HomeMy WebLinkAboutDeltaVision Benefits CertificateEffective Date: 4/2017
Form Number: DVInsight 04/17
Voluntary or Contributory with F & F
DeltaVision® is offered through Veratrus Benefit Solutions, Inc., a wholly-owned subsidiary of Delta Dental of Iowa
DeltaVision® Benefits Certificate
Enhanced $10/$10
Insight
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WELCOME TO VERATRUS BENEFIT
SOLUTIONS, INC.
DeltaVision® is offered through Veratrus Benefit Solutions, Inc., a wholly-owned subsidiary of
Delta Dental of Iowa.
It is important that you understand all parts of this Benefits Certificate (Certificate) to get the
most out of your coverage. To help make the information easier to understand, we use the words
you and your to refer to you and your eligible Covered Persons who qualify for coverage under
this Certificate. We, us, and our refers to Veratrus Benefit Solutions, Inc.
We will interpret the provisions of this Certificate and determine the answer to all questions that
arise under it. We have the administrative discretion to determine whether you meet our written
eligibility requirements, or to interpret any other term in this Certificate. If any Benefit in this
Certificate is subject to a determination of vision necessity and appropriateness, we will make
that factual determination. Our interpretations and determinations are final and conclusive.
In this Certificate we sometimes refer to certain laws and regulations. Laws and regulations
can and do change from time to time. If you have a question as to how laws and regulations
may apply to your coverage, please contact us.
To administer your Benefits properly, there are certain rules you must follow. Different rules
appear in different sections of your Certificate. We urge you to become familiar with the entire
Certificate.
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DeltaVision® Contact Information
Benefits & Claims Information
Contact Customer Service for questions concerning Benefits and claims payments.
Available Hours: Monday – Saturday 7:00 AM – 6:00 PM, Sunday 10:00 AM- 3:00 PM
(CST)
Toll-free: 1-888-899-3747
Eligibility & Enrollment Updates
Please contact your Employer or Group Sponsor or call DeltaVision’s Group Administration
Department for address changes, or any other information changes related to eligibility and
enrollment.
Available Hours: Monday – Friday 8:00 AM to 4:30 PM (CST)
Toll-free: 1-877-983-3582
Provider Locations
For a list of Vision Care Provider locations, Covered Persons may visit the DeltaVision website or
contact the Benefit and Claims Phone number listed above.
www.deltadentalia.com/deltavision
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TABLE OF CONTENTS
SUMMARY OF BENEFITS CHART......................................................................................................... 6
IMPORTANT INFORMATION ......................................................................................................................... 7
UNDERSTANDING BENEFITS CERTIFICATE VOCABULARY ................................................. 7
UNDERSTANDING AMOUNTS YOU PAY TO SHARE COSTS .............................................. 8
HELPING WHEN YOU HAVE QUESTIONS ........................................................................................ 8
BENEFITS (COVERED VISION PROCEDURES) ............................................................................... 8
SERVICES NOT COVERED ....................................................................................................................... 9
NOTIFICATION/DOCUMENTATION REQUIREMENTS ..................................................................... 11
FILING CLAIMS .............................................................................................................................................. 11
WHEN TO FILE YOUR CLAIM ............................................................................................................ 11
COORDINATION OF BENEFITS ........................................................................................................ 11
APPEALING A DENIED CLAIM ......................................................................................................... 12
YOUR CERTIFICATE ......................................................................................................................................... 13
ELIGIBLE COVERED PERSONS ........................................................................................................ 13
LATE ENTRANT AND RE-ENROLLMENT PROVISIONS .......................................................... 13
TYPES OF COVERAGE .............................................................................................................................. 14
QUALIFIED MEDICAL CHILD SUPPORT ORDER (QMCSO) .................................................14
WHEN COVERAGE BEGINS ................................................................................................................... 14
WHEN COVERAGE ENDS ........................................................................................................................ 14
CONTINUED COVERAGE (COBRA) ............................................................................................... 15
EVENTS CHANGING COVERAGE ........................................................................................................ 16
NOTIFICATION OF CHANGE ............................................................................................................. 16
NOTICES .................................................................................................................................................... 16
AUTHORIZED CERTIFICATE CHANGES ....................................................................................... 17
EFFECTS OF TERMINATION .................................................................................................................. 17
OUR RIGHT TO RECOVER PAYMENTS ........................................................................................ 17
OTHER INFORMATION ............................................................................................................................. 17
YOUR ERISA RIGHTS ................................................................................................................................ 18
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SUMMARY OF BENEFITS CHART
The information on this page summarizes your Benefits and payment obligations.
Benefit Frequency Contact Lenses or Lens
Exam Frame
Once every calendar year Once every calendar year Once every 2 calendar years
Vision Care Services In-Network Member Cost Out-of-Network
Reimbursement
Exams Exam Dilation
Eye Exam Refraction
$10 Copay
$0
$0
Up to $35
N/A
N/A
Lens Single Vision Bi-focal Tri-focal Standard Progressive Lens Premium Progressive Lens Tier 1 Tier 2 Tier 3 Tier 4 Lenticular Other Lens Type
$10 copay (standard plastic) $10 copay (standard plastic) $10 copay (standard plastic) $75 Premium Progressive as follows: $95 $105 $120 80% of charge less $120, plus $75 copay $10 copay 80% of charge
Up to $25 Up to $40 Up to $55 Up to $40 Up to $40 Up to $55 N/A
Frame Frame 80% of Balance over $150 Up to $75 Lens Options Standard Polycarbonate Standard Plastic Scratch Coating Tint UR Treatment Standard Anti-reflective Coating Premium Anti-Reflective Coating Tier 1 Tier 2 Tier 3 Photochromatic/Transitions Other Lens Options
$40 Copay $15 Copay $15 Copay $15 Copay $45 Copay Premium Anti-Reflective as follows $57 $68 80% of Retail $75 80% of charge
N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Contact Lenses Contact Lens – Conventional Contact Lens – Disposable Standard Fit And Follow-up Premium Fit And Follow-up Medically Necessary Contacts
85% of Balance over $150 Balance over $150 $0 $0 Copay, 10% off retail price then apply $55 allowance $0
Up to $120 Up to $120 Up to $40 Up to $40 Up to $200 Non-Scheduled Items Doctor Misc. Material 80% of Charge N/A
Lasik or PRK Vision Correction 85% of Retail Price or 95% of Promotional Price N/A
Benefit Frequencies are determined by calendar year
Benefit Allowances provide no remaining balance for future use within the same Benefit Frequency
SEE SECTION ON SERVICES NOT COVERED AND NOTIFICATION/DOCUMENTATION REQUIREMENTS FOR
ADDITIONAL INFORMATION
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IMPORTANT
INFORMATION
DeltaVision has been selected by your
Employer to provide your group vision
coverage. We are pleased to bring these
important Benefits to you and your eligible
Covered Persons. Please read this Benefits
Certificate, including the SUM-MARY OF
BENEFITS CHART and all endorsements, if
any, carefully so you know and understand
your coverage
UNDERSTANDING BENEFITS
CERTIFICATE VOCABULARY
Allowance or Allowable Expense means
the amount or percentage available for a
single application toward the cost of
covered vision services and materials.
Aniseikonic Lenses are lenses
specially designed to correct spatial
perception when there is a
difference in retinal image size of
the same object between the two
eyes.
Benefit or Benefits means those vision
services or procedures that are covered
by DeltaVision under the terms of your
Employer’s Contract as specified in the
SUMMARY OF BENEFITS CHART and
subject to the exclusions, terms, and
conditions contained in this Benefits
Certificate.
Copay or Copayment means the dollar
amount or percentage as shown on the
SUMMARY OF BENEFITS CHART that
the Eligible Covered Person is required
to pay directly to an In-Network
Provider for a service or product
received that is a Benefit under the
contract.
Effective Date means the date your vision
coverage begins.
Eligible Covered Person is an Employee
who has met the Employer’s eligibility
requirements and the Employee’s
eligible spouse or eligible child(ren).
Employee means an individual actively
employed by the Employer for
purposes of Social Security laws or
who otherwise is included as a
member of staff as required by law
(or a member of the Board of
Directors of an Employer).
Employer or Employer Group or
Group Sponsor is the particular
employing individual, agency,
corporation, partnership, or company,
or that particular association or trust
which has entered into this agreement
to provide vision coverage to its
Eligible Employees or Eligible
Members and is responsible for
appointing a Plan Administrator for
the Group Vision Program.
In-Network Provider means a vision
care Provider who has entered into an
agreement to provide Benefits to
Eligible Covered Persons.
LASIK is Laser-Assisted In Situ
Keratomileusis, a type of laser eye
procedure used to treat various
refractive or focusing errors of the
eye. LASIK creates a flap that is
opened to expose inner corneal tissue
for reshaping, thereby eliminating (or
reducing) the corneal refractive error
and significantly changing the
requirement for corrective eyewear.
Out-of-Network Provider” means a
vision care Provider who is not an In-
Network Provider.
Out-of-Network Reimbursement is the
amount that the program is contractually
obligated to pay for the covered
services submitted by an Eligible
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Covered Person who received services
from an Out-of-Network Provider.
Plan Administrator means the
Employer Group (or the individual(s)
designated by the Employer Group)
who maintains the Plan under which
these Benefits are provided.
PRK is Photo-Refractive Keratectomy, a
type of laser eye procedure used to
treat various refractive or focusing
errors of the eye. PRK reshapes tissue
on the surface of the cornea, thereby
eliminating (or reducing) the corneal
refractive error and significantly
changing the requirement for corrective
eyewear.
Provider is any licensed Optometrist,
Ophthalmologist and/or dispensing
optician.
UNDERSTANDING AMOUNTS YOU
PAY TO SHARE COSTS
Copay or Copayment is the dollar
amount or percentage, as shown on the
SUMMARY OF BENEFITS CHART, that
the Eligible Covered Person is
required to pay directly to an In-
Network Provider for a service or
product received that is a covered
Benefit under the contract. The
Copayment is applied to the
contracted fee for Benefits with the
In-Network Provider, or to be applied
to the amount in excess of the
Allowable Expense for covered
Benefits, whichever is applicable.
HELPING WHEN YOU HAVE
QUESTIONS
If you have any questions about your Benefits
after reading this Certificate, you may contact us.
BENEFITS
(COVERED VISION
PROCEDURES)
Only vision procedures designated as
Benefits on your SUMMARY OF
BENEFITS CHART are covered under
your Group’s contract.
Benefits are subject to the limitations
described in the SUMMARY OF BENEFITS
CHART and the exclusions outlined in this
DeltaVision Certificate. We will pay up to
the Allowance shown in the SUMMARY OF
BENEFITS CHART for Benefits. Eligible
Covered Persons will be responsible for any
remaining amount.
Some procedures may require
documentation before you receive
Benefits (refer to section NOTIFICA-
TION/DOCUMENTATION
REQUIREMENTS).
Eligible Covered Persons will also be
responsible for any vision care products
and services that are not Benefits under
the contract regardless of whether the
vision care services were provided by an
In-Network Provider or an Out-of-
Network Provider.
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SERVICES NOT
COVERED
This DeltaVision Certificate does not provide
Benefits for vision services listed in this section.
Please note: Certificate does not provide
Benefits for vision services listed in this
Certificate
Certificate Exclusions And Limitations
Benefits Are Not Provided For Services
or Materials Arising From:
Aniseikonic Lenses
Benefits Combined
Benefits may not be combined with any
discount, promotional offering or other
group Benefits Plans.
Brand Names
You are not covered for certain brand
name vision materials in which the
manufacturer imposes a no-discount
practice.
Broken Appointments
You are not covered for any fees
charged because of broken
appointments.
Charges for Consultation
Drugs
You are not covered for prescription,
non-prescription drugs, or medicines or
therapeutic drug injections.
Effective Date
You are not covered for services or
supplies received before the Effective
Date of coverage under this
Certificate.
Employment
You are not covered for corrective
eyewear required by an Employer as a
condition of employment, and safety
eyewear unless specifically covered
under your plan.
Experimental or Investigative
You are not covered for services or
supplies that are considered
experimental, investigative or have a
poor prognosis. Peer reviewed
outcomes data from clinical trials, Food
and Drug Administration regulatory
status, and established governmental
and professional guidelines will be used
in this determination.
Eye Surgery
You are not covered for medical and/or
surgical treatment of the eye, eyes,or
supporting structures (except as noted
on the SUMMARY OF BENEFITS CHART
or Notification/Documentation
Requirements.)
Government Programs
You are not covered for services or
supplies when you are entitled to
claim Benefits from governmental
programs (except Medicaid).
Incomplete Services
You are not covered for vision services
that have not been completed.
Lost, Broken, or Stolen Lenses,
Frames, Glasses or Contact Lenses
Lost, broken, or stolen lenses, frames,
glasses or contact lenses will not be
replaced except in the next Benefit
Frequency when vision materials would
next become available.
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Military Service
You are not covered for services or
supplies which are required to treat an
illness or injury while you are on active
status in the military services.
Orthoptic or Vision Training,
Subnormal Aids, and Any Associate
Supplemental Testing
Payment Accountability
You are not covered for services or
supplies when someone else has the
legal obligation to pay for your care,
and when, in the absence of this
Certificate, you would not be charged.
Plano Nonprescription Lenses and
Nonprescription Sunglasses
Procedures Not Specifically Covered
Under This Contract
Remaining Balance
Benefit allowances provide no remaining
balance for future use within the same
Benefit Frequency (Calendar Year)
Termination Date
You are not covered for treatment
received after the coverage termination
date of this Certificate, except when
Vision materials ordered before
coverage ended are delivered, and the
services rendered are to the Eligible
Covered Person are within 31 days from
the date of such order.
Timely Benefit Submission
You are not covered for services or
supplies submitted more than 365
days after the services were
rendered.
Treatment By Other Than A Licensed
Eye Care Provider
You are not covered for services or
treatment performed by anyone other
than a licensed eye care Provider, or his
or her Employees.
Two Pair of Glasses in Lieu Bifocals
Vision Care Injuries or Disease
You are not covered for vision care
injuries or disease caused by riots or
any form of civil disobedience if the
Eligible Covered Person was a
participant therein; war or act of war or
terrorism; injuries sustained while in the
act of committing a criminal act, injuries
intentionally self-inflicted; and injuries or
disease caused by atomic or
thermonuclear explosion or by radiation
resulting therefrom.
Workers Compensation
You are not covered for services or
supplies that are or could have been
compensated under Workers’
Compensation laws, including services
or supplies applied toward satisfaction
of any deductible under your
Employer’s Workers’ Compensation
coverage.
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NOTIFICATION/DOC-
UMENTATION
REQUIREMENTS
Lasik and PRK Vision Correction
LASIK and PRK Vision Correction are
elective procedures, performed by specially
trained Providers. To receive Benefits,
Covered Persons must first call 877-
5LASER6 for information on the nearest
facility and to receive authorization for the
discount. Any discount off retail or
promotional price for LASIK or PRK vision
correction may not always be available from
a Provider in your immediate area.
Medically Necessary Contacts
Medically necessary contacts require
documentation of medical necessity from
the Provider. In-Network Providers should
include the required documentation with
the claim submission. If service is provided
by an Out-of-Network Provider
documentation of medical necessity
should be included with the claim form
submitted by you. (See FILING CLAIMS
section.)
FILING CLAIMS
Once you obtain services, we need to
receive a claim to determine the amount
of your Benefits. The claim lets us know
the services you received, when you
received them, and from which Provider.
You will need to file a claim only when
using an Out-of-Network Provider. All
In-Network Providers will submit claims for
you.
When to File Your Claims
After you obtain services, you should file
a claim. Submission of claims should be
made within thirty (30) days unless it is
not reasonably possible to do so. Claims
received more than 365 days after the
services were rendered will not be
considered for Benefit.
You should file a claim only after services
are rendered. Do not file for payment
before you receive a service. For Out-of-
Network claim submissions, you must
complete and sign an Out-of-Network
claim form and include itemized paid
receipts for the services and materials
received on the date of service. The
complete information should be mailed to
the address provided. If you need a claim
form or have any questions after reading
this section, please contact us or visit our
website at
www.deltadentalia.com/deltavision. If you
must file your own claim, send it to the
following address:
DeltaVision
ATTN: OON Claims
P.O. Box 9010
Johnston, Iowa 50131-9010
Coordination of Benefits
Coordination of Benefits (COB) applies
when a Covered Person has vision care
coverage under more than one plan. The
COB rules determine which plan will pay as
the primary plan. The primary plan pays
first without regard to any other vision
care coverage that is also in effect. A
secondary plan pays after the primary
plan, and Benefits may be reduced so that
payments from all group plans do not
exceed 100% of the total Allowable
Expense. Your DeltaVision plan considers
itself the primary plan, and will coordinate
as the secondary plan if you submit a
claim that indicates another plan has
already paid as the primary plan.
What Should You Do
When you receive vision services, you
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need to let your provider know if you have
other coverage. Other coverage includes:
group insurance
other group coverage (such as HMOs,
PPOs, and self-insured programs)
Medicare or other governmental
coverage
and the medical coverage in your
automobile insurance (whether issued
on a fault or no-fault basis).
To help us coordinate your Benefits, you
should:
Inform your Provider by giving him or
her information about your other
coverage at the time you receive
services.
You or your provider should send a
claim form to us along with an
Explanation of Benefits (EOB) from
your primary plan.
What We Will Do
Coordination of Benefits is complicated.
There are certain rules we follow to help
us determine which benefit plan pays first
when you have other coverage that
provides the same or similar benefits as
this Certificate. We will use the COB
guidelines adopted by the Iowa Insurance
Division to determine the payment to you
or your provider.
If you have any questions about your
Coordination of Benefits, contact us at:
DeltaVision
ATTN: Claims
P.O. Box 9010
Johnston, IA 50131-9010
Appealing A Denied Claim
Your Initial Request For A Review
If part or all of the services submitted on
your claim have been denied, and you think
the service should be covered, you or your
representative can ask for a full and fair
review of that claim. To file for a review,
submit a request within 180 days of
receiving the notice of Benefit denial,
including the reason why you disagree
with the claim decision, and any
documents, records or any other
information related to the claim. The
Eligible Covered Person’s name,
identification number, and the patient’s
name should be included on all documents.
Our Reply
Within 30 days of receiving your request,
we will send you our written decision and
indicate any action we have taken. How-
ever, when special circumstances arise, we
may require 60 days. We will notify you in
the event we require additional days.
Reviewing Records
Upon your request, we will provide you free
of charge, access to and copies of all
documents, records and other information
relevant to your claims for Benefits. You
can review records that deal with your
request from 8:00 a.m. to 4:30 p.m., Central
Standard Time, Monday through Friday, at
our office in Johnston, Iowa. Since so many
records are electronically filed, please call us
in advance so we can have copies ready for
you.
Send Requests to:
DeltaVision
ATTN: Quality Assurance Dept.
P.O. Box 9010
Johnston, IA 50131-9010
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Your Certificate
Our responsibilities to you, as well as the
conditions of your coverage with us, are
defined in the documents that make up
your contract. Your contract includes any
application you submitted to us or to your
Employer or Group Sponsor, any
agreement or group policy we have with
your Employer or Group Sponsor, any
application completed by your Employer or
Group Sponsor, this Benefits Certificate,
and any riders or amendments. All of the
statements made by your Employer or
Group Sponsor or you in any of these
materials will be treated by us as
representations to us upon which we may
rely. We will not use the statements to
deny any claim unless we’ve furnished you
with a copy of the statement.
Eligible Covered Persons
An Eligible Covered Person is an Employee
who has met the Employer’s eligibility
requirements and the Employee’s eligible
spouse and/or eligible child(ren).
Spouse means your husband or wife as the
result of a marriage that is legally
recognized in Iowa. An eligible child can
be your natural child, a child placed with
you for adoption or a legally adopted child,
a child for whom you have legal
guardianship, a stepchild, or a foster
child. Children must meet at least one of
the following standard requirements to be
an eligible child:
The child is under age 26.
The child is age 26 or older not married
and a full-time student. For an eligible
child to be considered a full-time
student they must be enrolled in an
accredited institution of higher learning,
such as a college, university, nursing,
or trade school, and carry enough hours
to be classified by the institution as full-
time. Full-time student status continues
during regularly scheduled school
vacation periods, and during absence
from class in which enrolled for up to
four months due to a physical or mental
dis-ability. DeltaVision may require the
disability be substantiated by a written
statement from a physician.
The child is a dependent of the child’s
parent and is totally or permanently
disabled, either physically or mentally. If
the dependent child is permanently
disabled, the disability must have
existed before the child was age 19 or
while the child was a full-time student
under 26 years of age, and the
dependent child must have had
continuous qualifying vision coverage
without a break of 63 days or more
since the child turned age 19 or while
the child was a full-time student under
age 26.
A child who has been placed in your
home for the purpose of adoption or
who you have adopted shall be eligible
for coverage as of the date of
placement for adoption or as of the date
of actual adoption, whichever occurs
first.
LATE ENTRANT AND RE-ENROLLMENT
PROVISIONS
If you decline coverage (for yourself or your
eligible Covered Persons) when you are
initially eligible as determined by your
Employer Group’s enrollment guidelines,
you are not eligible for this coverage except
as follows:
During a subsequent anniversary date of
the contract between us and your
Employer or special enrollment period
determined by your Employer Group.
If a qualifying event occurs as listed
under EVENTS CHANGING COVERAGE.
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If you terminate this coverage, for
whatever reason, you are not eligible to
re-enroll at a later time unless you have
a qualifying event or during a
subsequent anniversary date of the
contract between us and your
Employer Group or special enrollment
period determined by your Employer
Group.
TYPES OF COVERAGE
There are different categories of coverage
you may hold under this Certificate:
With Single coverage, you are the only
one covered.
With Family coverage, you, your
eligible spouse, and each of your
eligible children are covered. Each
eligible Covered Person must be listed
on your vision application for coverage
or added later following a qualifying
event.
QUALIFIED MEDICAL CHILD SUPPORT
ORDER (QMCSO)
If you have a child and your Employer
receives a Medical Child Support Order
recognizing the child’s right to enroll in
this benefit plan, your Employer will
promptly notify both you and the child
that the order has been received. Your
Employer also will inform you and the child
of the Employer’s procedures for
determining whether the order is a
Qualified Medical Child Support Order.
You may obtain, without charge, a copy
of QMCSO procedures from your Employer
or Group Sponsor.
WHEN COVERAGE BEGINS
Your coverage under this Certificate begins
on your Effective Date. If you have just
started a new job, check with your
Employer or Group Sponsor to determine
your Effective Date.
Please note: Before you receive Benefits
under this Certificate, you have agreed in
your application for coverage (or in
documents kept by us or your Employer or
Group Sponsor) to release any necessary
information requested about you so we
can process claims for Benefits. You must
allow any healthcare Provider or his or her
employee to give us information about a
treatment or condition. If we do not
receive the information requested, or if you
withhold information in your application,
your Benefits may be denied.
If you fraudulently use your Benefits or
misrepresent or conceal material facts in
your application, then we may terminate
this Certificate.
WHEN COVERAGE ENDS
Your eligibility for coverage will terminate at
the end of the month for any of these reasons:
You become ineligible for coverage
under this Certificate. See Eligible
Covered Persons earlier in this section.
You become unemployed. Termination
of your Certificate for this reason
applies only if you receive your
coverage through your Employer or
Group Sponsor. Your Employer or Group Sponsor
decides to discontinue or replace this
coverage.
We decide to terminate coverage of all
similar Certificates by giving written
notice to your Employer or Group
Sponsor 90 days prior to termination.
Your coverage may end if any of the following occurs:
You use this Certificate fraudulently or
you fraudulently misrepresent or
conceal material facts in your
application. If this happens, we will
recover any claim payments we made,
minus any premiums paid.
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You or your Employer or Group Sponsor
fail to make payments to us when due.
AUTHORITY TO TERMINATE, AMEND, OR
MODIFY
Your Employer or Group Sponsor has the
authority to terminate, amend or modify
the coverage described in this Certificate
at any time. Any amendment or
modification will be in writing and will be
as binding as this Certificate. If your
contract is terminated, you may not receive
Benefits.
CONTINUED COVERAGE (COBRA)
There are some federal and state laws that
may affect your coverage with us. These
laws apply to continuing your coverage
when you are no longer eligible for group
coverage.
Coverage Continuation Under Federal
Law - COBRA
The Consolidated Omnibus Budget
Reconciliation Act (COBRA) applies to
Employers with 20 or more Employees.
COBRA entitles you, your eligible spouse,
and your eligible child(ren) to a
continuation of coverage under this
Certificate if coverage is lost due to any of
the following qualifying events:
Death of the Employee covered under
this Certificate.
Termination of employment for reasons
other than gross misconduct.
A reduction in hours causing loss of
coverage.
Divorce or legal separation.
The Employee covered under this
Certificate becomes entitled to
Medicare.
Child/Children no longer considered
eligible by our eligibility rules.
The Employer, from whom the covered
Employee retired, files bankruptcy
under federal law (in certain cases).
Please note: You, your eligible spouse, or
your eligible children are responsible for
notifying your Employer or Group Sponsor
of a dissolution of marriage, legal separation
or a child losing eligibility status.
If you wish to continue your coverage, you
must complete an election form and
submit it to your Employer within 60 days
of the later of the date:
you are no longer covered; or
you are notified of the right to elect
COBRA continuation coverage.
You will be responsible for paying any
premiums to your Employer for the
continuation of this Certificate.
Depending on how you qualify, you may
continue your coverage for up to 18 or 36
months.
If during the period of COBRA coverage, a
child is born to you or placed with you for
adoption, the child can be covered under
COBRA coverage and can have election
rights of his or her own.
If you or any other eligible Covered
Person(s) who have elected COBRA
coverage is determined to be disabled
under the Social Security Act during the
first 60 days of continuation coverage,
your COBRA coverage may continue for
up to 29 months. The 29-month period will
apply to you, your eligible spouse and/or
eligible child(ren) who elected COBRA
coverage. You must provide notice of the
disability determination to your Employer
within 60 days after the determination.
If you lose your coverage, contact your
Employer or Group Sponsor. They should
help you with any necessary paperwork
and let you know the cost of continuing
your coverage.
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Length of Coverage under COBRA
Continuation coverage ends at the earliest of one of these events:
The last day of the 18-, 29-, or 36-month
maximum coverage period, whichever is
applicable.
The first day (including grace periods, if
applicable) on which timely payment is
not made.
The date on which the Employer ceases
to maintain any group plan (including
successor plans).
The first day on which a beneficiary is
actually covered by any other group
plan. However, if the new group plan
contains an exclusion or limitation
relating to any preexisting condition of
the beneficiary, then coverage will end
on the earlier of the satisfaction of the
waiting period for preexisting
conditions contained in the new group
plan or upon the occurrence of any one
of the other events stated in this section.
The date the qualified beneficiary is
entitled to Medicare Benefits.
Premiums
You or your Employer or Group Sponsor
must pay us in advance of the due date
assigned for your Certificate. For example,
payment must be made prior to the
beginning of each calendar month.
Events Changing Coverage
Certain events may require you to change
who is covered by this Certificate. These
events include:
Active Duty in the Military of an eligible
child or spouse
Appointment as a Legal Guardian of a
child
Birth or Adoption of a child
Care of a Foster Child (when placed in
your home by an approved agency).
Completion of Full-time Schooling of
an eligible child age 26 or older
Death
An Eligible Child (who is not a full-time
student or permanently disabled)
reaches age 26
Divorce, Annulment, or Legal
Separation
Exhaustion of COBRA Coverage
Marriage
Spouse or Child Loses Eligibility for
Qualifying Vision Coverage or
Employer or Group Sponsor ceases
contribution to qualifying vision
coverage. In this case, your eligible
spouse and any eligible children
previously covered under the prior
qualifying vision coverage are eligible
for coverage under this Certificate.
NOTIFICATION OF CHANGE
You must notify us within 31 days of the
date of the event that changes the status
of your eligibility except birth or adoption
of a child. DeltaVision must be notified
within 60 days of the date of the event
that changes the status of your eligibility
for births or adoptions. You can ask your
Employer or Group Sponsor to help you
make this request. If a change to your
eligibility is not made within 31 days of an
event (except birth or adoption of a child
which is 60 days), the person(s) affected
may lose important coverage.
NOTICES
Notice to your Employer or DeltaVision
will be considered sufficient if mailed to
each party’s regular office address.
Notices to you, as the Covered Person,
will be considered sufficient if mailed to
your last known address or the last
known address of your Group. It is the
responsibility of your Group to notify
you regarding changes or termination of
your coverage.
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AUTHORIZED CERTIFICATE CHANGES
No agent, Employee, or representative of
ours is authorized to vary, add to, change,
modify, waive, or alter any of the
provisions of this Certificate. This
Certificate cannot be changed except by:
written amendment signed by an
authorized officer and accepted by
you or your Employer or Group
Sponsor as shown by payment of the
monthly premium.
our receipt of proper notification that
your marital or eligibility status has
changed and we receive an
appropriate monthly premium in
advance, then we will change your
coverage to the correct coverage type.
See Types of Coverage explained
earlier in this section.
EFFECTS OF TERMINATION
If your Certificate is terminated for fraud,
misrepresentation, or the concealment of
material facts:
We will not pay for any services or
supplies provided after the date the
coverage is terminated.
We will retain legal rights. This includes
the right to initiate a civil action based
on fraud, concealment, or
misrepresentation.
We may, at our option, declare the
coverage void.
If your coverage is terminated for reasons
other than fraud, concealment, or
misrepresentation of material facts, we
will stop Benefits the day your coverage is
terminated.
OUR RIGHT TO RECOVER PAYMENTS
If for any reason we make payment under
this Certificate in error, we may recover the
amount we paid.
OTHER INFORMATION
Veratrus Benefit Solutions, Inc.’s Liability
In no instance is Veratrus Benefit
Solutions, Inc. liable for any conduct,
including but not limited to tortuous
conduct, negligence, or wrongful acts or
omissions by any service Provider or other
professional practitioner or their agents or
Employees in the provision or receipt of
health care. In no instance is Veratrus
Benefit Solutions, Inc. liable for services of
facilities that, for any reason, are unavailable
to you.
Nonassignment
Benefits for covered services in this
Certificate are for the Eligible Covered
Person(s) and cannot be transferred or
assigned to anyone else without our
consent. Any attempt to assign this
Certificate or rights to payment without our
consent will be void.
Governing Law
To the extent not superseded by the laws
of the United States, this Certificate will be
construed in accordance with and
governed by the laws of the State of Iowa.
Any action brought because of a claim
under this Certificate will be exclusively
litigated in the state or federal courts
located in the State of Iowa and in no other.
Legal Action
No legal or equitable action may be
brought against us because of a claim
under this Certificate, or because of the
alleged breach of this Certificate, more
than two years after the end of the
calendar year in which the services or
supplies were provided.
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Information If You or A Covered
Person Of Your Family Is Enrolled In
Medicaid
Assignment of Rights
This plan will provide payment of Benefits
for covered services to you, your
beneficiary, or any other person who has
been legally assigned the right to receive
such Benefits under requirements
established pursuant to Title XIX of the
Social Security Act (Medicaid).
Enrollment without regard to Medicaid
Your receipt or eligibility for medical
assistance under Title XIX of the Social
Security Act (Medicaid) will not affect
your enrollment as an Eligible Covered
Person of this plan, nor will it affect our
determination of any Benefits paid to you.
Acquisition by States of Rights of Third
Parties
If payment has been made by Medicaid and
we have a legal obligation to provide
Benefits for those services, then we will
make payment of those Benefits in
accordance with any state law under which
a state acquires the right to such
payments.
YOUR ERISA
RIGHTS
Your rights concerning your coverage may
be protected by the Employee Retirement
Income Security Act of 1974 (ERISA). Any
employee benefit plan established or
maintained by an employer or by an
employee organization or both is subject
to this federal law unless the benefit plan is
a governmental or church plan as defined in
ERISA. If ERISA applies to your group,
you will want to read this section
carefully.
Your ERISA Rights
The Employee Retirement Income Security
Act of 1974 (ERISA) provides that you will be
entitled to:
Examine certain plan documents and
copies of documents (such as annual
reports) filed by the plan with the United
States Department of Labor. You may
examine these documents at the Plan
Administrator’s office or at specified
locations. You will not be charged to
examine these documents. The latest
annual report is available at the Public
Disclosure Room of the Employee
Benefits Security Administration.
Obtain copies of certain plan
documents from the Plan Administrator
upon written request. The Plan
Administrator may request a reasonable
charge for the copies
Receive a summary of the plan’s annual
financial report if your Employer or
Group Sponsor has 100 or more
participants in your plan. The Plan
Administrator is required by law to
furnish you with a copy of this summary
annual report.
The Responsibility of your Employee
Benefit Plan
In addition to creating rights for you and
other participants, ERISA imposes duties
upon the people responsible for the
operation of your Employee Benefit Plan.
The people responsible are called
fiduciaries of the plan. Fiduciaries have a
duty to operate your Employee Benefit Plan
prudently and in the interest of you, other
plan participants, and your 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 covered
Benefit or exercising your rights under
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ERISA. If your claim for a covered 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 requirements.
Steps You Can Take to Enforce Your
Rights
Under ERISA, there are steps you can
take to enforce the above rights. For
instance, if you request the plan
document from the Plan Administrator and
do not receive it within 30 days, a federal
court may require the Plan Administrator
to provide the materials and pay you up to
$110 a day until you receive the document,
unless the document was not sent because
of matters reasonably 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. 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 you 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.
Who to Contact When you Have
Questions
If you have any questions about your plan,
you should contact the Plan Administrator,
i.e. your Employer or Group Sponsor. If you
have 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 Area Office of the
Employee Benefits Security
Administration, 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, N.W.
Washington, D.C. 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.
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CONTACT INFORMATION
(Claims and Benefits)
1-888-899-3747
DeltaVision Contact Information
(Enrollment and Eligibility)
1-877-983-3582
www.deltadentalia.com/deltavision
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Form Number: DVIAOAS - 082019
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Form Number: DVIAOAS - 082019