2015 UTC Dental Plan Summary Plan Description For UTC Aerospace Systems Windsor Locks, CT employees represented by the International Association of Machinists and Aerospace Workers, AFL-CIO, Local 743
Contents Introduction 1 Overview 1 Who Is Eligible 3 Eligibility Information 3 Dependent Eligibility 3 Coverage Levels 5 Coverage Level Categories 5 If You and Your Spouse Both Work for UTC 5 When Coverage Begins 6 Your Coverage Begins 6 If You Do Not Enroll 7 When You Don t Enroll 7 Paying for Coverage 8 Cost of Coverage 8 Making Changes During the Year 9 Qualified Changes in Status 9 Change of Address 10 Special Enrollment Rights 11 Enrollment Rights 11 The Advocacy Team 11 When Coverage Ends 12 When Your Coverage Ends 12 Extension of Coverage 13 If You Are Laid Off 13 Your Rights Under the Family and Medical Leave Act of 1993 (Family Leave) 13 Continuation Coverage for Employees in the Uniformed Services 13 To Continue Coverage Under COBRA 14 COBRA Coverage 14 Your Right to Pay for Continued Coverage in Certain Qualifying Events 14 Giving Notice That a COBRA Qualifying Event (or Second Qualifying Event) Has Occurred 14 How Long Coverage May Be Continued 15 Newly Acquired Dependents 16 Procedures to Obtain Continued Coverage 16 Cost of Continued Coverage 17 i
Providing Notification of Your Status to Health Plan Vendors and Providers During the Grace Period 17 Termination of Continued Coverage 17 Address Change 17 Qualified Medical Child Support Order 18 Converting to an Individual Contract 19 Terms You Should Know 20 Glossary 20 Summary of Dental Benefits 21 Your Dental Benefits 21 Preventive and Diagnostic Care (Class I Dental Services) 21 Basic Corrective Services (Class II Dental Services) 21 Major Replacement Services (Class III Dental Services) 22 Orthodontic Services (Class IV Dental Services) 22 Predetermination of Benefits for Expenses Over $100 23 Alternate Procedures (Reduced Benefits) 23 Coordination of Dental Benefits 24 If You Are Covered by Another Dental Plan 24 An Example 24 Coordination of Children s Benefits Under Special Circumstances 24 How to File a Claim 26 Submitting Claims 26 Services Not Covered by the Dental Plan 27 Services Not Covered 27 Other Plan Information 29 If a Third Party Is Liable 29 Conditional Claim Payment 29 If You Are in Treatment 29 Death of Active Employee 29 Administrative Information 30 Plan Administration 30 Plan Sponsor 30 Plan Funding 30 Plan Administrators 30 Claims Administrators 30 Plan Year 31 Plan Trustee 31 Employer Identification Number 31 Plan Name and Number 31 Type of Plan 31 Legal Process 31 ii
Collective Bargaining Agreements 32 Plan Administrator s Discretionary Authority 32 Your Legal Rights as a Plan Participant 33 Legal Rights 33 Claim Determination and Appeal Procedures 35 Claims and Appeals 35 Claims and Appeals Management (CAM) 35 Procedures for Filing a Claim or Appeal 36 Procedures Regarding Medical Necessity Determinations 37 Pre-Service Medical Necessity Determinations 37 Concurrent Medical Necessity Determinations 38 Post-Service Medical Necessity Determinations 38 Procedures Regarding Claim Payment Determinations 38 Post Service Claim Determinations 38 Notice of Adverse Determination 39 Claims and Appeal Process 40 If a Claim Is Denied 40 First Level Appeal 40 External Appeals Review 41 Preliminary Review 41 Referral to an Independent Review Organization (IRO) 41 Expedited External Review 42 Appeals to the State Department of Insurance or Health 42 Plan Is Not a Contract of Employment 42 Plan Continuance and Right to Amend 43 Definitions of Common Dental Terms 44 HIPAA Privacy Rights 47 Privacy Rights 47 Protected Health Information 47 1. Restriction on Use of Genetic Information 47 2. Use or Disclosure of PHI 47 3. Plan Compliance 49 4. Terms of Compliance 49 5. Employee Access to PHI 50 6. Privacy Officer 50 7. Complaints 50 8. Breach Notification Rules 51 Coverage Level and Options 52 Your Dental Coverage 52 Cigna Dental Care Patient Charge Schedule 55 Patient Charge Schedule 55 iii
Introduction Overview This Summary Plan Description (SPD) describes the dental benefits for UTC Aerospace Systems Windsor Locks, CT employees who are represented by the International Association of Machinists and Aerospace Workers, AFL-CIO, Local 743. The UTC dental plan helps you and your family pay for many types of dental expenses. Because UTC believes that regular, preventive dental care is the best way to avoid costly dental problems, the plan covers 100% of reasonable & customary (R&C) expenses for preventive care such as exams and cleanings with no deductible. Other types of dental care, including fillings, crowns and dentures, are covered according to a schedule of benefits after you meet an annual deductible. There are four types of dental benefits: Class I Services Routine exams and cleanings, X-rays, space maintainers, fluoride treatments and emergency treatment for pain are covered at 100% of R&C charges. Class II and III Services Fillings, inlays, crowns, extractions, oral surgery, gum treatment, root canals, bridgework and dentures are covered up to a maximum scheduled amount after you pay an annual deductible, shown in the section named Coverage Level and Options. A maximum annual benefit applies to each covered person. Class IV Services Orthodontia is covered at 100% of R&C charges up to a maximum lifetime benefit of $1,500 per covered person, shown in the section named Coverage Level and Options. This SPD describes the dental benefits effective January 1, 2015. Your other UTC benefits are described in separate SPD booklets. If you have any questions about your benefits, please contact a representative at the UTC Benefits Center via AccessDirect at 1-800-243-8135 Monday through Friday, 8:00 a.m. to 9:00 p.m., Eastern Time (ET). 1
How to Access Your Gateway Throughout this SPD, you will see references to Your Gateway and AccessDirect. Your Gateway. This website is your best source for detailed, personalized information on your UTC Choice benefits and for most benefits-related transactions. It gives you the information you need to make informed decisions. To log on to Your Gateway: From work, click on the Your Gateway link found under Pay & Benefits on Employee Self-Service (ESS) on your business unit s intranet page. From home (or from any other computer with internet access), go to www.mydirectory.com/utc. You ll be asked to enter your User ID and Password. If you don t have or know your User ID and/or Password, Register as a New User or follow the prompts to reset your User ID and/or Password. AccessDirect. While Your Gateway should be your first choice for managing your benefits, you can call AccessDirect at 1 800 243 8135 to reach all employee benefits and services. You will need to supply some identifying information (e.g., the last four digits of your Social Security Number (SSN) and your birth date) and enter your Password. If you don t know or have forgotten your Password, follow the prompts to set up a Password. Benefits Center representatives are available to help you between 8:00 a.m. and 9:00 p.m., ET, Monday through Friday. 2
Who Is Eligible Eligibility Information You are eligible to participate in the UTC Dental Plan if you are covered by a collective bargaining agreement (CBA) between your business unit and your union provided that the CBA specifies coverage under the UTC Dental Plan. This plan is effective as of the date specified in your CBA. Coverage will begin on the 31st working day after your date of hire if you are enrolled in the plan. Dependent Eligibility Your eligible dependents can also participate in the UTC dental coverage you select, provided you enroll them. Your dependents become eligible for coverage when you do. Eligible dependents include: Your legal spouse* (unless legally separated or divorced). Your same-gender civil union or domestic partner if:** Your state allows domestic partner registration or civil unions for same-gender couples, and you have fulfilled the legal requirement, or Your state does not allow any such same-gender relationships, and for at least six months you and your same-gender partner: Are at least age 18, Are not legally married to another person or part of another domestic partner relationship, Intend to remain each other's sole domestic partner indefinitely, Reside together in the same principle residence and intend to do so indefinitely, Are emotionally committed to one another and share joint responsibilities for your common welfare and financial obligations, Are not related by blood closer than would be prohibited by marriage in the state in which you live, and Are mentally competent to enter into contracts. *If you choose to cover your same-gender spouse or the child(ren) of your same-gender spouse on your medical, dental or vision benefits, and you either work or live in a state that does not recognize same-gender marriages, the value of that coverage is exempt from federal income and FICA (Social Security and Medicare) taxes but not from state income taxes. In such a situation, the premium to cover your same-gender spouse or the child(ren) of your same-gender spouse including the portion of the premium UTC pays, will be imputed income for state tax purposes. This imputed income is reported on your Form W-2 as part of your annual compensation and taxed at your applicable rate for state income tax. If you choose to cover your same-gender spouse or the child(ren) of your same-gender spouse on your medical, dental or vision benefits, and you work in a state that recognizes same-gender marriages, the value of that coverage is exempt from federal income, FICA (Social Security and Medicare) and state income taxes. **If you choose to cover your same-gender domestic partner or the child(ren) of your same-gender domestic partner on your medical, dental or vision benefits, the law requires certain tax treatment unless those covered are eligible to be claimed as dependents according to IRS rules. Your premium, including the portion of the premium UTC pays, will be imputed as income to you. This imputed income is reported on your Form W-2 as part of your annual compensation for federal income, FICA (Social Security and Medicare) and state income tax purposes and taxed at your applicable rate. We urge you to consult your accountant or other tax professional to determine whether your same-gender domestic partner or child(ren) of your same-gender domestic partner are eligible to be claimed as dependents on your federal income tax. 3
Your current state does not allow marriage, domestic partner registration or civil unions for samegender couples, but you previously fulfilled the legal requirements of another state and the relationship remains intact. Your children up to the end of the month in which they reach age 26. Eligible children include: Your natural children or legally adopted children, Your pre-adopted children (if you have assumed custody and have applied for adoption), Children for whom you are a court-appointed legal guardian, Stepchildren, and Children of your covered same-gender civil union or domestic partner.** (See this footnote on the previous page.) Your children who become physically or mentally handicapped while covered as dependents, regardless of their age, and who depend on you for support. (To continue dental coverage after your child ages out of the plan, you must contact the UTC Benefits Center to obtain the appropriate forms to begin the disabled dependent certification process within 30 days of the date your child s dental coverage would otherwise end. Return the completed forms to the health plan vendor at the address printed on the form for review and approval. You will then receive an approval or denial letter from the health plan vendor.) UTC reserves the right to request verification of eligibility of spouse or child(ren) s dependent status. When you add a dependent to coverage, you will be required to submit documentation verifying your dependent s eligibility after you enroll. You will receive more information on this process in your home mail if this applies to you. Note: In most cases, UTC offers equal benefits to spouses, same-gender domestic partners and civil unions. Therefore, for the purposes of this SPD, the term spouse includes same-gender civil unions and domestic partnerships, except where otherwise noted. 4
Coverage Levels Coverage Level Categories If you enroll for dental coverage, you must choose from one of these coverage categories: You only, You plus spouse, You plus child(ren), or You plus family (spouse and child or children). If You and Your Spouse Both Work for UTC If you and your spouse both work for UTC and are both eligible for dental benefits, you may each select different coverage levels, where one of you may elect employee coverage and cover the other as a dependent. There is no benefit to being covered under your own and your spouse s UTC plan. With the No Coverage option and the plans coordination of benefits provisions, consider carefully whether one of you wants to opt out of dental coverage. Make your choices carefully, because you cannot change your elections until the next Annual Enrollment unless you have a qualified change in status. (Refer to the section named Making Changes During the Year.) 5
When Coverage Begins Your Coverage Begins If you are a new employee enrolling during the year, coverage for you and your dependents (if you enroll them) will begin on the 31 st day starting from your hire date, if you have enrolled and are considered an active employee. For example, if your hire date is January 1, coverage for you and your dependents will begin on January 31. You will be asked to complete your enrollment either online via Your Gateway or by calling the UTC Benefits Center. If you do not enroll when you are first eligible for dental coverage, you will automatically be enrolled in the Comprehensive Dental Plan for yourself only. If you enroll during Annual Enrollment that occurs each fall, coverage for you and your dependents will begin on January 1 and remain in effect through December 31. According to Internal Revenue Service (IRS) rules, you may only make changes in your election during the year if you have a qualified change in status or if you experience an event permitting a mid-year election change (refer to the section named Making Changes During the Year for details). If you terminate and are rehired within 12 months or if you are laid off and are rehired within 24 months, you are not required to satisfy a new waiting period. If you terminate and are rehired after 12 months or if you are laid off and are rehired after 24 months, the waiting period applies. 6
If You Do Not Enroll When You Don t Enroll If you do not enroll when you are first eligible, you will be automatically enrolled in the following benefits: Medical High Deductible Health Plan Option 1 for employee only Dental for employee only Vision No coverage Employee Basic Life Insurance Optional Supplemental Life Insurance No coverage Survivor Income Accidental Death and Dismemberment (AD&D) Insurance Weekly Disability Total and Permanent Disability (TPD) Insurance Health Care Spending Account and Dependent Care Spending Account No participation Employee Assistance Program (EAP) Business Travel Accident Insurance If you currently have coverage and you don t actively enroll, you will automatically be defaulted into your current coverage, including any tax-advantaged account elections, unless it is no longer available. If you want to change your coverage, you must take action during your Annual Enrollment. It s important to be involved in making your benefits elections otherwise, you could end up with coverage that may not fit your needs and/or the needs of your family. 7
Paying for Coverage Cost of Coverage You and the company share in the cost of your dental coverage for you and your dependents. Your portion of the cost is deducted from your paycheck on a pre-tax basis; that is, before federal and, in most cases, state income taxes and FICA taxes are withheld. If you are on an unpaid leave of absence, you are responsible for paying for your portion of the cost during your leave or upon your return to work. The contribution amount will be communicated to you when you enroll during Annual Enrollment. Your contribution amount is subject to the terms of the collective bargaining agreement. Your cost depends on the coverage level you elect. Your pre-tax contributions for dental coverage may impact your future Social Security benefits. This is because you pay Social Security taxes based on your earnings after any contributions are deducted. Your future Social Security benefits could be slightly reduced. The savings through pre-tax contributions, however, are generally greater than any Social Security benefit reduction that could result. 8
Making Changes During the Year Qualified Changes in Status Because you pay for your UTC dental coverage with pre-tax dollars, you may make changes during the year only if you have a change in your family or employment status (referred to as a qualified change in status ), or if you experience a different event permitting a mid-year election change. Approved qualified changes in status under this plan include: You get married, divorced or legally separated, or you have an annulment, Your dependent s coverage options change mid-year, You enter into or end a same-gender domestic partnership or civil union, You add a child by birth or adoption (or add a child through marriage or assumption of legal guardianship), Your dependent dies, Your dependent loses his or her job or loses coverage, Your dependent begins a job or gains coverage, or Your dependent child attains age 26. Any changes you make as a result of a qualified change in status must be permitted by law and consistent with the qualifying event. Benefit changes are consistent with the event only if they: Result in you or your dependent gaining or losing eligibility to participate in this plan or the plan of your dependent s employer, and Are on account of, and correspond with, a gain or loss of coverage. You must report the qualified change in status and enroll or drop your dependent on Your Gateway or by calling the UTC Benefits Center within 30 days of the event. The effective date of the change in your coverage will be the date of the qualifying event. In the case of a newborn child, the child is automatically covered for the first 30 days following birth. If you do not enroll your child in the plan during this period, however, coverage will end after these first 30 days and you will not be able to enroll your child until the next Annual Enrollment. Other permissible mid-year election changes include: Changes consistent with the special enrollment rights under the Health Insurance Portability and Accountability Act (HIPAA). Changes required by a Qualified Medical Child Support Order (QMCSO) or national medical support notice, resulting from a divorce, legal separation, annulment or change in legal custody. If the QMCSO directs you to cover the child in the health care plans, you must enroll the child (and yourself) in the plan. If the order directs someone other than you to cover the child, you may drop coverage for the child. Changes due to entitlement (or loss of entitlement) to Medicare or Medicaid. If you or a covered dependent becomes entitled to Medicare or Medicaid, you may drop or reduce medical coverage for the individual enrolled in Medicare or Medicaid. If you or a dependent loses entitlement to Medicare or Medicaid, you may enroll or increase medical coverage for that individual (and yourself) in the plan. 9
Changes consistent with taking leave under the Family and Medical Leave Act (FMLA). If you take a leave of absence for more than 30 days under the FMLA, you may revoke your election under this plan and make such other election for the remaining portion of the period of coverage as may be provided for under the FMLA. Changes consistent with taking Military Leave. If you are on a Military Leave for more than 30 days, you can make changes to your coverage. Change of Address The address on file with your payroll department is used to determine your eligibility for some benefit plans. If you have a change of address, you should generally be able to change your address through Employee Self-Service (ESS) from your business unit s intranet page. If you do not have access to ESS, you can contact your Human Resources representative to update your address. 10
Special Enrollment Rights Enrollment Rights If you or your dependents declined coverage under the UTC Dental Plan because you or they have dental coverage elsewhere, and one of the following events occurs, you have 30 days from the date of the event to enroll yourself and/or your dependents in this plan: You and/or your dependents lose the other dental coverage because eligibility was lost for reasons including legal separation, divorce, death, termination of employment or reduced work hours (but not due to failure to pay premiums on a timely basis, voluntary disenrollment or termination for cause). The employer contributions to the other coverage have stopped. The other coverage was COBRA and the maximum COBRA coverage period ends. Refer to the section named To Continue Coverage Under COBRA for additional information. As an employee, you may enroll your new spouse and any eligible children within 30 days of your marriage and a new child within 30 days of his or her birth, adoption or placement for adoption. In addition, if you are not enrolled in the plan as an employee, you also must enroll in the plan when you enroll any of these dependents. And, if your spouse is not enrolled in the plan, you may enroll him or her in the plan when you enroll a child due to birth, adoption or placement for adoption. The Advocacy Team Through UTC, you have access to an advocacy service, the Advocacy Team, to help ensure you get the most out of your UTC benefits. The service is confidential and available through the UTC Benefits Center. The Advocacy Team can help you resolve conflicts you may have with your medical, dental, vision, life insurance, disability, mental health/substance abuse or Spending Account vendor. If you have not received a satisfactory outcome or would like further clarification after contacting your plan vendor to discuss your issue, the Advocacy Team can help you by researching your issue and working with your health plan vendor to resolve it on your behalf. To reach the Advocacy Team, call AccessDirect at 1 800 243 8135 and follow the prompts. You will need to supply some identifying information (e.g., the last four digits of your Social Security Number and your birth date) and enter your Password. If you don t know or have forgotten your Password, follow the prompts to set up a Password. Benefits Center representatives are available to help you between 8:00 a.m. and 9:00 p.m., ET, Monday through Friday. Please note: Contacting the Advocacy Team about an issue with a vendor does not guarantee the resolution you want; the terms of the plan still apply. 11
When Coverage Ends When Your Coverage Ends In general, coverage under the UTC Dental Plan will end: The last day of the payroll period in which your employment ends for any reason, unless you are totally disabled, laid off or on severance and your collective bargaining agreement provides benefits continuation or you elect to continue coverage under COBRA. (Refer to the section named To Continue Coverage Under COBRA), When you cancel dental coverage. Your coverage ends on the last day of the payroll period in which a life status change results in cancellation of coverage. Your coverage ends on December 31 of the current year, if you decline coverage during Annual Enrollment for the next plan year, When you are no longer an eligible employee or you are no longer eligible to participate in the plan, The date the group contract is discontinued, When you fail to pay the required premiums, if any, or The date the plan is terminated. Your dependents coverage will end when your coverage ends or the last day of the payroll period in which: Your individual dependent ceases to meet the eligibility requirements of the plan, You fail to pay the required premiums, if any, for dependent coverage, or A life status change results in the loss of a covered dependent. 12
Extension of Coverage If You Are Laid Off If you are laid off, you will be notified by the UTC Benefits Center as to how long your dental coverage will continue. Your Rights Under the Family and Medical Leave Act of 1993 (Family Leave) The UTC Family and Medical Leave Policy allows an employee to take unpaid Family or Medical Leave. If your Family or Medical Leave lasts longer than 30 days, your medical, dental, vision and employee basic life insurance coverage will continue, but other benefits will end. Contact the UTC Benefits Center for more information on the benefits that will end. Contact your Human Resources representative for additional information on the Family and Medical Leave Policy. Continuation Coverage for Employees in the Uniformed Services The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) guarantees certain rights to eligible individuals who enter military service. Please call the UTC Benefits Center for additional information on the Military Leave Policy. For information on your coverage during other leaves of absence, contact the UTC Benefits Center. 13
To Continue Coverage Under COBRA COBRA Coverage Under a federal law called the Consolidated Omnibus Budget Reconciliation Act (COBRA), you, your spouse and your dependent children may elect to pay for continued dental coverage for limited periods if certain qualifying events occur. Your COBRA rights are described in this section. Your Right to Pay for Continued Coverage in Certain Qualifying Events You may purchase continued coverage under the dental plan for up to 18 months if you lose coverage under the plan due to: Termination of employment (for reasons other than gross misconduct), Retirement from UTC, A reduction of work hours, or The end of a benefits continuation following involuntary separation. Your spouse and other covered dependents may continue their coverage if they lose coverage as a result of: Your death, Your entitlement to (i.e., enrollment in) Medicare benefits as a retiree (Part A, Part B or both), A reduction of your scheduled work hours, such that you no longer meet the eligibility requirements of the plan, Termination of your employment (for reasons other than gross misconduct), Your divorce or legal separation, or Loss of dependent status. Once your employment with UTC ends through termination or retirement and you become entitled to Medicare, you are no longer eligible for COBRA coverage under the UTC Dental Plan. A spouse or dependent child may be eligible to continue dental coverage under COBRA for the remainder of the 18-month continuation period after you become entitled to Medicare. Giving Notice That a COBRA Qualifying Event (or Second Qualifying Event) Has Occurred The plan will offer COBRA continuation coverage to individuals only after the plan administrator has been given timely notification that a qualifying event has occurred. When the qualifying event is the employee s termination of employment (other than for gross misconduct), reduction of work hours or death of the employee, the employer must notify the COBRA plan administrator of the qualifying event. The plan administrator must be notified of a dependent qualifying event within 60 days. 14
How Long Coverage May Be Continued Under COBRA, you and your covered dependents may continue coverage for: 18 months in the event of termination of employment, retirement or reduction of hours. COBRA may be extended for dependents up to a total of 36 months from the date of the original qualifying event, if other events, such as divorce, death or loss of dependent status occur during that 18-month period. You or your dependent must notify the plan administrator if one of these events occurs. 36 months for a spouse and dependent children in the event of: The death of the employee, Divorce or legal separation, or The dependent no longer meets the eligibility requirements of the dental plan. There are two ways in which the 18-month period of COBRA continuation coverage due to your termination of employment or reduction of work hours can be extended: You, your spouse or any of your dependent children covered under the plan is determined by the Social Security Administration (SSA) to be disabled on the date of your termination of employment or reduction of work hours, or at any time during the first 60 days of COBRA continuation coverage due to such qualifying event, each qualified beneficiary (whether or not disabled) may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have to have started at some time before the 60 th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. To qualify for this disability extension, you must notify the COBRA plan administrator in writing of the person s disability status: Within 60 days after the latest of: i) the date of the disability determination by the SSA, ii) the date on which the qualifying event occurs, iii) the date on which you lose (or would lose) coverage under the plan due to the qualifying event, or iv) the date on which you are informed of both the responsibility to provide this notice and the plan s procedures for providing such notice to the COBRA plan administrator, and Before the original 18-month COBRA continuation coverage period ends. Also, if the Social Security Administration determines that the individual is no longer disabled, you are required to notify the COBRA plan administrator in writing within 30 days after this determination. If these procedures are not followed, or if the notice is not provided in writing to the COBRA plan administrator within the required period, you will not receive a disability extension of COBRA continuation coverage. 15
If your spouse and/or dependents experience a second qualifying event while receiving the initial 18 months of COBRA continuation coverage, your spouse and dependent children (but not you) can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months from the first qualifying event, if timely written notice of the second qualifying event is given to the COBRA plan administrator. This extension may be available to your spouse and any dependent children receiving COBRA continuation coverage if you die, become divorced or legally separated, or if the dependent child stops being eligible under the plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the plan had the first qualifying event not occurred. If a second qualifying event occurs at any time during the 29-month disability continuation period (as described above), then each qualified beneficiary who is your spouse or dependent child (whether or not disabled) may further extend COBRA continuation coverage for seven more months, for a total of up to 36 months from your termination of employment or reduction of work hours. If these procedures are not followed or if the notice is not provided in writing to the COBRA plan administrator within the required 60-day period, you will not receive an extension of COBRA continuation coverage due to a second qualifying event. The COBRA plan administrator can be reached via AccessDirect at 1 800 243 8135. You should call the COBRA plan administrator to provide appropriate notice and to determine where to send written requirements. Newly Acquired Dependents If you acquire a new dependent spouse or a dependent child (or wish to add a dependent as permitted during Annual Enrollment) while your dental coverage is being continued under COBRA, that dependent is eligible for COBRA continuation if the required premium is paid, and you enroll the dependent within 30 days of the date you first acquire the dependent or during Annual Enrollment. In the event of your death, divorce or legal separation after the qualifying event, your newly acquired or newly added dependent spouse will not be entitled to COBRA continuation. However, a newborn child or a dependent child adopted or placed for adoption is entitled to up to 36 months of COBRA continuation if you die, divorce or legally separate after the qualifying event or if the child loses dependent status. Procedures to Obtain Continued Coverage You or your covered dependents may keep the same coverage you had before the qualifying event occurred. You may change your dental coverage during the next Annual Enrollment. If you become eligible for continued coverage through COBRA, the plan administrator(s) will notify you. However, if your dependent becomes eligible because of divorce, legal separation or loss of dependent status, you have an obligation to notify the UTC Benefits Center within 60 days after the later of: The date of the qualifying event, or The date the individual loses (or would lose) coverage under the plan as a result of the qualifying event. You will be provided with coverage continuation information within 44 days following notification that a qualifying event has occurred. You will then have 60 days to contact the plan administrator(s) to enroll. You have 60 days from the later of the coverage end date or enrollment worksheet date to pay the initial premium(s). The initial COBRA dental premium(s) must be paid in full, retroactive to the date COBRA continuation coverage started. 16
Cost of Continued Coverage You and your covered dependents will be required to pay 102% of the full group cost for your continued coverage. (If you are eligible for the 11-month disability extension, your contribution will increase to 150% of the full group cost after the first 18 months of COBRA continuation.) You will be asked to pay for coverage in monthly installments, and you must make your first payment no later than 60 days after the date you elected continued coverage. Subsequent payments will be due on the first of each month, with a 60-day grace period. If payment is made within the grace period in an amount not significantly less than the amount the plan requires to be paid, then the amount is deemed to satisfy the plan s grace period requirement. However, you will be notified and will have at least 30 days after notice is provided to pay the difference. If the cost of benefits changes in the future for active employees, these changes will also affect continued coverage under COBRA. You will be notified in advance of any changes in the cost of coverage. Providing Notification of Your Status to Health Plan Vendors and Providers During the Grace Period If, after you elect COBRA, a health plan vendor or provider contacts the plan to confirm coverage for a period for which the premium has not yet been received, the plan must give a complete and accurate response. Termination of Continued Coverage Your right to continue group coverage may end before the expiration of the maximum coverage period if: You or your covered dependents fail to make the required payment on time, UTC terminates the UTC Dental Plan for all employees, You or your dependent becomes entitled to Medicare, or You or your covered dependents become covered under another group dental plan, including a UTC plan. Please note: Coverage under COBRA will be provided as required by law. If the law changes, your rights will also change. Address Change In order to protect your family s rights, you should inform the UTC Benefits Center of any changes in address for you and covered family members or report the address change on Your Gateway. 17
Qualified Medical Child Support Order The plan administrator will comply with a Qualified Medical Child Support Order (QMCSO). A QMCSO must be a judgment, decree or order (including approval of a settlement agreement) or administrative notice issued by a court of competent jurisdiction which: Provides for support of a covered employee s child, Provides for health benefit coverage to the child, Is made pursuant to a state domestic relations law (including a community property law) or to an administrative process, Relates to benefits under the group health plan, and Is qualified within the meaning of ERISA Sections 609(a) and Sections 514(b)(8) or applicable state law. A QMCSO also means a state court order or judgment that enforces a state Medicaid law regarding medical child support required by the Consolidated Omnibus Budget Reconciliation Act of 1993. If a QMCSO is issued for your child, the child will be eligible for coverage as required by the order and you will not be considered a late entrant for dependent coverage. You must notify the UTC Benefits Center and elect coverage for that child and yourself, if you are not already enrolled, within 30 days of the date the QMCSO is issued. The QMCSO requires that any reimbursement for dental claims will be made to the recipient, custodial parent or guardian. The QMCSO may not require the plan to provide coverage for any type or form of benefit or option not otherwise provided under the plan, except to the extent necessary to comply with state laws regarding child health care coverage. A copy of the procedures for determining a QMCSO can be obtained by accessing the Qualified Order Center website via the My Events page on Your Gateway, by calling AccessDirect at 1-800-243-8135 or by writing to the UTC Benefits Center at: United Technologies Corporation (UTC) Benefits Center QMCSO P.O. Box 1542 Lincolnshire, IL 60069-1542 The QMCSO must satisfy all of the following: The order recognizes or creates a child s right to receive group health benefits for which a participant or beneficiary is eligible, The order specifies the employee s name and last known address, except that the name and address of an official of a State or political subdivision may be substituted for the child s mailing address, The order provides a description of the coverage to be provided, or the manner in which the type of coverage is to be determined, The order states the period to which it applies and each plan to which the order applies, and 18
If the order is a National Medical Support Notice completed in accordance with the Child Support Performance and Incentive Act of 1998, such Notice meets the requirements above. Any payment of benefits in reimbursement for covered expenses paid by the child, the child s custodial parent or legal guardian, shall be made to the child, the child s custodial parent or legal guardian, or to a state official whose name and address have been substituted for the name and address of the child. Converting to an Individual Contract You may not convert your dental coverage to an individual policy. 19
Terms You Should Know Glossary To help you understand how the dental plan works, you should know these terms: Company United Technologies Corporation (UTC) and any of its subsidiaries that participate in this plan. Covered Expenses The charges for those dental services that qualify for full or partial benefit payment under the plan. Expenses covered by the plan, and those that don t qualify for any plan benefits, are described in this SPD. Covered dental expenses are described in detail in the section named Cigna Dental Care Patient Charge Schedule. Deductible The amount you pay each year for Class II and Class III coverage before plan benefits begin. Dentist An individual licensed to practice dentistry or perform oral surgery. A physician is considered a dentist when he or she performs the dental services covered by the plan and is operating within the scope of his or her license. Maximum Dental Benefits The maximum benefit payable for covered services under the dental plan. There is no maximum benefit for Class I services. Pretreatment Review Review by the Claims Administrator, before treatment begins, of the proposed treatment and expected charges. This feature will let you and your dentist know what the plan will pay before any work begins. Reasonable and Customary (R&C) Charges The range of usual fees for comparable services charged by dental professionals in the geographic area in which they practice. Cigna determines R&C charges based on its research and updates are performed twice each year. Other factors are also taken into account. These include the nature and complexity of the dental services received plus the training, knowledge and skill of the dentist involved. Charges for a service are reasonable and customary to the extent that they do not exceed an amount based on the lesser of: The dentist s usual charge for the service, or The prevailing charge for the service made by other providers in the same geographic area. If your dentist charges more than the R&C fee, you will be responsible for paying the difference. There may be cases where an R&C charge cannot be easily identified. In such cases, Cigna will determine the extent to which the charge is covered, taking into account the complexity of the service, the degree of professional skill required, and other factors relating to the services or supplies provided. 20
Summary of Dental Benefits Your Dental Benefits Preventive and Diagnostic Care (Class I Dental Services) Class I services are covered up to 100% of R&C charges with no deductible for preventive and diagnostic care. Preventive and diagnostic benefits include: Routine oral examinations twice in any calendar year, Routine cleaning and scaling of teeth twice in any calendar year, Bitewing X-rays twice in any calendar year, Full mouth panoramic bitewing X-rays once in any three calendar years, Fluoride treatment for children once every year up to age 19, Topical application of fluoride once in any calendar year over age 19, Topical application of sealants on back teeth of children under age 14 one treatment per tooth in any three calendar years, Space maintainers limited to non-orthodontic treatment for prematurely removed or missing teeth for persons under age 19, and Emergency treatment for temporary relief of pain when no other services are performed as needed. Basic Corrective Services (Class II Dental Services) Class II services cover more complex and costly dental work, such as fillings, extractions and root canal therapy. Benefits are based on a schedule (refer to the section named Cigna Dental Care Patient Charge Schedule). The plan will pay either 100% of your dentist s fee or the scheduled benefit, whichever is less. Class II services include: Fillings (amalgam, silicate, acrylic, synthetic, porcelain or composite), Inlays, onlays, gold fillings and crowns, if the tooth cannot be restored with a filling described above and if it is not replacing a crown installed under the plan within the last five years, Simple extractions and oral surgery to treat disease, remove wisdom teeth or prepare for dentures, if not covered by your medical plan, General anesthesia for oral or dental surgery, if medically necessary and not covered by your medical plan, Periodontal treatment of gums, Endodontics (treatment of dental pulp) root canal treatment, including any X-rays, laboratory exams and follow-up care, Antibiotic injections administered by a dentist, A prosthetic device, supported by an implant or implant abutment, Repair or recementing of crowns, inlays, onlays, bridgework or dentures more than six months after initial installation, and Relining or rebasing dentures more than six months after initial installation once in any three calendar years. 21
Major Replacement Services (Class III Dental Services) Class III services cover the cost of replacement of natural teeth or dentures and bridgework. Benefits are based on a schedule (refer to the section named Cigna Dental Care Patient Charge Schedule). The plan will pay either 100% of your dentist s fee or the scheduled benefit, whichever is less. Class III services include: Initial installation of fixed bridgework, including inlays and crowns as abutments and removable dentures, but not any additional charges for attachments and adjustments during the six months following installation, Replacing or adding to existing bridgework or dentures to: Replace teeth extracted after the appliance was initially installed, Replace a temporary denture with a permanent one once within any calendar year, or Replace a bridge, crown or denture damaged beyond repair while in the mouth as a result of an injury received while covered for dental benefits, and Replace bridgework, crowns or dentures installed more than five years before, if the initial installation was covered by this plan; otherwise, at any time. Note that crown restorations are covered only when the tooth, as a result of extensive caries or fracture, cannot be restored with amalgam, composite/resin, silicate, acrylic or plastic restoration. Replacement for dentures and bridgework is allowed if any of the following criteria are met: Since the denture or bridgework was initially installed, you have had additional teeth extracted so additional teeth must be replaced. The existing denture or bridgework is more than five years old and cannot be repaired or made serviceable. It is necessary following surgery for the removal of a tumor, cyst or redundant tissue. Replacement must be completed within 12 months following oral surgery that was covered by the medical plan. For the replacement of existing crowns, inlays, onlays and gold fillings, these items must be more than three years old. Orthodontic Services (Class IV Dental Services) The plan pays up to 100% of R&C charges with no deductible for orthodontic services, teeth straightening or repositioning. There is a lifetime maximum benefit of $1,500 for each eligible employee or dependent. Orthodontic services include: Full banded orthodontic treatment, including: Preliminary radiographs, diagnostic casts and treatment plan, The first month of active treatment, including all active and retention appliances, Monthly active treatment, and Retention and observation treatment, per visit, if charged in addition to the case fee. Other treatment: Removable or fixed appliances for tooth guidance (one per person), and Removable or fixed appliances to control harmful habits (one per person). Additional services: Cephalometric radiograph, and Examination, treatment or adjustment of appliance, per visit. 22
For orthodontic services performed while you are covered by the plan, the plan pays benefits in installments: 25% of the total charges when the appliance is installed, and Quarterly payments, prorated over the course of active treatment, up to the plan lifetime maximum. Predetermination of Benefits for Expenses Over $100 When you and your dentist are planning non-emergency treatment that will cost more than $100, you should get an estimate of what the plan will pay before treatment begins. Ask your dentist to submit a claim form, including X-rays, describing the procedure and an estimate of the charge. Cigna will review the claim form and send your dentist a statement showing how much the plan will pay toward the proposed treatment. If Cigna determines that a lower-cost alternative method of treatment would produce a satisfactory result, then a lower benefit will be payable if you follow the treatment your dentist proposes. In all cases in which alternate methods of treatment are available, the maximum amount payable may be based on the charge for a dental service that provides professionally adequate treatment at a lesser charge. You are free to choose your own course of treatment. You must pay your dentist, however, for any charges above the amount Cigna allows. After you complete treatment, your dentist should indicate on the claim form the date services were completed, sign the form and return it to Cigna for payment. The predetermination of benefits is not required in emergencies or when treatment will cost less than $100. Alternate Procedures (Reduced Benefits) Often there is more than one way to treat a particular dental problem. For example, either a crown or a filling could be used to restore a tooth. Also, choices can be made regarding materials to be used; for example, precious metals or plastic. The plan may pay a reduced amount for a covered procedure, provided the treatment meets acceptable dental standards. Whenever the Alternate Procedures provision is applied, the Claims Administrator s dental consultant reviews the claim. The Predetermination of Benefits provision of the plan is important because under the Alternate Procedures provision, the plan has the right to pay a reduced amount for the most economical method of treatment that does the job properly for a covered dental procedure. If Cigna determines that a lower-cost alternative method of treatment would produce a satisfactory result, then a lower benefit will be payable if you follow the treatment your dentist proposes. In all cases in which alternate methods of treatment are available, the maximum amount payable may be based on the charge for a dental service that provides professionally adequate treatment at a lesser charge. If you and the dentist decide you want the more costly treatment for a covered dental procedure, you are responsible for the additional charges beyond those for the less costly appropriate treatment paid by the plan. 23
Coordination of Dental Benefits If You Are Covered by Another Dental Plan The dental plan has a coordination of benefits (COB) provision. If you or your family members have other dental care coverage through another group plan for example, your spouse s plan any benefits you receive (or would have received if you filed a claim for them) from the other plan will be coordinated with benefits from the UTC plan. That is, any payments you receive from another source, together with payments from your UTC Dental Plan, will not exceed what would have been payable by UTC s plan alone. The UTC plan normally pays first for your own expenses. If your other coverage is through your spouse s plan, that plan will normally pay first for your spouse. If your children are covered by both plans, the primary payor (the plan that pays claims first) will be determined by the birthday rule. That is, the plan of the parent whose birthday (month and day) falls first during the calendar year will pay first, unless there is a court decree which establishes financial responsibility for the child s dental expenses). If the other plan does not have a coordination of benefits provision, that plan is always considered the primary plan and pays first. If you have coverage through another dental plan, you may receive reimbursement of your allowable expenses, subject to R&C charges or the scheduled amount, whichever is applicable. An allowable expense is any necessary, R&C item covered by any one of the group plans involved. However, your UTC Dental Plan will only pay the difference, if any, between the benefit from your other dental plan and your normal UTC Dental Plan benefit. If you and your spouse work for UTC, be sure to review your options and the COB rules carefully before making your elections. An Example Assume that you incur R&C dental expenses of $215 for your child, and your spouse s plan is the primary plan (your spouse s birthday is before yours). Also assume that your spouse s plan pays $100 and that UTC s plan if you had no other coverage pays $190. Under coordination of benefits, your spouse s plan would pay $100, then the UTC plan would pay $90 the difference between the benefit from your other dental plan and the UTC benefit of $190. Coordination of Children s Benefits Under Special Circumstances Court order If a court decree has established financial responsibility for dental expenses for dependent children, the plan that covers the child as a dependent of the responsible parent would pay benefits first. Custody In the absence of a court order, the plan that covers a child as a dependent of the parent with custody will pay benefits before the plan of a stepparent or a parent without custody. The plan that covers a child as a dependent of a stepparent will pay benefits before the plan of a parent without custody. When the above rules do not determine which plan should pay first, the plan that has covered the dependent, for whom the claim is made, for the longer period of time will pay first. There is one exception to this rule: A plan that covers the person as an active employee will pay first the claims involving both the person and his or her dependents, before a plan that covers the person as an inactive or retired employee. If the other plan does not have this rule that results in each plan determining its benefits after the other, then this rule will not apply. 24