is only effective after DDTN receives the premium for the period to be covered. If DDTN does not receive the premium when it is due, we may stop paying claims until payment is received. If premiums have not been received within 30 days after the due date, DDTN may cancel the contract with the group. DDTN does not bill individuals for premiums. This contract may be cancelled upon renewal by DDTN with 30 days prior written notice or by the Group with 15 days prior written notice. II. Choosing a Dentist DDTN does not directly provide dental services and therefore is not liable for a dentist s refusal to provide services. It has contracted with Participating Dentists. These dentists are independent contractors who have agreed to accept certain fees for the service they provide to you. Dentists that have not contracted with Delta Dental are referred to as Non-Participating Dentists. The fact that a dentist has or has not chosen to participate with DDTN should not be viewed as a statement about their qualifications. DDTN COC 2010 Ortho 1
Although you are free to choose any dentist, your out of pocket expenses may be less if you choose a participating dentist. Therefore, you should always ask your dentist if he is a participating dentist or verify with DDTN that your dentist is a participating dentist before receiving any dental services. DDTN is not responsible for any injuries or damages suffered due to the actions of any dentist. DDTN shares in the public concern over the spread of infectious disease, but it cannot require a dentist to be tested for them. Information about the need for clinical precautions as recommended by recognized health authorities is provided to dentists. If you have questions about your dentist s health status or use of recommended clinical precautions, you should discuss them with your dentist. III. General Provisions A. Participating dentists will file your claim with DDTN. If you need a claim form for services provided by a non-participating dentist you may contact DDTN which will provide you with a claim form. To be considered for benefits, a claim must be filed within 15 months of the date of service. B. If you require emergency dental care, you may seek services from any dentist. Your out of pocket expenses may be less if you choose a participating dentist. C. You may get an estimate of the cost of certain dental procedures before they are done. This estimate is referred to as a predetermination. You may have your dentist send DDTN a claim form detailing the projected treatment and DDTN will give an estimate of the benefits to be paid. A predetermination is not a guarantee of payment. Actual benefit payments will be based upon procedures completed and will be subject to continued eligibility along with plan limitations and maximums. D. If you or your covered dependent receive an injury requiring dental treatment because of the action or fault of another person, and if DDTN is unaware of other coverage, DDTN may pay benefits but would assume the subscriber s or covered dependent s rights to recover from the other person. The subscriber and covered dependent would be required to help DDTN in making such a recovery. This dental plan does not replace any workers compensation coverage. E. If a subscriber or covered dependent has two dental coverages, DDTN will coordinate benefits with the other coverage. The following rules will be used to determine which coverage should be primary. 1. The program covering the patient as an employee is primary over a program covering the patient as a dependent. 2. Where 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. 3. If there is a court decree stating that one parent has financial responsibility for a child's dental care expenses, any dependent coverage of that parent will be primary to any other dependent coverage. F. After a claim is processed, an Explanation of Benefits (EOB) will be sent to the subscriber. If any payment for services was denied, the EOB will give the reason why. If the subscriber disagrees with the denial he or she must submit a request in writing asking that the claim be reviewed. Such request should include the reason why the subscriber believes the claim was wrongly denied. The request must be received by DDTN within 180 days of the subscriber s receipt of the EOB. DDTN will make a review and may ask for more documents if needed. Unless unusual circumstances arise, a decision will be sent to the subscriber within 30 days after DDTN receives the request for review. If the subscriber does not agree with the first level review decision, he or she may refer the request for review to the Professional Relations Advisory Committee of DDTN. This second level review request must be in writing and received by DDTN within a reasonable time after the subscriber receives the first level review decision. Unless unusual circumstances arise, a decision will be sent to the subscriber within 30 days after DDTN receives the request for second level review. If the subscriber does not agree with the second level review decision, he or she may file civil action in court. DDTN COC 2010 Ortho 2
IV. Benefits Not every dental procedure is a benefit of your dental plan nor are they paid at the same level of copayment. The Schedule of Benefits in this COC reflects the procedures that DDTN will cover as well as certain limitations and exclusions for these covered benefits. These services will be covered when a dentist or an employee of a dentist who is licensed to perform the service provides them. These services must be necessary and must be provided in accordance with generally accepted dental practice standards. Some allowable procedures are subject to deductibles, maximums, and copayments as described on the Benefit Summary Page. In addition to the limitations and exclusions shown in the Schedule of Benefits section, DDTN does not pay for the following: General Limitations and Exclusions A. Treatment of injury or illness covered by Workers' Compensation or Employer's Liability Laws. B. Services received without cost from any federal, state or local agency. This exclusion will not apply if prohibited by law. C. Cosmetic surgery or procedures for purely cosmetic reasons. D. Services for congenital (hereditary) or developmental malformations. Such malformations include, but are not limited to, cleft palate, or upper and lower jaw malformations. This does not exclude those services provided under Orthodontic benefits, if covered. E. Treatment to restore tooth structure lost from wear. F. Treatment to rebuild or maintain chewing surfaces due to teeth out of alignment or occlusion or treatment to stabilize the teeth. For example: equilibration, periodontal splinting and double abutments on bridges. G. Oral hygiene and dietary instructions, treatment for desensitizing teeth, prescribed drugs or other medication, experimental procedures, conscious sedation and extra oral grafts (grafting of tissues from outside the mouth to oral tissues). H. Charges by any hospital or other surgical or treatment facility and any additional fees charged by the dentist for treatment in any such facility. I. Diagnosis or treatment for any disturbance of the temporomandibular joints (jaw joints) or myofacial pain dysfunction. J. Services by a dentist beyond the scope of his or her license. K. Dental services for which the patient incurs no charge. DDTN COC 2010 Ortho 3 L. Dental services where charges for such services exceed the charge that would have been made and actually collected if no coverage existed. M. DDTN will apply the limitations and exclusions of this benefit plan based upon the member s complete and prior history as reflected in DDTN s records. In the event a member transfers from one dentist to another during the course of treatment, payment by DDTN will be limited to the amount that would have been paid had only one dentist rendered the service. V. Optional Services In cases where alternate or optional methods of treatment exist, DDTN will pay for the least costly professionally accepted treatment. This determination is not intended to reflect negatively on the dentist s treatment plan or to recommend which treatment should be provided. It is a determination of benefits under the terms of the subscriber s coverage. The dentist and subscriber or dependent should decide the course of treatment. If the treatment rendered is other than the covered benefit, the difference between DDTN s allowance and the dentist s fee, up to the approved amount, for the actual treatment rendered is due from the subscriber. For example, if your benefit plan allows for amalgams only even though a metal or porcelain inlay is suggested by your dentist, DDTN will pay for only the cost of the amalgam. VI. Schedule of Benefits In addition to the limitations and exclusions listed in the Schedule of Benefits, the General Limitations and Exclusions found in Section IV of this Certificate of Coverage also apply. A. Diagnostic & Preventive Benefits, Limitations & Exclusions Oral examinations and cleanings (prophylaxis). Oral exams and cleanings, to include periodontal maintenance procedures, are limited to two times in any 12 month period. Members with high risk health conditions may receive a total of four cleanings, to include periodontal maintenance procedures, in any 12 month period. Eligible members include diabetics and pregnant women with periodontal disease, those with renal failure, those with suppressed immune systems such as those undergoing chemotherapy/radiation treatment, HIV positive or organ or stem cell transplant patients or those at high risk for infective
endocarditis. Adult prophylaxis for members under 14 years of age are not allowed. Comprehensive oral examinations or extensive oral examinations performed by the same dentist are allowed once within 36 months. X-rays. One set of bite-wing x-rays is covered in a 12 month period. Full mouth x-rays are covered once within 3 years, unless special need is shown. Fluoride. Topical application of fluoride is covered for members up to 19 years of age. Space maintainers. Space maintainers are covered for members 14 years of age and under. B. Sealant Benefits, Limitations & Exclusions Sealants resin filling used to seal grooves and pits on the chewing surface of permanent molar teeth. A sealant is a benefit only on the unrestored, decay free chewing surface of the maxillary (upper) and mandibular (lower) permanent first and second molars. Sealants are only a benefit on members under 16 years of age. Only one benefit will be allowed for each tooth within a lifetime. C. Basic Benefits, Limitations & Exclusions Simple extractions. General Anesthesia & I.V. Sedation is covered only when administered by a properly licensed dentist in a dental office in conjunction with covered surgery procedures or when necessary due to concurrent medical conditions. Minor Restorations amalgams (silver fillings) composites (white fillings) and prefabricated stainless steel crown restorations for the treatment of decay. Restorative benefits are allowed once per surface in a 24 month period, regardless of the number or combinations of procedures requested or performed. The replacement, by the same dentist or dental office, of amalgam or composite restorations within 24 months is not allowed. The replacement of a stainless steel crown by the same dentist or dental office within a 24 month period of the initial placement is not allowed. Gold foil restorations and porcelain, composite, and metal inlays are Optional Services. Denture Repairs services to repair complete or partial dentures. D. Oral Surgery Benefits, Limitations & Exclusions. Oral Surgery complex extractions and other surgical procedures (including preand post operative care). E. Endodontic Benefits, Limitations & Exclusions Endodontia treatment of the dental pulp (root canal procedures). Payment for root canal treatment includes charges for x-rays and temporary restorations. Root canal treatment is limited to once in a 24 month period by the same dentist or dental office. F. Periodontic Benefits, Limitations & Exclusions Periodontia treatment of the gums and bones that surround the tooth. Payment for periodontal surgery shall include charges for three months post operative care and any surgical re-entry for a three year period. Root planing, curettage and osseous surgery are not a benefit for members under 14 years of age. Scaling and root planing procedures are allowed once within 24 months. G. Major Restorative Benefits, Limitations & Exclusions Cast Restorations. Crowns and onlays are benefits 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. Replacement of crowns or cast restorations received in the previous five years is not a benefit. Payment for cast restorations shall include charges for preparations of tooth and gingiva, crown build-up, impression, temporary restoration and any recementation by the same dentist within a 12 month period. A cast restoration on a tooth that can be restored with an amalgam or composite restoration is not a benefit. Procedures for purely cosmetic reasons are not benefits. Porcelain, gold or veneer crowns for children under 12 years of age are not a benefit. DDTN COC 2010 Ortho 4
H. Prosthodontic Benefits, Limitations & Exclusions Prosthodontics. Procedures for construction of fixed bridges, partial or complete dentures and repair of fixed bridges. Replacement of any fixed bridges or partial or complete dentures that the member received in the previous five years is not a benefit. Payment for a complete or partial denture shall include charges for any necessary adjustment within a six month period. Payment for standard dentures is limited to the maximum allowable fee for a standard partial or complete denture. A standard denture means a removable appliance to replace missing natural, permanent teeth. A standard denture is made by conventional means from acceptable materials. If a denture is constructed by specialized techniques and the fee is higher than the fee allowable for a standard denture, the patient is responsible for the difference. Payment for fixed bridges or cast partials for children under 16 years of age is not a benefit. A posterior bridge where a partial denture is constructed in the same arch is not a covered benefit. Temporary partial dentures are a benefit only when upper anterior teeth are missing. Complete or Partial Denture Reline and Rebase procedures. Payment for a reline or rebase of a partial or complete denture is limited to once in a three year period and includes all adjustments required for six months after delivery. interfere with function to be a benefit. Orthodontic benefits are limited to members shown on the Benefit Summary Page. DDTN shall make regular payments for orthodontic benefits. If orthodontic treatment began prior to enrolling in this plan, DDTN will begin benefits with the first payment due the dentist after the subscriber or covered dependent becomes eligible. Benefits end with the next payment due the dentist after loss of eligibility or immediately if treatment stops. Benefits are not paid to repair or replace any orthodontic appliance received. Orthodontic benefits do not pay for extractions or other surgical procedures. However, these additional services may be covered under other benefits of this plan. The initial payment (initial banding fee) made by DDTN for comprehensive treatment will be 33% of the total fee for treatment subject to your copayment percentage and lifetime maximum. Subsequent payments will be issued on a regular basis for continuing active orthodontic treatment. Payments will begin in the month following the appliance placement date and are subject to your copayment percentage and lifetime maximum. I. Implant Benefits, Limitations & Exclusions Implants. The surgical placement of an endosteal (in the bone) implant and the connecting abutment are covered benefits. Replacement of implants or abutments received in the previous five years is not a benefit. The removal of an implant is allowed once per lifetime. Specialized techniques are not benefits (ie. bone grafts, guided tissue regeneration, precision attachments, etc.). Implant maintenance procedures are allowed once in a 12 month period. J. Orthodontic Benefits, Limitations & Exclusions Orthodontics. Procedures using appliances to treat poor alignment of teeth and/or jaws. Such poor alignment must significantly DDTN COC 2010 Ortho 5