Monterey County Dental Plan

FOREWORD

We are pleased to present you with this Booklet, which describes the Self-funded Program of Dental Care Coverage.  The COUNTY OF MONTEREY and the MONTEREY COUNTY WATER RESOURCES AGENCY have arranged this Coverage for you.  Healthcare Insurance Administrators provides certain administrative services.

 

We believe this Program provides worthwhile protection for you and your family.

 

Please read this Booklet carefully.  If you have any questions about the Program, we will be happy to answer them.

 

IMPORTANT NOTICE:  This Booklet is an important document and should be kept in a safe place.

 

TABLE OF CONTENTS

 

SCHEDULE OF BENEFITS. 3

Dental Expense Coverage. 3

Dental Care Coverage. 3

Other Information. 4

When You Have A Claim.. 4

Who Is Eligible To Become Covered?. 4

 

WHO IS ELIGIBLE TO BE COVERED UNDER THIS INSURANCE?. 5

When Does Coverage Become Effective?. 6

Coverage During Authorized Leave Of Absence. 7

When Your Coverage Ends. 7

Continuation Of Group Coverage Upon Termination. 8

Veterans. 8

Coverage Extensions. 8

 

DELAY OF EFFECTIVE DATE. 9

For Employee Coverage. 9

Coverage During Authorized Leave Of Absence Without Pay. 9

Dental Care Coverage. 9

Covered Expenses. 10

 

GENERAL INFORMATION.. 14

 

SCHEDULE OF BENEFITS

Covered Classes:  The “Covered Classes” are the Employees of the Employer (and its Associated Companies):  All Employees who are not covered under an alternate dental care plan provided by the Sponsor.

 

Plan date:  July 1, 1996.  This Booklet describes the benefits under the Group Dental Program as of the Plan date.

 

You should know…

 

Ÿ         The Coverage in this Booklet is available to you if you are included in the Covered Classes.  The rules for becoming covered are in this Booklet’s When You Become Covered section.

Ÿ         There is a Delay of Effective Date section.  The rules of that section may delay the start of your coverage.

Ÿ         The Delay of Effective Date section also applies to any change, including a change in class, unless otherwise stated.

Ÿ         The Coverage is described more fully on later pages of this Booklet.  Be sure to read these pages carefully.  They show when benefits are or are not payable under the Plan.  They also outline when your coverage ends and the conditions, limitations and exclusions that apply to the Coverage.  The benefit otherwise payable under the Plan for a person’s dental care expenses may be reduced because of benefits from other sources.  See later pages for details.

Ÿ         A Definitions section is included in this Booklet.  Many of the terms used in this Booklet, such as “Active Work Requirement”, are described in that section.

Ÿ         The Employer expects to continue the Group Program indefinitely.  But the Employer reserves the right to change or end it at any time.  This would change or end the terms of the Group Program in effect at that time for active and retired Employees.

 

dental expense coverage

 

Ÿ         This Coverage pays benefits for many of the charges incurred for services of you or your Qualified Dependent.  Not all charges are eligible; some are eligible only to a limited extent.  There is a Deductible that applies to all Eligible Charges except for preventive dental expenses.  It must be met in the Deductible Period for each Calendar Year.  There are benefit maximums.

 

deductible

Applies to all Eligible Charges except Preventive dental expenses.

Ÿ         No benefits are payable for Eligible Charges used to meet the Deductible.

 

Deductible Amount:  $50.00 of Eligible Charges for each person in each Calendar Year.  But once the Covered Persons in a Family have incurred a total of $100.00 of Eligible Charges in the Deductible Period for a Calendar Year, from then on each Covered Person in that Family will be considered to have met the Deductible for that Calendar Year.  Only those Eligible Charges for which no benefits are payable can be counted toward that $100.00.

 

“Family” means you and your Qualified Dependents.

 

Ÿ         Deductible Period:  A Calendar Year.

 

DENTAL CARE COVERAGE

 

Calendar Year Deductible:  $50

 

Calendar Year Maximum:  $1,000 per Family Member

 

Family Deductible:  $100

 

Benefits for each calendar year are payable as follows:

 

For Preventive Dental Expenses:  100%

 

For Basic Dental Expenses:  80%

 

For Major Dental Expenses:  50%

 

other information

Employer:  COUNTY OF MONTEREY and the MONTEREY COUNTY WATER RESOURCES AGENCY

 

Employment Waiting Period:  Coverage begins on the first day of the month following the date of hire.  However, if the date of hire is the first working day of the month, coverage begins that day.

 

For seasonal employees, coverage will begin on the first day of the month following your return to work.

 

The Dependent Coverage in this Booklet is Contributory Coverage.  You will be informed of the amount of your contribution when you enroll.

 

Claims Administrator’s Address:

Ÿ         Pacific Health Alliance

1350 Old Bayshore Highway, Suite 560

Burlingame, CA  94010-1814

Tel: (650) 375-5800

Fax: (650)375-5820

 

when you have a claim

Each time a claim is made, it should be made without delay.  Use a claim form, and follow the instructions on the form.

 

If you do not have a claim form, contact your Benefit Coordinator.

 

WHO IS ELIGIBLE TO BECOME COVERED?

ELIGIBILITY

 

WHO DO I CONTACT WITH ELIGIBILITY PROBLEMS?

 

If you encounter any problems with eligibility, you should contact your departmental benefit coordinator or the Human Resources-Benefits Office at 755-5456.  Typical eligibility issues that frequently require intervention include:

Ÿ         no record of enrollment

Ÿ         dispute with regard to the effective date of coverage or cancellation dates

Ÿ         changes in family status that must be reported (enrollment of newborns or spouse due to loss of coverage, etc.)

 

WHO IS ELIGIBLE TO BE COVERED UNDER THIS INSURANCE?

 

Employee Coverage

 

You are eligible for Employee coverage:

 

Ÿ         while you are a full-time permanent or part-time permanent or permanent seasonal employee of Monterey County and are a member of a representative (bargaining) unit who is eligible to participate in this Plan (full-time means you are regularly working for Monterey County at least the number of hours in the normal full-time work week but not less than 40 hours per week or 80 hours per pay period; Part-time means you are regularly working not less than 20 hours per week or 40 hours per pay period)  OR

 

Coverage for an Employee who is the Spouse of an Employee

 

If you are an eligible Employee under this plan and the spouse of an Employee who is also eligible under this plan, your coverage will be as an Employee and not as a dependent of your spouse.  You cannot be covered as both an Employee and a Dependent under the dental insurance plans sponsored by the County or any outside insurance plans for which the County contributes all or a portion of dependent coverage premiums.

 

Coverage For Dependents

 

You are eligible for Dependent coverage (covering your dependents) while you:

Ÿ         are eligible for Employee coverage; and

Ÿ         have a qualified dependent

 

Who are Qualified Dependents?

 

Qualified Dependents are those persons for whom you may obtain Dependent coverage.  They are:

Ÿ         your lawful spouse.  There are two exceptions for spouses.  Your spouse is not your Qualified Dependent while:

1.     on active duty in the armed forces of any country; or

2.     covered by any health insurance plans sponsored by the County or any outside insurance plans for which the County contributes all or a portion of dependent coverage premiums.

 

Ÿ         your unmarried children less than 19 years old.  There are two exceptions for unmarried  children: 

 

1.   The age 19 limit does not apply to a child who:

Ÿ         wholly depends on you for support and maintenance; and

Ÿ         is enrolled as a full-time student in a school; and

Ÿ         is less than 23 years of age

2.     A child who is physically or mentally incapable of self-support upon attaining age 19 may be continued under the health care benefits while remaining incapacitated and unmarried, subject to your own coverage continuing in effect.  This privilege will also apply to a child who has remained covered beyond the child’s nineteenth birthday if the child later ceases to be a qualified dependent and is then physically or mentally incapable of self-support and is not married.  To continue a child under this provision proof of incapacity must be received by the Claims Administrator within 31 days after coverage would otherwise terminate.  Additional proof will be required from time to time to substantiate the continued incapacity of dependents covered under this provision.  If these conditions are met the age limit will not cause the child to stop being a qualified dependent.  This will apply only so long as the child remains so incapacitated.

 

Who Are Children Eligible for Dependent Coverage?

 

Your children include your legally adopted children, children placed with you for adoption, stepchildren and foster children who depend on you for support and maintenance.

 

Coverage For Dependents Who are the Dependents of Two Employees

 

A child will not be considered the Qualified Dependent of more than one Employee.  The child will be considered the Qualified Dependent of the Employee who first enrolls the child as a dependent by completing an enrollment form, unless stated otherwise in a legal document, such as, a court order, etc.

 

 

ENROLLMENT

 

New employees may enroll within 31 days of their date of hire. 

 

Current employees (those with more than 31 days of service) may enroll:

Ÿ         during the County’s regular annual open enrollment period

Ÿ         within the first 31 days following a change in family status

Ÿ         within the first 31 days of loss of other group dental insurance coverage not as a result of failure to make premium payments or due to termination of coverage for cause subject to:  a) a signed statement at the time coverage was initially offered that the other coverage was the reason for declining enrollment in this plan; and b) proof of loss of the other insurance coverage

Ÿ         within the first 31 days of the birth or adoption of a child IF the child is also being enrolled as a dependent

 

Dependents may be enrolled:

Ÿ         within the first 31 days after the Employee’s date of hire

Ÿ         during the County’s regular annual open enrollment period

Ÿ         within the first 31 days following a change in family status

Ÿ         within the first 31 days of loss of other group dental insurance coverage not as a result of failure to make premium payments or due to termination of coverage for cause subject to:  a) a signed statement at the time coverage was initially offered that the other coverage was the reason for declining enrollment in this plan; and b) proof of loss of the other insurance coverage

Ÿ         spouses only may be enrolled within the first 31 days of the birth or adoption of a child IF the child is also being enrolled as a dependent

 

 

WHEN DOES COVERAGE BECOME EFFECTIVE?

 

Coverage is effective the first of the month following the date of enrollment.  If the employee’s first day of work is the first working day of the month, coverage will be effective that day.

 

Coverage is effective from the moment of the child’s birth for newborn children who are enrolled within 31 days of their date of birth.  Coverage is effective as of the date of adoption for adopted children who are enrolled within 31 days of their date of adoption. 

 

COVERAGE DURING AUTHORIZED LEAVE OF ABSENCE

 

Family Medical Leave Act:  The County of Monterey fully complies with the federal Family and Medical Leave Act (FMLA) and the California Family Rights Act (CFRA).  County contributions toward dental benefits which are in effect at the beginning of the leave are continued during the time of an approved leave under the provisions of the FMLA and CFRA.  Questions concerning FMLA and/or CFRA leave of absence should be directed to your departmental benefits coordinator.

 

Leave of Absence With Pay:  County contributions toward dental benefits which are in effect at the beginning of the leave will continue for employees who request and are granted a leave of absence with pay.  Any employee share of premiums for employee and/or dependent coverage will continue to be deducted from the employee’s regular paycheck on a monthly basis.

 

Leave of Absence Without Pay - (non- FMLA) Employee Coverage: Continuance of Employee dental insurance coverage while an Employee is on leave of absence without pay for any reason in excess of 30 days requires that the Employee pay their own premium.  This provision also applies to permanent seasonal employees and their eligible dependents for the period of time they are on leave due to lack of work.

 

Leave of Absence Without Pay - (non-FMLA) Dependent Coverage:  Continuance of Dependent dental insurance coverage while an Employee is on leave of absence without pay for any reason  that requires the Employee to pay their full dependent premium.

 

Leave of Absence Without Pay - Loss of Coverage:  Employees who, during a leave of absence without pay, elect to discontinue their dental insurance coverage for themselves or who do not pay their own health insurance premium will lose insurance coverage for themselves.  In addition, their currently enrolled dependents will become ineligible for coverage as of the end of the last month for which a premium payment was made.  Employees who do not continue to pay their Dependent dental insurance premium during a leave of absence without pay will lose insurance coverage for their dependents as of the end of the last month for which a premium payment was made. 

 

Upon return to work, after a leave of absence without pay, employees desiring to reinstate their Employee and/or Dependent dental insurance coverage must re-enroll into the plan by completing an enrollment form within 31 days of their return to work.  Coverage will be effective the first of the month following the date of re-enrollment.

 

Note:  DO NOT JEOPARDIZE YOUR DENTAL INSURANCE COVERAGE!  If you stop actively working for ANY reason, contact your Employer at once to request a leave of absence and to determine what arrangements are necessary should you wish to continue your insurance coverage.

 

WHEN YOUR COVERAGE ENDS

 

Employee and Dependent Coverage

 

Your employee coverage will end at the end of the month in which the first of these occurs:

 

Ÿ         you fail to meet the eligibility requirements of the plan

Ÿ         part or all of the Plan terminates

Ÿ         premium payments/contributions are not made

 

Your eligible dependent coverage will end at the end of the month in which the first of these occurs:

 

Ÿ         you and/or your eligible dependent(s) fail to meet the eligibility requirements of the plan

Ÿ         part or all of the Plan terminates

Ÿ         the plan terminates dependent coverage

Ÿ         dependent premium payment/contributions are not made

Ÿ         entry of a final decree of divorce, annulment or dissolution of marriage

Ÿ         attainment of the age limits specified in the definition of  “dependents”

Ÿ         when your dependent ceases to meet the definition of “dependent”

Ÿ         employees terminating coverage for their eligible dependents anytime during a calendar year, will not be allowed to re-enroll dependents (including newly acquired dependents), until the second Open Enrollment period following the month in which the dependent coverage was discontinued.

EXAMPLE:  Dependent coverage terminated on August 1, 2000.  Re-enrollment cannot take place until the Open Enrollment in September of 2001 with coverage commencing January 1, 2002.

 

 

CONTINUATION OF GROUP COVERAGE UPON TERMINATION

 

COBRA COVERAGE

 

In accordance with the Consolidated Omnibus Budget Reconciliation Act (COBRA), each participant (covered employee and eligible covered dependent) is entitled to continue Group coverage under the Plan if a participant should lose coverage because of a qualifying event (QE).  A qualifying event is defined as any one of the following occurrences:

 

1)     employee voluntarily terminates or separates from employment for a reason other than gross misconduct

2)     employee’s work hours are reduced to less than the number of hours required for eligibility

3)     employee’s death

4)     employee’s entitlement to Medicare benefits

5)     employee’s divorce or legal separation

6)     employee’s dependent child ceases to be a dependent as defined under definition of “dependents”

7)     employer files for protection under the bankruptcy law (Chapter 11)

 

If a qualifying event occurs, each participant will receive notice of eligibility for the continuation of Group coverage and other related information directly from the Plan Administrator (or employer).  However; if qualifying event (5) or (6) above occurs, or a disability determination is made by Social Security, a participant must first notify the Employer within 60 days of the qualifying event, or lose the right to continue coverage.  Contact the Human Resources-Benefits Office for more information.

 

The Plan Administrator (or employer) will give a written election notice of the right to continue the coverage.  Such notice will state the amount of the premium payments required for the continued coverage, the required time frames for responding to the Plan Administrator and for making the first premium payment and the qualifying events under which qualified beneficiaries may be eligible for COBRA coverage extensions.

 

VETERANS

If coverage ends because you are recalled to active military duty, continuation of medical coverage may be available to a family member for 18 months under the federal Uniformed Services Employment and Reemployment Rights Act of 1993.  A notice/election form will be provided by the Plan Administrator (or employer).  Contact the Human Resources-Benefits Office for further information concerning this provision.

 

COVERAGE EXTENSIONS

A participant’s coverage under this Plan may be extended after the date that participant ceases to be an eligible participant if, on that date, the participant is totally disabled from a Sickness or Injury and is under a Physician’s care.  The extension is only for that sickness or injury.  It will be for the time the person remains so disabled from any such sickness or injury and under such care, but not beyond one month.

 

Coverage will apply during a coverage extension as if the person were still an active participant in the Plan.  There are two exceptions:

 

a)     restorations will not be allowed under the Overall Maximum section of the medical expense coverage

b)    coverage will apply only to the extent that other coverage for the eligible charges is not provided for by another health plan

 

LIMITS ON ASSIGNMENTS

 

Benefits under this Plan that would otherwise be payable to the employee may be assigned without restriction.  The Plan will not decide if an assignment does what it is intended to do.  The Plan will not be held to know that an assignment has been made unless it or a copy is filed with the Claims Administrator.

 

DELAY OF EFFECTIVE DATE

for employee coverage

Your Employee Benefits under the Plan will be delayed if you do not meet the Active Work Requirement on the day your coverage would otherwise begin.  Instead, it will begin on the first day you meet the Active Work Requirement and the other requirements for the coverage.  The same delay rule will apply to any change in your coverage that is subject to this section.  If you do not meet the Active Work Requirement on the day that change would take effect, it will take effect on the first day you meet that requirement.

 

If you have enrolled for dependent’s coverage, coverage for your eligible dependents usually begins on the date your coverage begins.

 

coverage during authorizeD leave of absence without pay

In order to continue your dental care coverage while you are on leave of absence, for any reason, without pay for a period in excess of 30 days, you will be required to pay for your own coverage, as well as any contributory coverage for your eligible dependents.  This also applies to permanent seasonal employees, and eligible dependents, for the period you are on leave due to lack of work.

 

You may elect to discontinue coverage for yourself and your dependents when on a leave of absence without pay in excess of 30 days.

 

Upon return to work, after leave of absence, you must re-enroll into the plan by completing a benefit enrollment form.

 

dental care coverage

the deductible

You must pay the Deductible Amount shown in the Schedule of Benefits of each FAMILY Member’s Covered Expenses each calendar year.  There are some liberalizations for Covered Dental Expenses.

 

Family Limit

You do not have to pay more than a total amount shown in the Schedule of Benefits for all family members combined.  After that, each family member’s Deductible will be considered paid for that year.

 

Covered Expenses Not Subject to Deductible

Covered expenses for Preventive Dental Services are not subject to the deductible.

 

The Sponsor will pay a co-insurance percentage of your Covered Expenses for Preventive Dental Services.  After you pay the Deductible, the Sponsor will pay co-insurance percentages of your Basic Dental Services, and your Major Dental Services for the rest of the calendar year.  This also true for each family member.

 

The co-insurance percentages are shown in the Schedule of Benefits.

 

Maximum Benefit

The Sponsor will pay a maximum for all Covered Expenses of a family member during a calendar year.

 

The benefit maximums are shown in the Schedule of Benefits.

 

Alternate Benefits

There is often more than one service or supply that can be used to treat a dental problem or disease.  In determining what the Sponsor will pay, different materials and methods of treatment may be considered.  Covered Expenses will be limited to the charge for the least costly service that meets broadly accepted standards of dental care as determined by the Plan Administrator.  You and your dentist may decide on a more costly procedure or material than the Sponsor has determined to be satisfactory for the treatment of the condition.  The Sponsor will pay a benefit toward the cost of the selected procedure or material.  But, payment will be limited to the Usual or Prevailing Charge, subject to any plan limited to the Usual or Prevailing Charge, subject to any plan limits, for the least costly treatment.  The Sponsor will not pay the excess amount.

 

Pre-Determination Before Treatment Starts

Whenever the estimated cost of recommended dental treatment exceeds $300, you should ask your dentist to describe the proposed treatment and charges on a Dental Coverage Claim form before treatment begins.  The Form should be accompanied by supporting pre-operative x-rays and any other appropriate diagnostic material.  The form should then be sent to the Claims Administrator.

 

The Claims Administrator will notify you of how much the Sponsor will consider as Covered Expenses and how much the Sponsor will pay.  In determining the amount that the Sponsor will pay, consideration will be given to alternate procedures that accomplish a professional satisfactory result.  If you or your dentist decide on a more costly method of treatment than the Claims Administrator predetermines, the Claims Administrator will consider the more costly treatment, but pay only up to the Usual or Prevailing Charge for the alternate procedure the Claims administrator has approved for pre-determination.  The Plan Administrator will not pay the excess amount.  Since this may result in significant out-of-pocket expense, the Plan Administrator strongly encourages you to request that benefits be predetermined for any treatment which will exceed $300 in cost.

 

covered expenses

Subject to the Alternate Benefits section set forth above, Covered Expenses are USUAL OR PREVAILING CHARGES by a dentist for necessary care of the teeth, gums, mouth or supporting structures of the teeth furnished to a family member while covered under the Plan’s Dental Care Coverage.  There are three types of Covered Expenses:  Preventive Dental Expenses, Basic Dental Expenses, and Major Dental Expenses.  Not all expenses are covered.  See-WHAT EXPENSES ARE NOT COVERED?

 

A Covered Expenses will be deemed incurred as follows:

 

1.              For Full Dentures or Partial Dentures:  on the date the final impression is taken.

 

2.              For Fixed Bridges, Browns, Inlays, or Onlays; on the date the teeth are first prepared.

 

3.              For Root Canal Therapy; on the date the pulp chamber is first opened.

 

4.              For Periodontal Surgery; on the date the surgery is actually performed.

 

5.              For All Other Services:  on the date the service is performed.

 

A temporary dental service will be deemed an integral part of the final dental service rather than a separate service.

 

Preventive Dental Expenses

Preventive Dental Expenses are for the following services.

 

ROUTINE ORAL EXAMS—Charges for routine exams, including cleaning of teeth, but no more than two every calendar year.

 

DIAGNOSTIC X-RAYS—Charges for bitewing x-rays (but no more than four such x-rays, twice during any period of 12 consecutive months as part of routine oral exam), complete mouth survey or panoramic x-rays, (but no more than one during any period of 36 consecutive months) as part of a routine oral exam.

 

SPACE MAINTAINERS—Charges for space maintainers for missing primary teeth to a family member under age 16, but no more than one every calendar year.

 

FLUORIDE TREATMENT—Charges for topical application of sodium or stannous fluoride to a family member under age 18, but no more than one every calendar year.

 

SEALANTS—Charges for the application of sealants to a family member under age 15, but no more than once, per tooth, during any calendar year.

 

basic dental expenses

Basic Dental Expenses are for the following services:

 

ORAL SURGERY—Charges for surgery performed on the gums and teeth.  This includes removal of impacted or erupted teeth and preparation of the gums for dentures.

 

X-RAYS—Charges for any dental x-ray not provided above in Preventive Dental Expenses when needed in connection with the diagnosis or treatment of a specific condition.

 

EXTRACTIONS—Charges made for extractions.

 

ANESTHESIA—Charges for anesthesia administered in connection with covered dental services.

 

PERIODONTICS—Charges for treatment of periodontal and other disease of the gums and tissues of the mouth.  Charges for periodontal scaling and root planing are limited to no more than one time per quadrant of the mouth in any period of 12 consecutive months.

 

ENDODONTICS—Charges for root canal therapy.

 

FILLINGS—Charges for fillings, other than gold fillings.

 

MEDICINE—Charges for medicines and drugs administered by a dentist.

 

PALLIATIVE TREATMENT—Charges for palliative treatment (treatment to relieve pain) will be covered as a separate procedure only if no other service (except x-rays) is rendered during the visit.

 

REPAIR WORK—Charges for repair and recementing or crowns, inlays and fixed bridgework; or relining or rebasing of dentures more than six months after the installation of an initial or replacement denture, but no more than one relining or rebasing during any period of 24 consecutive months.

 

major dental expenses

Major Dental Expenses are for the following services:

 

RESTORATIONS—Charges for inlays, Onlays, crowns, and gold fillings.

 

BRIDGES AND DENTURES—Charges for initial installation of dentures or fixed bridgework or crowns if the existing denture, bridgework or crown was installed at least five years prior to its replacement and cannot be made serviceable or cannot be repaired.  The replacement will not be covered if due to loss or theft.

 

Also, charges for replacement of existing dentures or fixed bridgework, or for the addition of teeth to existing dentures or fixed bridgework, if needed to replace at least one natural tooth extracted while the family member is covered under the Plan’s Dental Care Coverage.

 

expenses not covered

The following charges are not covered or are covered only to the extent stated.

 

CHARGES FOR WHICH THE INSURED IS NOT RESPONSIBLE – This Plan only considers reimbursement of charges that are the responsibility of the insured to pay.

Benefits will not be paid for charges the insured has no responsibility to pay.  This may occur as a result of recovery from a third party, from a dentist not billing (waiving) deductibles and co-insurance requirements of the Plan, etc.

The Plan may require proof of payment for deductibles and co-insurance portions of the bill.  Be sure to keep all cancelled checks or receipts of cash payments for at least one-year in the event the administrator requires verification.  Benefits may be reduced for any payment made by the Plan for which the insured was not financially responsible.

OCCUPATIONAL INJURY - Charges due to an on the job injury.  “On the job” means employment with any Employer or self-employment.

 

OCCUPATIONAL SICKNESS - Charges due to any sickness for which an insured person is entitled to benefits under a Worker’s Compensation Act or similar act.

 

GOVERNMENT SERVICES - Charges for dental service furnished by or paid for by any government or government agency would not have been required to pay for the services in the absence of insurance for dental care.

 

COSMETIC DENTISTRY - Charges in connection with dental services primarily for the purpose of improving appearance.  For example, the following are not covered:

 

·               alteration or extraction and replacement of SOUND TEETH.

 

·               any treatment of the teeth to remove or lessen discoloration except in connection with endodontic treatment;

 

·               replacement of congenitally missing teeth; and

 

·               all appliances and restorations for the purpose of splinting teeth, except A-splinting and provisional splinting in connection with periodontal treatment.

 

TREATMENT STARTED BEFORE COVERAGE BEGINS—Charges for the following are not covered:

 

·               dentures, if the impression for the dentures was taken before the date the family member’s Dental Care coverage began;

 

·               crowns, inlays, bridges or gold restorations if preparation of the teeth was begun before the date the family member’s Dental Care coverage began;

 

·               root canal therapy if pulp cap was opened before the date the family member’s Dental Care coverage began.

 

SERVICES BY A HOSPITAL—Charges for dental services furnished by a hospital.

 

EXPERIMENTAL PROCEDURES—Charges for procedures that do not have uniformed professional endorsement, or are experimental in nature.  Charges for any related services furnished in connection with Experimental Procedures are also not covered.

 

FRACTURES—Charges for treatment of fractures or dislocation of jaw.

 

LOSS OR THEFT—Charges due to loss or theft of an appliance or prosthesis.

 

IMPLANTS—Charges for tooth implants are not covered.

 

ATHLETIC MOUTH GUARDS—Charges for athletic mouth guards are not covered.

 

APPLIANCES—Charges for veneers are not covered except for those procedures that are not done solely for cosmetic purposes.

 

TEMPOROMANDIBULAR JOINT SYNDROME—Charges for, in connection with, treatment of temporomandibular joint syndrome.

 

ORTHODONTIA—Charges for orthodontic treatment and appliances.

 

OTHER COVERED EXPENSES—Charges for any dental services that are not Covered Expenses under any part of this Plan.

 

worker’s compensation insurance EffectS benefit

This Plan’s benefits are not in lieu of and do not affect any requirement for coverage by Workers’ Compensation Insurance.

 

When You Have A Claim

Record of expenses

You should save all bills and receipts for dental expenses.  The Plan Administrator needs them as proof of your claim.

 

filing a claim

You should obtain a claim form from your Employer.  These forms explain how you should file a claim.  A claim form needs to be filed for benefits to be received.

 

submission of a claim

When you have a claim you should promptly submit the completed form and any bills or receipts.  The Plan Administrator has the right to reject claims submitted more than 180 days after the loss.  A late claim might be accepted if it is not reasonably possible to submit the claim during the 180 days.

 

 

payment of claims

The Plan Administrator will pay benefits after it receives proof of your claim.  The Plan Administrator will pay all other benefits as you direct on the claim form.

 

Address of the Claims Administrator:

Ÿ         Pacific Health Alliance

1350 Old Bayshore Highway, Suite 560

Burlingame, CA  94010-1814

Tel: (650) 375-5800

Fax: (650)375-5820

 

note:

The Plan Administrator will decide any claims for benefits under the plan, including any questions of eligibility for such benefits.  In carrying out it’s duties, the Plan Administrator shall have the discretionary authority to interpret and construe plan provisions, resolve any ambiguities of factual matters and decide any claims by any family members regarding their rights under the plan.

 

Before paying benefits, the Plan Administrator may require the following:

 

1.              A dental chart showing work done before the treatment which claim is made.

 

2.              X-rays, lab or hospital reports.

 

3.              Cast molds or other evidence of dental condition or treatment.

 

4.              Post-treatment examination of the patient, as its expense, by a dentist it selects.

 

third party liability

The Sponsor will pay benefits for Covered Expenses incurred due to the injury of a family member when a timely claim is made, when the Sponsor does so:

 

1.              The Sponsor shall be entitled, to the extent of such payment, to all of the family member’s rights of recovery against any third party because of such injury and;

 

2.              The family member shall; (a) sign and deliver to the Plan Administrator all necessary papers and do whatever else is necessary to secure such rights; and (b) do nothing to prejudice such rights without the Plan Administrator’s written consent.

 

 

GENERAL INFORMATION

definitions

 

Active Work Requirement:  A requirement that you are actively at work on full time at the Employer’s place of business, or at any other place that the Employer’s business requires you to go.

 

Allowable Expenses:  The usual or prevailing charge for an item of care at least part of which is covered by this Plan.

 

Calendar Year:  A year starting January 1.

 

Contributory Coverage, Non-contributory Coverage:  Contributory Coverage for which the Employer has the right to require your contributions.  Non-contributory Coverage is coverage for which the Employer does not have the right to require your contributions.  The Schedule of Benefits shows whether coverage   is Contributory Coverage or Non-contributory Coverage.

 

Coinsurance:  An amount paid by FAMILY MEMBERS in excess of the Plan Deductible.

 

Coverage:  A part of the Booklet consisting of:

 

(1)           A benefit page labeled as a Coverage in its title.

 

(2)           Any page or pages that continue the same kind of benefits.

 

(3)           A Schedule of Benefits entry and other benefits pages or forms that by their terms apply to that kind of benefits.

 

Covered Person under a Coverage; An Employee who is covered for Employee benefits under that coverage; a Qualified Dependent for whom an Employee is covered for Dependents benefits, if any under the Coverage.

 

Dentist:  A person who is licensed to practice dentistry and is acting within the scope of his or her license.  A Dentist shall also mean a licensed physician performing dental service who is acting within the scope of his or her license and a Dental Hygienist and Denturist described below.

 

Dental Hygienist:  A person who is licensed to practice dental hygiene and is acting under the supervision and direction of a Dentist and within the scope of his or her license.

 

Denturist:  A person who is licensed to make dentures and is acting within the scope of his or her license.

 

Dependents Coverage:  Coverage on the person of a dependent.

 

Family Member:  You and or any of your Qualified Dependents covered under the Sponsors Plan.

 

Usual or Prevailing Charges:  The lesser of:

 

1.              The charge usually made by the provider for the services or supplies furnished.

 

2.              The charge most other providers in the same locality would make for those or comparable services or supplies, as determined by the Claims Administrator.

 

 

 

 

 

 

County of Monterey

Human Resources & Employment Services Division

Risk Management & Employee Benefits Publication

Rev. 3/00