HomeMy WebLinkAboutAFSCME, Administrative, Confidential and Fire Coverage ManualGROUP DENTAL PLAN
CITY OF IOWA CITY
DELTA DENTAL PREMIER®
SUMMARY PLAN DESCRIPTION
CLAIMS ADMINISTERED BY
DELTA DENTAL OF IOWA
Plan 2
Effective Date: 07/01/2022
Electronic Date: 05/19/2022
Form Number: DDCERT 0120
Important Caution: A document like this
Summary Plan Description must be reviewed and
prepared by the employer’s legal counsel before
it is adopted by the employer and distributed to
its plan participants. In addition to this Summary
Plan Description, the employer should prepare
and adopt its own separate plan document[s].
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INTRODUCTION
City of Iowa City maintains the City of Iowa City Group Dental Plan (“the Dental
Plan”) for the exclusive benefit of and to provide dental benefits to their eligible
full-time employees, their eligible spouses, and eligible children. These benefits,
including information about who is eligible to receive benefits, are summarized in
this document, which constitutes the Summary Plan Description.
Claims for reimbursement of dental benefits under the Dental Plan are adminis-
tered by Delta Dental of Iowa (hereafter “Delta Dental”) pursuant to a contract
between City of Iowa City and Delta Dental.
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INTERPRETING THIS
SUMMARY PLAN
DESCRIPTION
It is important that you understand all parts of this Summary Plan Description to get
the most out of your benefits. To help make the information easier to understand,
we use the words you and your to refer to you and your other eligible Covered
Persons who have enrolled for coverage under this Dental Plan. In other places,
we use the word participant to refer to the employee enrolled under the Dental
Plan and the words beneficiary or beneficiaries to refer to the participant’s eligible
Covered Persons who are enrolled under the Dental Plan. The words, we, us, and
our refer to City of Iowa City, the Plan Administrator for your Dental Plan. Finally,
the term Plan Sponsor or group sponsor refers to your employer or other sponsor
of this Dental Plan.
We will interpret the provisions of this Summary Plan Description and determine the
answers to all questions that arise under it. Pursuant to a contract with Delta Dental,
we have delegated our administrative discretion to initially determine whether you
meet the Dental Plan’s written eligibility requirements, or to interpret any other term
of this Dental Plan. In addition, if any benefit in this Summary Plan Description
is subject to a determination of dental necessity and dental appropriateness, Delta
Dental will make that factual determination. Our interpretations and determinations
and those of Delta Dental are final and conclusive.
In this Summary Plan Description we sometimes refer to certain laws and regu-
lations. 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
your employer or group sponsor.
To administer your benefits properly, there are certain rules you must follow.
Different rules appear in different sections of this Summary Plan Description. We
urge you to become familiar with the entire Summary Plan Description.
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T ABLE OF CONTENTS
Summary Of Benefits And Payment .....................................................................7
Dental Plan Administration ...................................................................................9
Important Information .........................................................................................10
What You Should Know About Delta Dental Dentists ............................10
What You Should Know About Dentists Who Do Not
Participate With Delta Dental ...................................................................11
Questions Delta Dental Asks When You Receive Dental Care ................11
Delta Dental’s Payment Policy.................................................................13
Understanding Payment Vocabulary ........................................................13
Understanding Amounts You Pay To Share Costs....................................14
Helping When You Have Questions ........................................................15
Benefits ...............................................................................................................16
Check-Ups And Teeth Cleaning ...............................................................16
Cavity Repair And Tooth Extractions ......................................................17
Root Canals ..............................................................................................18
Gum And Bone Diseases ........................................................................19
High Cost Restorations ............................................................................20
Services Not Covered .........................................................................................22
The Notification Program ...................................................................................27
The Approval ............................................................................................27
The Treatment Plan ..................................................................................27
The Treatment Plan Review .....................................................................28
Filing Claims .......................................................................................................29
When To File Your Claim ........................................................................29
Filing When You Have Other Coverage .................................................29
Denied Claims And Appeals Procedures..................................................31
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Eligibility ............................................................................................................34
Coverage Eligibility .................................................................................34
Eligibility Enrollment Requirements.............................................34
Qualified Medical Child Support Order (QMCSO) .....................35
When Benefits Begin .....................................................................35
When Benefits End ........................................................................35
Continued Coverage (COBRA).....................................................36
Coverage Changes ....................................................................................38
Events Changing Coverage ...........................................................38
Notification Of Change .................................................................38
Coverage Termination ..............................................................................39
Effects Of Termination ..................................................................39
Delta Dental’s Right To Recover Payments .............................................39
Payment In Error ..........................................................................39
Subrogation ...................................................................................39
Other Information.....................................................................................40
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S UMMARY OF BENEFITS
AND PAYMENT
The information on this page summarizes your benefits and payment obligations.
For a detailed description of specific benefits and benefit limitations, see the Im-
portant Information and Benefits sections of this Summary Plan Description.
If a dollar amount for a deductible, benefit period maximum or lifetime maximum
is shown at the top of the chart and applies to a benefit category, “Yes” will be in-
dicated across from that category. If the information does not apply it will indicate
“Waived” or be left blank. If there is unique information for a specific benefit it
will appear across from that benefit.
Delta Dental Premier®
Plan 2
DEDUCTIBLE MEMBER
COINSURANCE
BENEFIT
PERIOD MAX
LIFETIME MAX
Benefit Categories $25/$75 $1,500 None
Check-Ups and Teeth Cleaning
(Diagnostic and Preventive
Services)
1. Dental Cleaning
2. Oral Evaluation
3. Fluoride Applications
4. X-rays
5. Sealant Applications
6. Space Maintainers
Waived 00%Yes
Cavity Repair and Tooth
Extractions
(Routine and Restorative
Services)
1. Emergency Treatment
2. General Anesthesia/Sedation
3. Restoration of Decayed or
Fractured Teeth
4. Limited Occlusal Adjustment
5. Routine Oral Surgery
Yes 20%Yes
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Delta Dental Premier®
Plan 2
DEDUCTIBLE MEMBER
COINSURANCE
BENEFIT
PERIOD MAX
LIFETIME MAX
Root Canals
(Endodontic Services)
1. Apicoectomy
2. Direct Pulp Cap
3. Pulpotomy
4. Retrograde Fillings
5. Root Canal Therapy
Yes 50%Yes
Gum and Bone Diseases
(Periodontal Services)
1. Conservative Procedures
2. Maintenance Therapy
Yes 20%Yes
High Cost Restorations
(Cast Restorations)
1. Cast Restorations
a. Crowns
b. Inlays
c. Onlays
d. Posts and Cores
Yes 50%Yes
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DENTAL PLAN
ADMINISTRATION
The administration of the Dental Plan is under the supervision of the Plan Admin-
istrator, City of Iowa City. The Personnel Administrator of City of Iowa City is the
person who acts on behalf of the Plan Administrator. The principal duty of the Plan
Administrator is to see that the terms of the Dental Plan are carried out in accordance
with its terms, for the exclusive benefit of persons entitled to participate in the Plan.
The Company bears all costs of administering the Plan and for paying all claims.
Under a contract with Delta Dental, the Plan Administrator has delegated its
authority to Delta Dental to act as the Claims Administrator for the Dental Plan
and to determine the initial eligibility for and the amount of any benefits payable
under the Dental Plan and for prescribing the procedures to be followed and the
forms to be used by you pursuant to the Dental Plan. We have further delegated to
Delta Dental, as the Claims Administrator, the authority to require you to furnish
it with such information as it determines is necessary for the proper administration
of the Dental Plan. If you have general questions regarding the Dental Plan, please
contact the Plan Administrator. However, if you have specific questions concerning
eligibility for and/or the amount of any benefits payable under the Dental Plan,
please contact Delta Dental.
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IMPORTANT INFORMATION
Delta Dental of Iowa is the Claims Administrator of your Delta Dental Premier
Dental Plan. By encouraging preventive care, this dental program is designed to help
contain dental costs. The key component of the Delta Dental Premier Program is
their panel of Participating Dentists, hereafter referred to as Delta Dental Dentists.
You may seek care from almost any dentist you wish. However, there are usually
advantages when you receive services from Delta Dental Dentists.
Your payment responsibilities are also outlined in this section of your Summary
Plan Description. How much you pay for Covered Services depends on the benefit
category of the service you receive and the dentist you receive services from. It
is most often to your financial advantage to receive services from a Delta Dental
Dentist.
WHAT YOU SHOULD KNOW ABOUT DELTA DENTAL DENTISTS
Delta Dental has contracting relationships with Delta Dental Dentists throughout
the state. Delta Dental’s contracts with Delta Dental Dentists include payment ar-
rangements based on Delta Dental’s applicable fee schedule or the Maximum Plan
Allowance. See Understanding Payment Vocabulary later in this section. This
applicable fee schedule or Maximum Plan Allowance usually results in savings
to you. When you receive services from Delta Dental Dentists who participate
with Delta Dental of Iowa or any other Delta Dental Member Company, all of the
following statements are true:
n Delta Dental Dentists agree to accept their local Delta Dental Member Compa-
ny’s payment arrangements, which may result in savings for Covered Services.
n Delta Dental Dentists agree to file claims for you.
n Delta Dental settles claims directly with Delta Dental Dentists. You are
responsible for any deductible and coinsurance amounts you may owe. See
Understanding Amounts You Pay To Share Costs later in this section.
n Delta Dental Dentists agree to handle the notification program for you. See
The Notification Program section.
n Delta Dental Dentists agree that he or she will only be paid the lesser of (i)
his or her billed charge, or (ii) the applicable fee schedule or Delta Dental’s
Maximum Plan Allowance for Covered Services. Important: This does not
apply in the situation where a service otherwise qualifying as a Covered Service
is provided and Delta Dental does not reimburse any part of such services.
In such situation, the Participating Delta Dental Dentist is not limited in the
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amount of the payment he or she may collect from you. See Understanding
Payment Vocabulary later in this section.
WHAT YOU SHOULD KNOW ABOUT DENTISTS WHO DO NOT
PARTICIPATE WITH DELTA DENTAL
When you receive services from nonparticipating (non-par) dentists, you will not
receive any of the advantages of Delta Dental contracts with Delta Dental Dentists.
As a result, when you receive services from nonparticipating dentists, all of the
following statements are true:
n Delta Dental does not have contracting relationships with nonparticipating
dentists and they do not agree to accept their local Delta Dental Member
Company’s payment arrangements. This means you are responsible for any
difference between your nonparticipating dentist’s billed charge and the Delta
Dental nonparticipating fee schedule.
n Nonparticipating dentists are not responsible for filing your claims.
n Delta Dental settles claims with you, not nonparticipating dentists. However,
for Iowa nonparticipating dentists, the payment will be mailed to you but the
check may be payable to the nonparticipating dentist. You are responsible for
paying your dentist in full, including any deductible, coinsurance and non-ap-
proved charges you may owe. See Understanding Payment Vocabulary
later in this section.
n Nonparticipating dentists do not agree to handle the notification program for
you. See The Notification Program section.
n Nonparticipating dentists may charge for “infection control,” which includes
the costs for services and supplies associated with sterilization procedures. You
are responsible for any extra charges billed by a nonparticipating dentist for
“infection control.” (All dentists are legally required to follow certain guide-
lines to protect their patients and staff from exposure to infection. However,
Delta Dental Dentists incorporate these costs into their normal fees and do not
charge an additional fee for “infection control.”)
n Nonparticipating dentists do not agree that he or she will only be paid the
lesser of (i) his or her billed charge or (ii) the applicable fee schedule or Delta
Dental’s Maximum Plan Allowance for Covered Services. See Understanding
Payment Vocabulary later in this section.
QUESTIONS DELTA DENTAL ASKS WHEN YOU RECEIVE DENTAL
CARE
Even though a procedure may appear in a given section such as Benefits, you should
note that before you are eligible to receive benefits, Delta Dental first answers all
of the following questions:
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Is the Procedure Dentally Necessary?
All of the following must be true for a procedure to be considered dentally necessary:
n The diagnosis is proper; and
n The treatment is necessary to preserve or restore the basic form and function
of the tooth or teeth and the health of the gums, bone, and other tissues sup-
porting the teeth.
Is the Procedure Dentally Appropriate?
All of the following must be true for a procedure to be considered dentally ap-
propriate:
n The treatment is the most appropriate procedure for your individual circum-
stances; and
n The treatment is consistent with and meets professionally recognized standards
of dental care and complies with criteria adopted by Delta Dental; and
n The treatment is not more costly than alternative procedures that would be
equally effective for the treatment or maintenance of your teeth and their
supporting structures. If you receive services which are more costly than
those equally effective for the treatment or maintenance of your teeth
and supporting structures, you are responsible for paying the difference.
Is the Procedure Subject to Benefit Limitations?
Benefit limitations refer to amounts that are your responsibility based on the terms
of the Dental Plan. Examples of benefit limitations include all of the following:
n Amounts for procedures that are not dentally necessary or dentally appropriate.
n Amounts for procedures that are not covered by this Summary Plan Description.
See Services Not Covered.
n Amounts for procedures that have limitations associated with them. For ex-
ample, teeth cleaning is covered twice per benefit period. More frequent teeth
cleaning may not be a benefit even if your dentist verifies that it is dentally
necessary and dentally appropriate. See Benefits for a description of covered
procedures and limitations associated with certain procedures.
n Amounts for procedures that have reached contract benefit maximums. See the
Summary of Benefits and Payment chart at the beginning of this Summary
Plan Description.
n Any difference between the dentist’s Billed Charge and the applicable fee
schedule or the Maximum Plan Allowance. Please note: This only applies
if you receive services from a nonparticipating dentist or for procedures that
are not Covered Services or services from a Delta Dental Dentist that are not
reimbursed by Delta Dental to some extent.
n Deductible(s) and Member Coinsurance.
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DELTA DENTAL’S PAYMENT POLICY
Delta Dental’s policy is to send payment for treatment after it is completed—not
before.
For example, Delta Dental will send payment for:
n A crown when it is seated.
n A root canal when it is filled.
UNDERSTANDING PAYMENT VOCABULARY
Anniversary Date
The Anniversary Date is the renewal date of the contract between your employer
or group sponsor and Delta Dental of Iowa.
Benefit Period
A benefit period is the same as a calendar year. It begins on the day your coverage
goes into effect and starts over each January 1. This is true for as long as you have
coverage.
The benefit period is important for calculating your deductible and benefit period
maximum, if applicable.
Billed Charge
The billed charge is the amount a dentist bills for a specific dental procedure.
Covered Charge
The covered charge is the amount a dentist bills for a dental procedure that is a
covered benefit under your Dental Plan.
Covered Person
Covered Person means any individual eligible for dental benefits under a dental
program that is insured or administered by Delta Dental (or by a Delta Dental
Member Company).
Covered Services
Covered Services means dental services allowed as a result of being insured by, or
included under a dental plan administered by, Delta Dental (or by a Delta Dental
Member Company).
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Delta Dental Member Company
Delta Dental Member Company means a company that is an active member or
affiliate member of Delta Dental Plans Association, as defined in the Delta Dental
Plans Associations Bylaws.
Maximum Plan Allowance
Maximum Plan Allowance is the amount which Delta Dental establishes as its
maximum allowable fee for certain Covered Services provided by dentists who
participate in the Delta Dental Premier Program. For services billed by dentists
outside of Iowa, the Maximum Plan Allowance is based on information from that
state’s Delta Dental Member Company.
The Maximum Plan Allowance is established by Delta Dental for dental services
contained in the “Current Dental Terminology” published by the American Dental
Association from time to time. It is developed from various sources that may in-
clude, but are not limited to, contracts with dentists, the simplicity or complexity
of the procedure, the Billed Charge for the same procedure by dentists in the same
geographic area and with similar training and skills, and a leading economic indi-
cator, such as the Consumer Price Index.
UNDERSTANDING AMOUNTS YOU PAY TO SHARE COSTS
Deductible
Deductible is the fixed dollar amount you pay for Covered Services for each Covered
Person in a benefit period before benefits are available under this Dental Plan. This
amount is shown on the Summary of Benefits and Payment chart at the beginning
of this Summary Plan Description. Please note: The family deductible is reached
from deductible amounts paid on behalf of any combination of Covered Persons.
Carryover Deductible
It is possible for you to have benefit dollars applied to your deductible in one benefit
period that also apply to your deductible for the next benefit period. This occurs
when you receive Covered Services during the last three months (October - De-
cember) of the benefit period, and benefits are applied to your deductible. Those
deductible accumulations during the last three months of the benefit period will
carry over as credit to meet your deductible the next benefit period.
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Member Coinsurance
Coinsurance is the amount, calculated using a fixed percentage, you pay each time
you receive certain Covered Services. These amounts are shown on the Summary
of Benefits and Payment chart at the beginning of this Summary Plan Description.
Coinsurance payments begin once you meet any applicable deductible amounts.
Coinsurance is calculated off the applicable fee schedule or the Maximum Plan
Allowance. In general, the percentage of coinsurance you pay depends on the
benefit category of the service you receive.
Enhanced Benefits Program (EBP)
The Enhanced Benefits Program offers additional oral health services to Eligible
Covered Persons with qualifying dental or medical conditions. Qualifying partic-
ipants may be eligible for:
■ Additional cleanings
■ Topical Fluoride Application
For information regarding the dental or medical conditions that may qualify you
for additional cleanings and/or topical fluoride applications visit Delta Dental of
Iowa’s website – www.deltadentalia.com – or call us. See Benefits section for
additional information.
If you qualify, it is your responsibility to register for the additional dental
benefits.
Benefit Period Maximum or Annual Maximum
The Benefit Period Maximum or Annual Maximum is the maximum benefit each
Covered Person is eligible to receive for certain Covered Services in a Benefit Peri-
od. The Benefit Period Maximum is reached from claims settled under this Summary
Plan Description in a Benefit Period. This amount is shown on the Summary of
Benefits and Payment chart at the beginning of this Summary Plan Description.
HELPING WHEN YOU HAVE QUESTIONS
If you have any questions after reading this Summary Plan Description, please call
Delta Dental. For your convenience, Delta Dental has listed their toll-free number
on the back cover of this Summary Plan Description.
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B ENEFITS
CHECK-UPS AND TEETH CLEANING
DIAGNOSTIC AND PREVENTIVE SERVICES
Dental Cleaning (Prophylaxis)
Removing plaque, tartar (calculus), and stain from teeth.
Limitation: Routine dental cleaning is a benefit only twice per benefit period.
Please Note: Delta Dental of Iowa’s Enhanced Benefits Program (EBP) offers
up to 2 additional dental cleaning benefits for Covered Persons with designated
dental or medical conditions. Total cleanings for qualifying participants in EBP are
limited to no more than 4 per benefit period. For information regarding the dental
or medical conditions that may qualify you for additional cleanings, visit Delta
Dental’s website, or contact Delta Dental. For your convenience, we have listed
our toll-free number on the back cover of this Summary Plan Description. If you
qualify for the additional cleaning(s), it is your responsibility to register at www.
deltadentalia.com or call Delta Dental of Iowa.
Oral Evaluations
Oral evaluations include all types of dental examinations including preventive
examinations, comprehensive examinations, consultations, and problem focused
evaluations.
Limitation: These evaluations/examinations are a benefit twice per benefit period.
Topical Fluoride Applications
Professionally administered procedure in which the dental surfaces are coated with
a fluoride solution or gel to discourage decay.
Limitation: Topical fluoride is a benefit only once every 6 consecutive months.
X-Rays:
Bitewing X-Rays
Bitewing is an x-ray that shows the crowns of the upper and lower teeth simulta-
neously and that is held in place by a tab between the teeth.
Limitation: Bitewing x-rays are a benefit only once every 12 consecutive months.
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Full-Mouth X-Rays
Full-mouth x-rays include a combination of individual x-rays such as periapical,
bitewing or occlusal taken by a dentist on the same service date.
A panoramic x-ray is a benefit if full-mouth x-rays have not been performed within
3 consecutive years of the panoramic x-ray.
Limitation: Full-mouth or panoramic x-rays are a benefit only once every 3 con-
secutive years.
Occlusal X-Rays
Occlusal x-rays capture all the upper and lower teeth in one image while the film
rests on the biting surface of the teeth.
Limitation: These x-rays are a benefit only once every 12 consecutive months.
Periapical X-Rays
A radiographic image of a tooth, or limited number of teeth, that includes the crown
and root portions.
Limitation: These x-rays are a benefit only once every 12 consecutive months.
Sealant/Preventive Resin Applications
Filling decay-prone areas of the chewing surface of molars.
Limitation: Sealant/Preventive Resin applications are a benefit once per permanent
first and second molars for eligible children through age 14.
Sealants and Preventive Resins for primary teeth, wisdom teeth, or teeth that have
already been treated with a restoration are not a benefit.
Space Maintainers for Missing Back Teeth
Space maintainers are passive appliances designed to prevent tooth movement.
Limitation: Space maintainers are a benefit only for eligible children through age 14.
CAVITY REPAIR AND TOOTH EXTRACTIONS
ROUTINE AND RESTORATIVE SERVICES
Emergency Treatment (Palliative Treatment)
Treatment to relieve pain or infection of dental origin.
General Anesthesia/Sedation
Limitation: General anesthesia and intravenous sedation are benefits only when
provided in conjunction with covered oral surgery and when billed by the oper-
ating dentist.
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Restoration of Decayed or Fractured Teeth
Pre-formed or stainless steel restorations and restorations such as silver (amalgam)
fillings, and tooth-colored (composite) fillings.
Limitation: If you choose a tooth-colored filling to restore back (posterior) teeth,
benefits are limited to the amount paid for a silver filling. You are responsible
for paying the difference.
Limited Occlusal Adjustment
Reshaping the biting surfaces of one or more teeth.
Limitation: Limited Occlusal Adjustment is a benefit only twice every 12 consec-
utive months.
Routine Oral Surgery
Including removal of teeth, and other surgical services to the teeth or immediate
surrounding hard and soft tissues that are being performed due to disease, pathology,
or dysfunction of dental origin.
Alveoloplasty
Surgical procedure for recontouring supporting bone, sometimes in preparation
for a prosthesis.
ROOT CANALS
ENDODONTIC SERVICES
Apicoectomy/Periradicular Surgery
Surgery to repair a damaged root as part of root canal therapy or to correct a pre-
vious root canal.
Direct Pulp Cap
Covering exposed pulp with a dressing or cement to protect it and promote healing
and repair.
Pulpotomy
Removing the coronal portion of the pulp as part of root canal therapy. When
performed on a baby (primary) tooth, pulpotomy is the only procedure required
for root canal therapy.
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Retrograde Fillings
Sealing the root canal by preparing and filling it from the root end of the tooth.
Root Canal Therapy
Treating an infected or injured pulp to retain tooth function. This procedure gen-
erally involves removal of the pulp and replacement with an inert filling material.
GUM AND BONE DISEASES
PERIODONTAL SERVICES
Please note: Certain Procedures in this category should receive our review before
they are performed. See The Notification Program section.
Full Mouth Debridement
Limitation: Full mouth debridement is a benefit once in a lifetime after 36 months
have elapsed since last dental cleaning (prophylaxis).
Conservative Periodontal Procedures (Root Planing and Scaling)
Removing contaminants such as bacterial plaque and tartar (calculus) from a tooth
root to prevent or treat disease of the gum tissues and bone which support it.
Limitation: Conservative periodontal procedures are a benefit only once every 24
consecutive months for each quadrant of the mouth.
Note: A quadrant is one of the four equal sections of the mouth into which the jaws
can be divided and represents four or more contiguous teeth or bounded teeth spaces.
Periodontal Maintenance Therapy
Includes various maintenance services such as pocket depth measurements, dental
cleaning (oral prophylaxis), removal of stain, and root planing and scaling.
Limitation: This procedure may follow conservative or complex periodontal thera-
py. When this procedure immediately follows complex or conservative periodontal
therapy, benefits are available up to four times in the first benefit period and twice
per benefit period, thereafter. This procedure replaces the dental cleaning benefit
(prophylaxis) described under Check-Ups and Teeth Cleaning earlier in this section.
Please Note: Delta Dental of Iowa’s Enhanced Benefits Program (EBP) offers
up to 2 additional dental cleaning benefits for Covered Persons with designated
dental or medical conditions. Total cleanings for qualifying participants in EBP are
limited to no more than 4 per benefit period. For information regarding the dental
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or medical conditions that may qualify you for additional cleanings, visit Delta
Dental’s website, or contact Delta Dental. For your convenience, we have listed
our toll-free number on the back cover of this Summary Plan Description. If you
qualify for the additional cleaning(s), it is your responsibility to register at www.
deltadentalia.com or call Delta Dental of Iowa.
HIGH COST RESTORATIONS
CAST RESTORATIONS
Please note: Certain Procedures in this category should receive our review before
they are performed. See The Notification Program section.
Procedures in this category are a benefit once every 5 consecutive years beginning
from the date the cast restoration is cemented in place.
Cast Restorations for Complicated Tooth Decay or Fracture
Restoring a tooth with a cast filling (including local anesthesia) when the tooth
cannot be restored with a silver (amalgam) or tooth-colored (composite) filling.
Crowns
Restoring form and function by covering and replacing the visible part of the tooth
with a precious metal, porcelain-fused-to-metal, or porcelain crown. Crowns placed
for the primary purpose of periodontal splinting, cosmetics, altering vertical dimen-
sion, restoring your bite (occlusion), or restoring a tooth due to attrition, abrasion,
erosion, and abfraction are not a benefit. Limitation: Crowns are a benefit only if
the tooth cannot be restored with a routine filling. Crowns which are supported by
surgically placed dental implants will be limited to the amount paid for a conven-
tional, natural tooth supported crown. Dental implants are not a benefit.
Inlays
Restoring a tooth with a cast metallic or porcelain filling.
Limitation: Inlay benefits are limited to the amount paid for a silver (amalgam)
filling. See Restoration of Decayed or Fractured Teeth, described under Cavity
Repair and Tooth Extractions earlier in this section.
Onlays
Replacing one or more missing or damaged biting cusps of a tooth with a cast
restoration.
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Posts and Cores
Preparing a tooth for a cast restoration after a root canal when there is insufficient
strength and retention.
Recementation of Cast Restorations
Recementation of an inlay, onlay, or crown that has become loose.
Limitation: Benefits are limited to once every 12 consecutive months after 6 months
have elapsed since initial placement.
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S ERVICES NOT COVERED
This Dental Plan does not provide benefits for dental treatment listed in this sec-
tion. Please note: Even if the treatment is not specifically listed as an exclusion,
it may not be covered under this Dental Plan. Call Delta Dental if you are unsure
if a certain service is covered. For your convenience, Delta Dental has listed their
toll-free number on the back cover of this Summary Plan Description.
EXCLUSIONS
Anesthesia or Analgesia
You are not covered for local anesthesia or nitrous oxide (relative analgesia) when
billed separately from the related procedure.
Broken Appointments
You are not covered for any fees charged by your dental office because of broken
appointments.
Complete Occlusal Adjustment
You are not covered for services or supplies used for revision or alteration of the
functional relationships between upper and lower teeth.
Complications of a Non-Covered Procedure
You are not covered for complications of a non-covered procedure.
Congenital Deformities
You are not covered for services or supplies to correct congenital deformities, such
as a cleft palate.
Controlled Release Device
You are not covered for services or supplies used for the controlled release of
therapeutic agents into diseased crevices around your teeth.
Cosmetic in Nature
You are not covered for services or supplies which have the primary purpose of
improving the appearance of your teeth, rather than restoring or improving dental
form or function.
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Desensitizing Medicament or Resin
You are not covered for the application of desensitizing medicament or resin for
cervical and/or root surface sensitivity either on a per tooth or per visit basis.
Drugs
You are not covered for prescription, non-prescription drugs, medicines or thera-
peutic drug injections.
Effective Date
You are not covered for services or supplies received before the effective date of
your coverage under this Dental Plan.
Experimental or Investigative
You are not covered for services or supplies that are considered experimental, inves-
tigative 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.
Government Programs
You are not covered for services or supplies when you are entitled to claim benefits
from governmental programs (except Medicaid).
Guided Tissue Regeneration
You are not covered for services or supplies to encourage regeneration of lost
periodontal structures.
Incomplete Services
You are not covered for dental services that have not been completed.
Indirect Pulp Caps
You are not covered for indirect pulp caps.
Infection Control
You are not covered for separate charges for “infection control,” which includes
the costs for services and supplies associated with sterilization procedures. Delta
Dental Dentists incorporate these costs into their normal fees and will not charge
an additional fee for “infection control.”
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Lost or Stolen Appliances
You are not covered for services or supplies required to replace lost or stolen dental
appliances.
Medical Services or Supplies
You are not covered for services or supplies which are medical in nature, including
dental services performed in a hospital, treatment of fractures and dislocations,
treatment of cysts and malignancies, and accidental injuries.
Military Service
You are not covered for services or supplies which are required to treat an illness
or injury received while you are on active status in the military services.
Payment Responsibility
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 Dental Plan, you
would not be charged.
Periodontal Appliances
You are not covered for services or supplies for periodontal appliances (bite guards)
to reduce bite (occlusal) trauma due to tooth grinding or jaw clenching.
Periodontal Services (Complex)
You are not covered for periodontal services including conservative, complex or
maintenance periodontal procedures.
Periodontal Splinting
You are not covered for services or supplies used for the primary purpose of re-
ducing tooth mobility, including crown-type restorations.
Plaque Control Programs, Oral Hygiene Instructions, and Dietary Instructions
You are not covered for services or supplies used for plaque control, oral hygiene,
and/or dietary instructions.
Prosthetics
You are not covered for prosthetics, including bridges, dentures, and dental implants.
Provisional Crowns, Bridges or Dentures
You are not covered for services or supplies for provisional crowns, bridges or
dentures.
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Repair, Replacement or Duplication of Orthodontic Appliances
You are not covered for services or supplies required to repair, replace or duplicate
any orthodontic appliance.
Sales Tax and Fees
We do not pay sales tax or fees billed by dentists for dental services.
Services Provided in Other Than Office Setting
You are not covered for services provided in other than a dental office setting.
Specialized Services
You are not covered for specialized, personalized, elective materials and techniques
or technology which are not reasonably necessary for the diagnosis or treatment
of dental disease or dysfunction. Specialized services represent enhancements to
other services and are considered optional.
Straighter Teeth - Corrective Orthodontics
You not covered for Corrective Orthodontics.
Temporary or Interim Procedures
You are not covered for temporary or interim procedures.
Temporomandibular Joint Dysfunction (TMD)
You are not covered for expenses incurred for diagnostic x-rays, appliances, res-
torations or surgery in connection with Temporomandibular Joint Dysfunction
(TMD) or myofunctional therapy.
Termination
Whether or not Delta Dental has approved a treatment plan, you are not covered
for treatment received after the date your coverage terminates.
Treatment By Other Than A Licensed Dentist
You are not covered for services or treatment performed by other than a licensed
dentist or his or her employees. Covered Services provided in states where other
types of dental providers can practice independently are allowed.
Treatment in Progress
You may not be covered for services or supplies related to treatment which began
prior to the effective date of this Dental Plan.
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Unerupted Teeth
You are not covered for the prophylactic removal of unerupted teeth (asymptomatic
and nonpathological). This means we will not pay for the removal of any tooth that
is not visible and not causing harm.
Workers’ Compensation
You are not covered for services or supplies that are or could have been compen-
sated under Workers’ Compensation laws, including services or supplies applied
toward satisfaction of any deductible under your employer’s Workers’ Compen-
sation coverage.
27
THE NOTIFICATION
PROGRAM
This section explains the notification program you or your dentist should follow
before you receive certain benefits available under this Dental Plan.
This program is the checks and balances of your dental coverage. It helps:
n Determine that services are dentally necessary and dentally appropriate;
n Confirm the benefits of your Dental Plan.
THE APPROVAL
The purpose of the notification program is to help control the cost of your bene-
fits — not to keep you from receiving dentally necessary and dentally appropriate
treatment.
You should notify Delta Dental of Iowa before you receive the following benefits:
n Periodontal Services
n High Cost Restorations including Crowns and Onlays
You should also notify Delta Dental of Iowa before you receive treatment from
any benefit category that will exceed $300.
Delta Dental’s review is based on the treatment plan submitted by your dentist.
THE TREATMENT PLAN
A treatment plan describes the treatment your dentist has recommended for you
and helps Delta Dental determine if the procedure is a benefit of your Dental Plan
as well as dentally necessary and dentally appropriate.
When to Submit a Treatment Plan
You will need to file a treatment plan only if your dentist is nonparticipating —
Delta Dental Dentists agree to file for you.
A complete treatment plan includes the plan of treatment and x-rays. Please send
the x-rays within 15 working days of receipt of the proposed treatment plan.
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Where to Send a Treatment Plan
Submit the proposed treatment plan, along with x-rays and supporting information
to:
Delta Dental of Iowa
P.O. Box 9000
Johnston, IA 50131-9000
THE TREATMENT PLAN REVIEW
Once Delta Dental receives the treatment plan and proper documentation, Delta
Dental will let you and your dentist know if the treatment plan is approved within
15 working days. Delta Dental will take one of the following three actions when
they receive your treatment plan:
n Accept it as submitted.
n Recommend an alternative benefit. If Delta Dental asks you to receive an
independent diagnosis from a dentist of Delta Dental’s choice, Delta Dental
will pay for the exam.
n Deny the treatment plan because:
— The procedure is not a benefit of this Dental Plan;
— You did not receive an independent exam after Delta Dental asked you
to; or
— The procedure is not dentally necessary and dentally appropriate.
Appeal
If Delta Dental denies a treatment plan, you can resubmit it with additional docu-
mentation and ask Delta Dental, in writing, to reconsider. If necessary, Delta Dental
will ask you to receive an independent diagnosis from an independent dentist of
Delta Dental’s choice—Delta Dental will pay for the exam.
Please note: Although Delta Dental may approve a treatment plan, neither Delta
Dental nor this Dental Plan are necessarily liable for the actual treatment you
receive from your dentist.
29
FILING CLAIMS
Once you receive dental services, Delta Dental needs to receive a claim to determine
the amount of your benefits. The claim lets Delta Dental know the services you
received, when you received them, and from which dentist. You will need to file
a claim only when you use a nonparticipating dentist who does not agree to file a
claim for you —Delta Dental Dentists file for you.
WHEN TO FILE YOUR CLAIM
After you receive services, you should file a claim only if your dentist has not filed
one for you. Delta Dental may deny payment of a claim submitted more than 365
days after the date services were rendered.
You should file a claim only after the procedure is completely finished. Do not file
for payment before a procedure is completed.
If you need a claim form or have any questions after reading this section, please
call Delta Dental of Iowa or visit their website www.deltadentalia.com. For your
convenience, Delta Dental has listed their toll-free number on the back cover of
this Summary Plan Description. If you must file your own claim, send it to the
following address:
Delta Dental of Iowa
P.O. Box 9000
Johnston, IA 50131-9000
FILING WHEN YOU HAVE OTHER COVERAGE
COORDINATION OF BENEFITS
You may have other insurance or coverage that provides the same or similar ben-
efit(s) as this Dental Plan. If so, Delta Dental will work with your other insurance
company or carrier or health plan. The benefits payable under this Dental Plan
when combined with the benefits paid under your other coverage will not be more
than 100 percent of either Delta Dental’s payment arrangement amount or the other
carrier ’s or health plan’s payment arrangement amount.
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What You Should Do
When you receive services, you need to let Delta Dental know that you have other
coverage. Other coverage includes: group insurance, other group benefit plans
(such as HMOs, PPOs, and self-insured programs); Medicare or other govern-
mental benefits; and the medical benefits coverage in your automobile insurance
(whether issued on a fault or no-fault basis). To help Delta Dental coordinate your
benefits, you should:
n Inform your dentist by giving him or her information about your other coverage
at the time you receive services. Your dentist will pass the information on to
Delta Dental when the claim is filed.
n Indicate that you have other coverage when you fill out a claim form by com-
pleting the appropriate boxes on the form. Delta Dental will contact you if
any additional information is needed.
You must cooperate with Delta Dental and provide requested information about
your other coverage. If you do not give Delta Dental necessary information, your
claims will be denied.
What Delta Dental Will Do
There are certain rules Delta Dental follows to help determine which coverage pays
first when you have other insurance or coverage that provides the same or similar
benefits as this Dental Plan. Here are some of the rules:
n The coverage without coordination of benefits pays first when both cover-
ages are through a group sponsor such as an employer, but one coverage has
coordination of benefits and one does not.
n The dental benefits of your auto coverage will pay before this coverage if the
auto coverage does not have a coordination of benefits provision.
n The coverage which you have as an employee or contract holder participant
pays before the coverage which you have as a plan beneficiary spouse or child.
n The coverage you have as the result of your active employment pays before
coverage you hold as a retiree or under which you are not actively employed.
n The coverage with the earliest continuous effective date pays first when none
of the above rules apply.
If none of the guidelines just mentioned apply to your situation, Delta Dental will
use the Coordination of Benefits (COB) guidelines adopted by the Iowa Insurance
Division to determine payment to you or to your Delta Dental Dentist.
31
What You Should Know About Beneficiaries Who Are Children
To coordinate benefits for a child the following rules apply. For a child who is:
n Covered by both parents who are not separated or divorced or if they are,
neither parent has primary physical custody, the coverage of the parent whose
birthday occurs first in a calendar year pays first. If another carrier does not
use this rule, then the other plan will determine which coverage pays first.
n Covered by separated or divorced parents and a court decree says which
parent has financial or dental insurance responsibility, that parent’s coverage
pays first.
n Covered by separated or divorced parents and a court decree does not
stipulate which parent has financial or dental insurance responsibility, then
the coverage of the parent with custody pays first. The payment order for this
child is as follows: custodial parent, spouse of custodial parent, other parent,
and spouse of other parent.
If none of these rules apply, the parent’s coverage with the earliest continuous
effective date pays first.
DENIED CLAIMS AND APPEALS PROCEDURES
CLAIM DENIALS
Pursuant to our contract with Delta Dental, we have delegated the responsibility for
evaluating all claims for reimbursement to Delta Dental as the Claims Administra-
tor. Delta Dental will decide your claim within a reasonable time not longer than
30 days after it is received. This time period may be extended, however, where a
claim is incomplete or there are other circumstances beyond Delta Dental’s control.
In such a case, Delta Dental will provide you with written notice of any required
extension in the time for them to respond, including the reasons for such an exten-
sion and information on the date on which a decision is expected to be made. If
an extension is necessary because a claim is incomplete, the written notice to you
will also request that you provide Delta Dental with certain additional information
within 45 days. The time period for Delta Dental to respond to your claim can be
extended for an additional 15 days from the date on which Delta Dental receives
the requested additional information.
Delta Dental may obtain the advice of independent dentists or require such other
evidence as it deems necessary to decide your claim.
32
If Delta Dental denies your claim, in whole or in part, you will be furnished with
a written notice setting forth the following information:
1. The specific reasons for the denial;
2. Reference to the specific provisions of the Dental Plan on which the denial
is based;
3. A description of any additional material or information necessary for you to
complete your claim and an explanation of why such material or information
is necessary; and
4. Appropriate information as to the steps to be taken if you wish to appeal the
decision of Delta Dental, including your right to submit written comments
and have them considered, your right to review (on request and at no charge)
relevant documents and other information.
APPEALING A DENIED CLAIM OR ADVERSE BENEFIT DETERMINATION
Your Initial Request for A Review
If Delta Dental of Iowa does not pay all or part of your claim 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 re-
ceiving the notice from Delta Dental of Iowa, including the reason why you disagree
with Delta Dental’s claim decision, documents, records, and any other information
related to the claim. Include your name, patient’s name and your identification
number on all documents.
Delta Dental’s Reply
Within 30 days of receiving your request, Delta Dental of Iowa will send you their
written decision and indicate any action they have taken. However, when special
circumstances arise, Delta Dental of Iowa may require 60 days. Delta Dental of Iowa
will notify you in the event they require additional days. After that time, they will
make the final decision on the claim based on the information they have in your file.
Reviewing Records
Upon your request, Delta Dental of Iowa will provide you free of charge access to
and copies of all documents, records and other information relevant to your claim
for benefits. You can review records that deal with your request from 8 a.m. to 4:30
33
p.m., Central Standard Time, Monday through Friday, at Delta Dental of Iowa’s
Johnston, Iowa location. Since so many records are electronically filed, please call
Delta Dental of Iowa in advance so they can have copies ready for you.
Send your request to:
Delta Dental of Iowa
P.O. Box 9010
Johnston, IA 50131-9010
Or call 1-800-544-0718
Delta Dental will review your request and decide your appeal within a reasonable
time not longer than 60 days after it is submitted and will notify you of its decision
in writing. The individual who decides your appeal will not be the same individual
who decided your initial claim denial and will not be that person’s subordinate.
Delta Dental may secure the advice of independent dentists or others and require
such evidence as it deems necessary to decide your appeal, except that any dental
or other expert consulted in connection with your appeal will be different from any
expert consulted in connection with your initial claim. The identity of any dental
or other expert consulted in connection with your appeal will be provided. If the
decision on review affirms the initial denial of your claim, you will be given a
notice of denial on review that provides the following information:
1. The specific reason(s) for the denial;
2. The specific provisions of the Dental Plan on which the decision is based;
3. A statement of your right to review (on request and at no charge) relevant
documents and other information;
4. If Delta Dental relied on an “internal rule, guideline, protocol, or other
similar criterion” in making the decision, a description of the specific rule,
guideline, protocol, or other similar criterion or a statement that such a rule,
guideline, protocol, or other similar criterion was relied on and that a copy
of such rule, guideline, protocol, or other similar criterion will be provided
free of charge to you upon request.
34
E LIGIBILITY
COVERAGE ELIGIBILITY
You are eligible to be a participant in the Dental Plan if you are an employee who
has met your employer’s eligibility requirements or if you are either the eligible
spouse or an eligible child of an employee who has met the employer’s eligibility
requirements.
Spouse means your husband or wife, of the opposite sex, as the result of a marriage
that is legally recognized in Iowa or a common law partner. 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. To
be an eligible beneficiary, a child must meet at least one of the following standard
requirements:
n The child is under age 26.
n 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 disability. The disability must be substantiated by
a written statement from a physician.
n 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 child must
have had continuous qualifying dental 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.
ELIGIBILITY ENROLLMENT REQUIREMENTS
This benefit plan includes the following eligibility enrollment requirements:
35
n You must apply for coverage when initially eligible or due to a Qualifying
Event.
n If you do not apply for coverage when initially eligible you will not be eligible
to enroll in this Plan until your employer or group sponsor ’s next Anniversary
Date; unless the election is due to a Qualifying Event.
n If you drop coverage you will not be eligible to re-enroll in this Plan, until
your employer or group sponsor’s next Anniversary Date; unless the election
is due to a Qualifying Event.
QUALIFIED MEDICAL CHILD SUPPORT ORDER (QMCSO)
If you have a child and we receive a Medical Child Support Order recognizing
the child’s right to enroll in this Dental Plan and/or any other benefit plan, we will
promptly notify both you and the child that the order has been received. We also
will inform you and the child of our 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 BENEFITS BEGIN
Your rights to receive benefits under this Dental Plan begin on your effective date.
If you have just started a new job, check with us or your group sponsor to find out
your effective date.
Please note: Before you receive benefits under this Dental Plan, you have agreed
on the application for benefits (or in documents kept by Delta Dental or us) to re-
lease any necessary information requested about you so Delta Dental can process
claims for benefits. You must allow any healthcare provider or his or her employee
to give Delta Dental information about a treatment or condition. If Delta Dental
does not receive the information requested, or if you withhold information in your
application, your benefits may be denied.
If you fraudulently use the identification card or misrepresent or conceal material
facts in your application, then Delta Dental may terminate your benefits.
WHEN BENEFITS END
Your eligibility for benefits under this Dental Plan will terminate at the end of the
month for any of these reasons:
n You become ineligible for coverage under this Dental Plan. See Eligibility
earlier in this section.
36
n You become unemployed. Termination of your coverage for this reason applies
only if you receive your coverage through us.
n We decide to discontinue or replace this coverage.
n Delta Dental decides to terminate this Dental Plan by giving written notice to
us 90 days prior to termination.
Your coverage will end if any of the following occurs:
n You use your dental benefits fraudulently or you fraudulently misrepresent or
conceal material facts in your application. If this happens, Delta Dental will
recover any claim payments made.
n Delta Dental will not pay claims if we fail to make payment to Delta Dental
when due.
Authority to Terminate, Amend, or Modify
We have the authority to terminate, amend, or modify the benefits and coverage
described in this Summary Plan Description at any time. Any amendment or
modification will be in writing. If this Dental Plan is terminated, you may not
receive benefits.
CONTINUED COVERAGE (COBRA)
There are some federal and state laws that may affect your dental benefits. These
laws apply to continuing your coverage when you are no longer eligible for this
Dental Plan.
Coverage Continuation Under Federal Law — COBRA
The Consolidated Omnibus Budget Reconciliation Act (COBRA) applies to em-
ployers with 20 or more employees. COBRA entitles you, your eligible spouse,
and your eligible children to a continuation of coverage under this Dental Plan if
coverage is lost due to any of the following qualifying events:
n Death of the employee covered under this Dental Plan.
n Termination of employment for reasons other than gross misconduct.
n A reduction in hours causing loss of coverage.
n Divorce or legal separation.
n The employee covered under this Dental Plan becomes entitled to Medicare.
n Child/Children are no longer considered eligible by our eligibility rules.
n The employer from whom the covered employee retired files bankruptcy under
federal law (in certain cases).
37
Please note: You, your eligible spouse, or your eligible children are responsible
for notifying us of a dissolution of marriage, legal separation or a child losing
eligibility status.
If you wish to continue your benefits, you must complete an election form and
submit it to us within 60 days of the later of the date:
n You are no longer covered; or
n You are notified of the right to elect COBRA continuation coverage.
You will be responsible for paying any premiums to us for the continuation of
benefits under this Dental Plan. 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 cover-
age 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 us within 60 days after the determination.
If you lose your coverage, contact us. We will help you with any necessary paper-
work and let you know the cost of continuing your coverage.
Length of Coverage under COBRA
Continuation coverage ends at the earliest of one of these events:
n The last day of the 18-, 29-, or 36-month maximum coverage period, which-
ever is applicable.
n The first day (including grace periods, if applicable) on which timely payment
is not made.
n The date on which we cease to maintain any group plan (including successor
plans).
n 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 relat-
ing to any preexisting condition of the beneficiary, then coverage will end on
the earlier of the satisfaction of the waiting period for preexisting conditions
38
contained in the new group plan or upon the occurrence of any one of the other
events stated in this section.
n The date the qualified beneficiary is entitled to Medicare benefits.
COVERAGE CHANGES
EVENTS CHANGING COVERAGE
Certain events may require you to change who is covered by this Dental Plan.
These events include:
n Active Duty in the Military of an eligible child or spouse
n Appointment as a Legal Guardian of a child
n Beneficiary who is an Eligible Child (who is not a full-time student or per-
manently disabled) reaches age 26
n Birth or Adoption of a child
n Care of a Foster Child (when placed in your home by an approved agency)
n Completion of Full-time Schooling of an eligible child age 26 or older
n Death
n Divorce, Annulment, or Legal Separation of a participant
n Exhaustion of COBRA Coverage
n Marriage
n Spouse or Child Loses Eligibility for Qualifying Dental Coverage or we
cease contributions to qualifying dental coverage. In this case, your eligible
spouse and any eligible children previously covered under the prior qualifying
dental coverage are eligible for coverage under this Dental Plan.
n Spouse’s Medicaid or Child’s Medicaid or Children’s Health Insurance
Program (CHIP) or Healthy And Well Kids in Iowa (Hawki) coverage is
terminated as a result of losing eligibility or the Eligible Covered Person be-
comes eligible for a premium assistance subsidy under Medicaid or CHIP. This
special enrollment opportunity is provided by the Children’s Health Insurance
Program Reauthorization Act (CHIPRA). You must request this special enroll-
ment opportunity within 60 days of losing Medicaid, CHIP, or Hawki coverage
or within 60 days of when eligibility for the premium assistance is determined.
NOTIFICATION OF CHANGE
You must notify Delta Dental within 31 days of the date of the event that changes
the status of your eligibility. Delta Dental of Iowa must be notified within 60 days
of the date of the event that changes the status of your eligibility for births, adop-
tions, or due to a change in eligibility status for Medicaid, CHIP, or Hawki. 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, the person(s) affected
may lose important coverage.
39
COVERAGE TERMINATION
EFFECTS OF TERMINATION
If your coverage is terminated for fraud, misrepresentation, or the concealment
of material facts:
n Delta Dental will not pay for any services or supplies provided after the date
the coverage is terminated.
n This Dental Plan will retain legal rights. This includes the right to initiate a
civil action based on fraud, concealment, or misrepresentation.
n Delta Dental may, at their option, declare the coverage void.
If your coverage is terminated for reasons other than fraud, concealment, or
misrepresentation of material facts, Delta Dental will stop benefits the day your
coverage is terminated.
DELTA DENTAL’S RIGHT TO RECOVER PAYMENTS
PAYMENT IN ERROR
If for any reason Delta Dental makes payment under this Dental Plan in error, Delta
Dental may recover the amount Delta Dental paid.
SUBROGATION
Once you receive benefits under this Dental Plan arising from an illness or injury,
the Dental Plan will assume any legal right you have to collect compensation,
damages, or any other payment related to the illness or injury, including benefits
from any of the following:
n The responsible person’s insurer.
n Uninsured motorist coverage.
n Underinsured motorist coverage.
n Other insurance coverage.
You and your other eligible Covered Person(s) agree to all of the following:
n You will let Delta Dental know about any potential claims or rights of recovery
related to the illness or injury;
n You will furnish any information and assistance that Delta Dental determines
Delta Dental will need to enforce the Dental Plan’s rights;
n You will do nothing to prejudice the Dental Plan’s rights and interests;
n You will not compromise, settle, surrender, or release any claim or right of
recovery described above, without getting Delta Dental’s written permission;
n You must reimburse Delta Dental to the extent of benefit payments made
under this Dental Plan if payment is received from the other party or parties;
40
n You must notify Delta Dental if you or your beneficiaries have the potential
right to receive payment from someone else;
n You must cooperate with Delta Dental to ensure that Delta Dental’s rights to
subrogation are protected.
OTHER INFORMATION
NOTICE
You may send any notice to the Dental Plan at the following address:
Delta Dental of Iowa
P.O. Box 9010
Johnston, IA 50131-9010
Any notice from Delta Dental to you is valid when sent to your address as it appears
on Delta Dental’s records or the address of the group through which you are enrolled.
You may contact our Claims Administrator at the following address:
Delta Dental of Iowa
P.O. Box 9010
Johnston, IA 50131-9010
NONASSIGNMENT
Benefits for Covered Services described in this Summary Plan Description are for
your personal benefit and cannot be transferred or assigned to anyone else without
our consent. Any attempt to assign your rights under this Dental Plan 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 Summary Plan
Description 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 Dental Plan will
be litigated exclusively 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 Delta Dental because of a
claim under this Dental Plan, or because of the alleged breach of the terms of this
Dental Plan more than two years after the end of the calendar year in which the
services or supplies were provided.
41
INFORMATION IF YOU ARE OR A MEMBER OF YOUR FAMILY
IS ENROLLED IN MEDICAID
Assignment of Rights
This Dental Plan will provide payment of benefits for Covered Services to a par-
ticipant, 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 a participant or bene-
ficiary of this Dental Plan, nor will it affect Delta Dental’s determination of any
benefits paid to you.
Acquisition by States of Rights of Third Parties
If payment has been made by Medicaid and Delta Dental has a legal obligation to
provide benefits for those services, then Delta Dental will make payment of those
benefits in accordance with any state law under which a state acquires the right to
such payments.
Delta Dental of Iow a
P.O. Box 9000
Johnston, IA 50131-9000
Hearing Impaired Toll Free: 1-888-287-7312
Toll Free: 1-800-544-0718
Local: 1-515-261-5500
***.deltadentalia.com
claims@deltadentalia.com