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HUMANA SPECIALTY BENEFITS
T.11Free: I -S00-558-4444
1100 Employers Blvd
Green Bay, M 54344
771470
CITY OF SEBASTIAN
1225 MAIN STREET
SEBASTIAN FL 32958
Dear CITY OF SEBASTIAN:
Thank you for choosing Humana Specialty Benefits. We appreciate the opportunity to work with you and
to serve you and your employees — now and for years to come.
The enclosed documents outline your plan benefits and explain how the plan works. If you have more
than one type of coverage with us — such as medical, dental, and life — you may receive separate
documents for each plan. These documents replace any other plan materials we may have sent you
previously.
If you find discrepancies in these documents or if you have questions about your plan benefits, please call
us at 1-800-558-4444.
Current benefits information can always be found on our Website, HumanaDental.com. Employees
enrolled in these benefits can view or print their documents through the Website or call us to request a
copy by mail.
Sincerely,
Humana Specialty Benefits
GHC-24159 07/07
09/14/2016
Humana
1100 Employers Blvd
Green Bay, WI 54344
THIS IS A NON -PARTICIPATING GROUP DENTAL INSURANCE POLICY
Group Policy Number: 771470
Issued To Policyholder: CITY OF SEBASTIAN
Effective Date: 10/01/2016
This Policy is delivered in and governed by the laws of Florida
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a HUMANA INSURANCE COMPANY, GREEN BAY, WISCONSIN, (hereafter called the Insurer)
Z agrees, subject to all terms and provisions of the Policy, to pay benefits as described in the Employee's
o Certificate of Insurance, incorporated by reference herein with respect to each Covered Person under the
Policy.
The Policy is issued in consideration of the application of the Policyholder, a copy of which is attached
and made part of the Policy, and such Policyholder's payment of premiums as provided and insured under
the Policy.
The Policy and the insurance it provides become effective at 12:01 A.M. (Standard Time) of the effective
date stated above. The Policy and the insurance it provides terminates at 12:01 A.M. (Standard Time) of
the date of termination. The provisions stated above and on the following pages are part of the Policy.
IN WITNESS WHEREOF Humana Insurance Company has caused this Policy to be issued at the address
of the Policyholder, as of the policy effective date.
If You should have any questions arise regarding Your coverage, or if You need assistance resolving a
complaint, contact US at 1-800-2334013.
Bruce Broussard
President
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FL -70090 -HC L 1/14 1
TABLE OF CONTENTS
Benefits..................................................................................................................................................................
3
Increases or decreases in amounts...........................................................................................................................
3
Ddiinitions.............................................................................................................................................................
4
Subsidiariesor affiliates.........................................................................................................................................
5
Rcquircmcnts for insurance coveragc......................................................................................................................
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Terminationof insumnce........ .................................... ..... —......... ..........................................................................
8
General provisions.................................................................................................................................................
9
Premiums.............................................................................................................................................................
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FL -70090 -HC L 1/14 2
Benefits
The benefits applicable to the Employee's Group Insurance Plan are the benefits specified in the
Employer Group Application and approved by the Insurer, shown in the Certificate of Insurance,
incorporated by reference herein.
Increases or decreases in amounts of individual employee's
Insurance
The Policyholder may elect that increases or decreases as specified below will be effective on the first day
of the calendar month coinciding with or next following the increase or decrease, or on an immediate
basis. Such election may be made on the Employer Group Application at the time the Employer becomes
the Policyholder, or at such later date as may be agreed to in writing by the Insurer.
Individual employee's changes resulting in an increase in insurance under the
policy
1. Any Employee's change resulting in an increase in that Employee's amount of insurance under the
Policy will, subject to provision #2 or #3 below, become effective on the date of change. An increase
will apply to covered conditions occurring on or after the effective date of the increase. The Insurer
must be notified of the change no more than 31 days following the date of change. If the Insurer is not
notified within 31 days of the date of change, any additional or increased insurance will become
effective on the date the Insurer receives written notification and approves the change
2. If an Employee is NOT in Active Status on the date an increase in the amount of insurance is to
become effective, the effective date of the increase will be deferred until the date next following the
date the Employee returns to Active Status.
3. If a Retired Employee is Totally Disabled on the date an increase in the amount of insurance is to
become effective, the effective date will be deferred until the date the Retired Employee is no longer
Totallv Disabled.
Individual employee's changes resulting in a decrease in insurance under the
policy
Any change resulting in a decrease in any Members amount of insurance under the Police kill become
effective on the date the Insurer approves the change. However, no such decrease will act to prejudice any
existing claim incurred prior to the date of the change.
Selection
Amounts of insurance provided by the Policy are available only on a basis which precludes individual
selection.
FL -70090 -HC L 1/14
Definitions
The Insurer shall apply the terms and meanings shown below wherever used in the Policy to determine
the intent and administration of insurance benefits.
Covered dependent
Covered Dependent means a Dependent whose coverage under the Policy is in effect in accordance with
the "Requirements for Insurance Coverage" provisions of the Policy.
Employee
The person who is regularly employed and paid a salary or earnings and is in active status at the
Employer's place of business. If the Employer is a union, the employee must be in good standing and
eligible for insurance according to the union's rules of eligibility.
Employer
The policyholder of the Group Insurance Plan, or any subsidiary described in the Employer Group
Application.
Insurer
Insurer means the Insurance Company as stated on the Policy face page. The Insurer in its capacity as
claims administrator has authority to make claim determination as described in section 503 of ERISA
The Insurer shall make final decisions under the Policy or Group Plan with respect to determining
eligibility for coverage and paying claims for benefits, including appeals of denied claims. As claims
administrator, the Insurer shall have full and exclusive discretionary authority to:
1. Interpret the Policy or Group Plan provisions:
2. Make decisions regarding eligibility for coverage and benefits; and
3. Resolve factual questions relating to coverage and benefits.
This in no way negates any appeal rights the insured may have.
Member
The person(s) covered under the policy and in good standing as defined by the policyholder's
requirements and bylaws.
Policyholder
The legal entity named as the Policyholder on the Face Page of this Policy.
FL -70090 -HC L 1/14
Subsidiaries or affiliates
Any Employer which is a subsidiary or affiliate of the Policyholder is eligible under the Policyholder's
Group Insurance Plan provided under the Policy if the following conditions are met:
1. The subsidiary or affiliate has been approved for coverage under the Policy, in writing, by both the
Policyholder and the Insurer;
2. The legal relationship between the Policyholder and the subsidiary or affiliate is in conformity with
all applicable laws of the state in which the Policyholder is organized;
3. The subsidiary or affiliate is listed in the Employer Group Application of the Policyholder, or in any
amendment thereto.
An Employee of such a subsidiary or affiliate of the Policyholder shall be considered to be an Employee
of the Policyholder.
A subsidiary or affiliate of the Policyholder shall cease to be eligible in the Policyholder's Group
Insurance Plan provided under the Policy on the earliest of the following:
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1. The date the legal relationship between the Policyholder and the subsidiary or affiliate is no longer in
conformity with all applicable laws of the state in which the Policyholder is located;
S 2. The date the Policy terminates; or
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3. The date the Policyholder's written notice of its intent to terminate the participation of the subsidiary
or affiliate is received by the Insurer, or on any later date as may be stated in such notice.
The insurance of any Employee of a subsidiary or affiliate of the Policyholder, and the insurance of such
Employee's Covered Dependents, shall immediately terminate on the date the subsidiary or affiliate
ceases participation in the Policyholder's Group Insurance Plan.
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Requirements for insurance coverage
THE FOLLOWING PROVISIONS APPLY TO THE PLAN OF BENEFITS AS REQUESTED ON THE
EMPLOYER GROUP APPLICATION BY THE POLICYHOLDER.
Eligibility
The Policvholder must indicate eligible classes of Members under the Policy as defined below:
l . The Policyholder will indicate Employee classes which are eligible for insurance under the
Policyholder's Plan in the Employer Group Application. Regular active full-time Employees, if
employed by the Policyholder and paid a reasonable salary or wage, are in an eligible class. The
eligible class may also include actively employed proprietors, partners, corporate officers and
directors.
2. The Policyholder's Group Insurance Plan may provide coverage for active full-time or retired
Employees and/or Dependents of active, full-time or retired Employees. The Retiree Class will be
eligible only if the Policyholder has 51 or more eligible full-time Employees in an Active Status. No
part-time or temporarily employed person may be included in an eligible class, unless the
Policyholder's Employer Group Application makes specific reference that part-time or temporarily
employed persons are included and is approved by the Insurer.
3. No Dependent may be included in an eligible class unless the Dependent's parent or spouse is an
Employee covered under the Policy.
Date eligible
The Policyholder's Group Insurance Plan may provide one of the following as the Date Eligible for
Employees and Dependents as provided by the Policy. The Date Eligible must be elected by the
Policyholder in the Employer's Group Application.
Immediate date eligible
1. Each Employee included in an Eligible Class and who is in Active Status on the effective date of this
policy will be eligible under the Policy on that date, provided the Employee has completed any
required Waiting period indicated on the Employer Group Application, if applicable.
2. Each Employee included in an Eligible Class and who is in Active Status on the effective date of this
Policy. and who had partially satisfied the required Waiting Period prior to the Policyholders
effective date under the Policy, will be eligible for insurance under the Policy on the first day after
completion of the Waiting Period, if applicable.
Each Employee who enters an Eligible Class and who is in Active Status AFTER the date the
Employer becomes the Policyholder, will be eligible for coverage:
• On the day immediately folloxN ing completion of any required Waiting Period; or
• On the Employee's date of employment, if a Waiting Period is not required.
FL -70090 -HC L 1/14
Deferred date eligible
Each Employee included in an Eligible Class and who is in Active Status on the effective date of this
Policy will be eligible under the Policy on that date, provided the Employee has completed any
required Waiting Period indicated on the Employer Group Application.
2. Each Employee included in an Eligible Class and who is in Active Status on the effective date of this
Policy, and who had partially satisfied the required Waiting Period prior to the effective date of this
Policy, will be eligible under the Policy on the first day of the calendar month coinciding with or next
following the date of completion of the Waiting Period.
3, Each Employee who enters an Eligible Class AFTER the effective date of this Policy will be eligible
under the Policy on the first day of the calendar month coinciding with or next following:
• Completion of any required Waiting Period; or
• The Employee's date of employment, if a Waiting Period is not required.
Effective date
The Effective date provision for Employees of the Policyholder is stated in the Employer Group
a Application. It may be immediately following or the first of the month following completion of the
Waiting Period, if any, or if the Employee is a Late Applicant, the date approved by the Insurer; but in no
event will the Employee's Effective Date be prior to the date that Employee's enrollment forms are
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received by the Insurer. The Employee must enroll on forms furnished and accepted by the Insurer.
If an Employee is not in Active Status on the effective date shown on the Employee's Schedule of
Benefits, the Delayed Effective Date Provision applies.
1. Each Employee must request insurance coverage for him or herself and, if so desired, for eligible
Dependents.
2. If the request for insurance is submitted to and approved by the Insurer BEFORE the Employee
and/or Dependent's eligibility date, insurance will become effective on the Eligibility Date.
3. If the request for insurance is submitted to and approved by the Insurer AFTER the Eligibility Date,
but within thirty-one days after the Employee's and/or Dependent's Eligibility Date, insurance will
become effective on:
• The date the enrollment form is received by the Insurer, if the Insurer has agreed with the
Policyholder to make coverage effective on an Immediate Date Eligible basis; or
• The first day of the calendar month coinciding with or next following the date the Insurer
approves coverage, if the Insurer has agreed with the Policyholder to make coverage effective on
a Deferred Date Eligible basis.
4. If the request for insurance is submitted to the Insurer MORE THAN thirty-one days after the
Employee's or eligible Dependent's Eligibility Date, the Employee or Dependent is a Late Applicant.
The Effective Date of Insurance will be the date designated by the Insurer.
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Termination of insurance
Termination of the Member's insurance will occur on the first day of the calendar month following the
date the first of the following events occurs with respect to the Policyholder's Group Insurance Plan.
1. The Policyholder no longer satisfies the minimum Underwriting and Participation Requirements of
the Insurer, as specified on the Employer Group Application.
The Insurer reserves the right to waive or modify the Underwriting and Participation Requirements.
2. The Policyholder, acting with the knowledge and written consent of the Insurer, deletes an Optional
Benefit under the policy from the Policyholder's Group Insurance Plan. Termination will occur with
respect to such deleted Optional Benefit Coverage.
3, The Policyholder, acting with the knowledge and written consent of the Insurer, deletes an eligible
class of Covered Persons from the Policyholder's Group Insurance Plan. Termination will occur only
with respect to Covered Persons included in the terminated class.
4. The Policyholder fails to remit premium when due, except that coverage is continued during the
Grace Period applicable to the due but unpaid premium. The Policyholder will be required to pay
premium for the grace period.
5. The Policyholder may terminate this Policy by giving written notice to the Insurer at anytime.
6. The Policyholder may, with the consent of the Insurer, terminate participation under any provisions of
the Policy. Termination will occur on a date mutually agreeable to the Policyholder and the Insurer.
7. The Insurer may terminate this Policy by giving written notice to the Policyholder not later than forty-
five days prior to the termination date. Termination will not prejudice a claim incurred prior to the
termination date.
Upon termination of this Policy, it is the Policyholder's responsibility to notify all Employees insured
under this Policy of such termination. If a Policyholder requires contributions toward the payment of
insurance premiums from the Employees covered through the Employer, the Policyholder is obligated to
refund to the Employees the portion of the contribution, if any, which the Policyholder collected for any
period of time following the termination of the Policy.
FL -70090 -HC L 1/14
General provisions
Entire contract
The Policy, Employer Group Application of the Policyholder and any amendments or riders constitute the
entire contract between parties.
Absent of fraud, all statements made by the Policyholder or by any Covered Person will be deemed
representations and not warranties. No statement made by the Policyholder or by any Covered Person can
be contested unless it is in written form and signed by the Policyholder or Covered Person. A copy of the
form must then be given to the Policyholder or Covered Person or their beneficiary.
Certificates
The Insurer will issue to the Policyholder in electronic format, for delivery to each covered Employee, an
individual certificate setting forth a statement of the insurance protection to which the Employee is
entitled, to whom benefits are payable under the Policy
Information to be furnished
o The Policyholder will furnish the Insurer information required to enable the Insurer to administer the
provisions of the Policy and to determine the premiums to be charged. All of the Policyholder's records
which have a bearing on the insurance provided under the Policy will be available for inspection by the
Insurer when and as often as required.
Modification of policy
1. This Policy maybe modified at anytime by written agreement between the Insurer and the
Policyholder without consent of any Employee or Beneficiary.
2. This Policy may also be amended by the Insurer at anytime without the consent of the Policyholder.
The Policyholder will be notified of such amendment, in writing, at least forty-five days prior to its
effective date, or forty-five days prior to the effective date of an amendment resulting in a decrease in
benefits. Payment of premium beyond the effective date of the endorsement constitutes the
Policyholder's consent to amendment.
3. No modification will be valid unless approved by the President, Vice -President, Secretary, or other
authorized officer of the Insurer.
4. No agent has authority to modify the Policy or waive any of the Policy provisions, to extend time for
premium payment, or bind the Insurer by making any promise or representation.
Sequence of the policy
The Policy follows a letter -number sequence. It is not necessary that the Policy include all letters or
numbers in complete sequence to be correct.
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FL -70090 -HC L 1/14
Premiums
Premium rate change
The Policy premiums will be calculated as specified in the "Premium Computation" section below. The
Insurer reserves the right to change any premium rate when the:
1. Terms of the Policy are changed.-
2.
hanged;2. Policyholder changes the terms of this Policy with the written consent of the Insurer:. or
3. Insurer provides written notice to the Policyholder that rates are to be changed not later than forty-
five days prior to the change in premiums.
Premium computation
1. The first premium is due on this Policy's effective date. Subsequent premiums are due on the first
day of each calendar month thereafter. The required premium due on each premium due date is the
sum of the premiums for all covered Employees under this Policy. All premiums are payable to the
Insurer at the Insurers address.
2. If an individual's insurance coverage or policy benefits are modified other than on a premum due
date, the change in premium resulting from the modification will become effective as follows:
• Group with over 51 eligible employees:
— If the change is effective on or before the 15'h of the month, the change in premium will be
effective on the first of the month during which the change in coverage is effective;
— If the change is effective after the 15'h of the month, the change in premium will be effective
on the first of the month following the effective date of change in coverage.
3. If premiums are due for the Insurer or premium refunds are due for the Policyholder or Employee as a
result of clerical error in the reporting of data to the Insurer, all premiums or refunds will be
calculated at the current rate of premium payment, limited to a maximum period of six months.
The effective date of a change in premium will only vary from the above upon mutual written agreement
between the policyholder and us.
Grace period
A grace period of thirty-one days will be allowed to the Policyholder for the payment of each required
premium due after the first premium. The Policy will remain in force during the grace period. If the
required premium is not paid by the end of the 31 day grace period, the Policy will terminate. The
Policyholder will be required to pay premium for the grace period.
Unpaid premium
Any premium due and unpaid or covered by any note or written order may be deducted from the claim
payment of an eligible claim under the Policy.
FL -70090 -HC L 1/14 10
Discounted Premium Disclosure
From time to time, We may offer prospective or renewing Policyholders discounted premium for the
selection of multiple lines of coverage with Us.
Return of premium
1. The Insurer reserves the right to rescind coverage on one or all Employees due to misrepresentation
or fraud on an application form.
2. If on the date coverage is rescinded no dental claims have been paid under the Policy, the Insurer will
return to the Policyholder or Employee all premiums paid for such coverage.
3. If on the date coverage is rescinded dental claims have been paid under the Policy, the Insurer
reserves the right to deduct an amount equal to the amount of such dental claims paid from the
premiums returned to the Policyholder or Employee.
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Benefits Enclosed
GN-61201.HH
Policyholder: CITY OF SEBASTIAN
Group number: 771470
Dental Plan
Certificate of Insurance
Humana Insurance Company
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This certificate outlines the insurance provided by the group policy. It is not an insurance policy. It does
not extend or change the coverage listed in the group policy. The insurance described in this certificate is
subject to the provisions, terms, exclusions and conditions of the group policy.
We will amend this certificate to conform to the minimum requirements of Florida laws. This certificate
replaces any certificate previously issued under the provisions of the group policy.
This certificate contains a deductible and excess coverage provision.
Ifyou should have any questions arise regarding your coverage, or ifyou need assistance in resolving a
complaint, contact us at 1-800-233-4013.
Humana
Bruce Broussard
President
FL -70146 -HC L 1/14 1
Table of Contents
Claims
Howyour plan works ......... ................................................................. --- ... ....................................................... 3
Howwe pay claims............................................................................................................................................... 5
Coordinating benefits with another insurer.........................................................................................................8
Recoveryrights................................................................................................................................................... 11
Eligibility
When you are eligible for coverage.................................................................................................................... 13
Terminatingcoverage......................................................................................................................................... 18
Replacementprovisions...................................................................................................................................... 20
Disclosures
Discount/Access Disclosure................................................................................................................................ 21
SharedSavings Program..................................................................................................................................... 22
Definitions.......................................................................................................................................................... 23
(Italicized words within text are defined in the Definitions section of this document)
Benefits
Summaryof your benefits..................................................................................................................................28
Waitingperiods..................................................................................................................................................30
Yourplan benefits..............................................................................................................................................
32
Limitations and exclusions (all services)............................................................................................................
36
Supplemental dental expense benefit (Orthodontia)......................................................................................40
Openenrollment rider........................................................................................................................................42
Implantrider, ...................................................................................................................................................... 44
FL -70146 -HC L 1/14 2
Claims
How your plan works
General benefit payments
We pay benefits for covered expenses, as stated in the Summary of your benefits and Your plan
benefits sections, and according to any riders that are part of your policy. Paid benefits are subject to the
conditions, limitations, exclusions and maximums of this policy.
After you receive a service, we will determine if it qualifies as a covered ,service. If we determine it is a
covered service, we will pay benefits as follows:
1. We will determine the total covered expense.
2. We will review the covered expense against any maximum benefits that may apply.
r 3. We will determine if you have met your deductible. If you have not, we will subtract any amount
a required to fulfill the deductible.
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S 4. We will make payment for the remaining eligible covered expense to you or your dentist, based on
o your coinsurance for that covered service.
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Deductibles
The deductible is the amount that you are responsible to pay per year before we pay any coinsurance (see
Summary of your benefits).
1. Individual deductible: You will have met the individual deductible when, each year the total eligible
covered expenses incurred reaches the individual deductible amount.
2. Family deductible: The total deductible that a family must pay in a vear. Once met, we will waive
any remaining individual deductibles for that year.
Coinsurance
The percentage of the reimbursement limit that we will pay. Coinsurance applies after the deductible is
satisfied and up to the maximum benefit.
Waiting periods
This is the time period that certain services are not eligible for coverage under this policy. This begins on
your effective date and lasts for the time shown in the Waiting periods provision of this certificate.
Benefit maximums
The amount we pay for services are limited to a maximum benefit. We will not make benefit payments that
are more than the maximum benefit for the covered services shown in the Summary of your benefits.
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FL -70146 -HC L 1/14 3
Claims
Alternate services
If two or more services are acceptable to correct a dental condition, we will base the benefits payable on
the covered expenses for the least expensive covered service that produces a professionally satisfactory
result, as determined by its. We will pay up to the reimbursement limit for the least costly covered service
and subject to any deductible, coinsurance and maximum benefit. You will be responsible for paying the
excess amount.
If you or your dentist decide on a more costly treatment than we determine to be satisfactory for treatment
of the condition, payment will be limited to the reimbursement limit and will be subject to any deductible
and coinsurance for the least costly treatment. You will be responsible for the remaining expense
incurred.
Pretreatment plan
We suggest that if dental treatment is expected to exceed $300, you or your dentist submit a dental
treatment plan for us to review before your treatment. The dental treatment plan should consist of
1. A list of services to be performed using the American Dental Association nomenclature and codes.
2. Your dentist's written description of the proposed treatment;
3. Supporting pretreatment X-rays showing your dental needs;
4. Itemized cost of the proposed treatment; and
5. Any other appropriate diagnostic materials that we may request.
An estimate for services is not a guarantee of what we will pay. It tells you and your dentist in advance
about the benefits payable for the covered expenses in the ireatment plan. We will notify you and your
dentist of the benefits payable based on the submitted treatment plan.
An estimate for .services is not necessary for emergency care.
Process and timing
An estimate for services is valid for 90 days after the date we notify you and your dentist of the benefits
payable for the proposed treatment plan (subject to your eligibility of coverage). If treatment will not
begin for more than 90 days after the date we notify you and your dentist, we recommend that you submit
a new treatment plan.
FL -70146 -HC L 1/14
Claims
How we pay claims
Identification numbers
You received an identification (ID) card showing your name, identification number and group member.
Show this ID card to your dentist when you receive services.
Claim forms
We do not require a standard claim form to process benefits. When we receive a claim, we will notify you
or your dentist if any additional information is needed.
Submitting claim information and proof of loss
Either you or the dentist must complete and submit to us all claim information for proof of loss. We would
like to receive this information within 90 days after the expense incurred date; however, the claim will not
be reduced or denied if it was not reasonably possible to meet the 90 -day guideline. In any event, we will
need written proof of loss notice within one year after the date proof of loss is requested, except if you
were legally incapacitated.
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Here are examples of information we may need (this is not a comprehensive list and only provides a few
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examples of the information we may request).
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1. A complete dental chart showing:
• Extractions;
• Missing teeth;
• Fillings;
• Prosthesis;
• Periodontal pocket depths;
• Dates of previously performed work.
2. An itemized bill for all dental work.
3. The following exhibits:
• X-rays;
• Study models;
• Laboratory and/or reports;
• Patient records.
4. Authorizations to release any additional dental information or records.
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FL -70146 -HC L 1/14
Claims
5. Information abort other insurance coverage.
6. Any information we need to determine benefits.
If you do not provide us with the necessary information, we will deny any related claims until you provide
it to us.
Paying claims
Once we receive all the necessary information, we will determine if benefits are available, and if they are,
we will pay any amount due under this police within 45 days of receipt of the claim. If we cannot process
your claim due to lack of information, we will notify you, or whoever is claiming payment under the
policy if it is not you, of the information needed within 45 days of receipt of claim. Once we have
received the necessary information, we will process your claim within 60 days of receipt of information.
We may pay all or a portion of any benefit provided for covered expenses to the provider unless you or the
covered person has notified us in writing by the time the claim form is submitted.
Extension of benefits
Benefits are payable for root canals, crowns, inlays, onlays, veneers, fixed bridges, dentures and partials
that are:
1. Incurred while vo:ir coverage is in force (see definitions of expense incurred and expense incurred
date in the Definitions section); and
2. Completed within the first 90 days after your coverage terminates. These bene fits are subject to the
provisions and conditions of this policy.
You have up to 90 days after your termination date to submit claims for these extended Benefits.
Reasons for denying a claim
Below is a list of the most common reasons we cannot pay a claim. Claim payments may be limited or
denied in accordance with any of the provisions contained in this certificate.
1. Not a covered benefit: The service is not a covered service under the certificate.
2. Eligibility: You no longer are eligible under the Terminating coverage section of this certificate, or
the expense incurred date was prior to your effective date.
3. Fraud: You make an intentional misrepresentation by not telling us the facts or withhold information
necessary for us to administer this certificate.
Insurance fraud is a crime. Anyone who willingly and knowingly engages in an activity intended to
defraud us by filing a claim or form that contains false or deceptive information may be guilty of
insurance fraud.
If a member commits fraud against us, as determined by us, coverage ends automatically, without
notice, on the date the fraud is committed. This termination may be retroactive. We also will provide
information to the proper authorities and support any criminal charges that may be brought. Further,
we reserve the right to seek civil remedies available to us.
We will not end coverage if, after investigating the matter, we determine that the member provided
information in error. We will adjust premium or claim payment based on this new information.
FL -70146 -HC L 1/14
Claims
If you provided correct information and we made a processing error, you will be eligible for coverage
and claims payment for covered expenses. We will adjust your premium or claim payment based on
the correct information.
4. Duplicating provisions: If any charge is described as covered under two or more benefit provisions,
we will pay only under the provision allowing the greater benefit. This may require us to make a
recalculation based on both the amounts already paid and the amounts due to be paid. We have no
obligation to pay for benefits other than those this certificate provides.
How to Challenge Our Claim Decision (Appeal Rights)
If a covered person disagrees with our decision on payment of a particular claim, the covered person can
request a second review of the claim, also known as an appeal. To request this review, you must send us a
letter requesting a second claim review within 60 days from the time you received notice of our claim
payment decision. The covered person may also send any documents or information that are relevant to
our decision of how to pay the claim.
Once we receive the request, we will make a second review of the claim and provide notice of our
decision within 15 business days.
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Legal actions
o You cannot bring a legal action to recover a claim until 60 days after the date written proof of loss is
a made. No action may be brought after the expiration of the applicable statute of limitations after such
proof of loss is required to be given.
Claims paid incorrectly
If a claim was paid in error, we have the right to recover our payments. We may correct this error by an
adjustment to any amount applied to the deductible or maximum benefits. Errors may include such actions
as:
1. Claims paid for services that are not actually covered under the policy.
2. Claims payment that is more than the amount allowed under the policy.
3. Claims paid based on fraud or an intentional misrepresentation.
We may seek recovery of our payments made in error from anyone to, for or with respect to whom such
payments were made; or any insurance companies or organizations that provide other coverage for the
covered expenses. We will determine from whom we shall seek recovery. For information on our process,
see the Recovery rights provision.
FL -70146 -HC L 1/14
Claims
Coordinating benefits with another insurer
Benefits subject to this provision
Benefits described in this certificate are coordinated with benefits you receive from other plans. This
prevents duplication of coverage and resulting increases in the cost of dental coverage. For purposes of
this section, the following definitions apply:
1. Plan—A plan covers medical or dental expenses and provides benefits or services by:
• Group, franchise or blanket insurance coverage;
• Group -based hospital service pre -payment plan, medical service pre -payment plan, group
practice or other pre -payment coverage:
• Coverage under labor-management, employer plans, trustee plans, union welfare plans,
employee benefit organization plan; and
• Governmental programs or programs mandated by state statute, or sponsored or provided by
an educational institution, if it is not otherwise excluded from the calculation of benefits
under this policy.
This provision does not apply to any individual policies or blanket student accident insurance
provided by or through an educational institution.
2. Allowable expense—Any eligible expense, a portion of which is covered under one of the plans
covering the person for whom the claim is made. Each plan will determine what an eligible
expense is based on the provisions of the plan. When a plan provides benefits in the form of
services rather than cash payments, the reasonable cash value of each service rendered will be
both an allowable expense and a benefit paid. An expense or service that is not covered by any of
the plans is not an allowable expense.
3. Claim determination period—A year. If, in any year, a person is not covered under this policy
for the entire year, the claim determination period will be the portion of the year in which he or
she was covered under this policy.
Effect on benefits
One of the plans involved will pay benefits first. This is called the primary plan. Under the primary plan,
benefits will be paid without regard to the other plan(s).
All other plans are called secondary plans. The secondary plan may reduce the benefits so that the total
benefits paid or provided by all plans during a claim determination period are not more than 100 percent
of the total allowable expense.
Order of benefit determination
To pay claims, it must be determined which plan is primary and which plan(s) is/are secondary. A plan
will pay benefits first if it meets one of the following conditions:
FL -70146 -HC L 1/14
Claims
1. The plan that covers the person as an employee submitting the claim, except when that person is
also a Medicare beneficiary and Medicare is secondary to the plan covering the person as a
dependent of an active employee. In that case the Order of benefit determination is:
• The benefits of the plan covering the person as an employee, employee or subscriber is
primary;
• The benefits of the plan of an active employee covering the person as a dependent is
secondary; and then
• Medicare benefits.
2. For a child covered under both parents' plans, the plan covering the parent whose birthday
(month and day) occurs first in the calendar year pays before the plan covering the other parent. If
the birth dates of both parents are the same, the plan that has covered the parent for the longer
period of time will be the primary plan.
In the case of dependent children covered under the plans of divorced or separated parents, the
following rules apply:
• The plan of a parent who has custody will pkv benefits first.
• The plan of a stepparent who has custody will pay benefits next.
• The plan of a parent who does not have custody will pay benefits next.
• The plan of a stepparent who does not have custody will pay benefits next.
A court decree may give one parent financial responsibility for the medical or dental expenses of
the dependent children. In this case the rules stated above will not apply if they conflict with the
court decree. Instead, the plan of the parent with financial responsibility will pay benefits first.
4. If a person is laid off or retired, or is a dependent of someone who was laid off or retired, that
plan becomes the secondary plan to the plan of an active employee.
5. When the person is covered under a COBRA continuation plan (as provided under the
Consolidation Omnibus Budget Reconciliation Act of 1987) and is also covered under another
group plan, the benefits of the plan which covers the person as an employee or as the employee's
dependent will be determined before the benefits of a plan covering the person as a former
employee or as the former employee's dependent.
If rules 1-5 do not determine the primary plan, the plan covering the person for the longest time is the
primary plan. If it still cannot be determined which plan is the primary plan, we will waive the above rules
and incorporate the rules identical with those of the other plan.
Excess coverage
We will not pay benefits for any accidental injury if other insurance will provide payments or expense
coverage, regardless of whether the other coverage is described as primary, excess or contingent. If your
claim against another insurer is denied or partially paid, we will process your claim according to the terms
and conditions of this certificate. If we make a payment, you agree to assign to us any right you have
FL -70146 -HC L 1/14
Claims
against the other insurer for dental expenses we pay. Payments made by the other insurer will be credited
toward any applicable coinsurance or calendar year deductibles.
Coordinating benefits with Medicare
Coordinating benefits with Medicare will conform to federal statutes and regulations in all instances.
Ifyou are eligible for Medicare benefits, whether enrolled or not, your benefits under this plan will be
coordinated to the extent benefits are paid or would have been payable under Medicare as allowed by
federal statutes and regulations. Medicare means Title XVIII, Parts A and B, of the Social Security Act,
as enacted or amended.
Right of recovery
We reserve the right to recover benefit payments made for an allowable expense under this plan in the
amount that exceeds the maximum amount we are required to pay under these provisions. This applies to
us against:
1. Anyone for whom we made such paN merit.
2. Any insurance company or organization that, according to these provisions, owes benefits for the
same allowable expense under any other plan.
Right to necessary information
We may require certain information to apply and coordinate these provisions with other plans. We will,
without your consent, release to or obtain information from any insurance company, organization or
person to implement this provision. You agree to furnish any information we need to apply these
provisions.
FL -70146 -HC L 1/14 10
Claims
Recovery rights
Your obligation in the recovery process
We have the right to collect our payments made in error. You are obligated to cooperate and assist us and
our agents to protect our recovery rights by:
1. Obtaining our consent before releasing any party from liability for payment of dental expenses.
2. Providing us with a copy of any legal notices arising from your injury and its treatment.
3. Assisting our enforcement of recovery rights and doing nothing to prejudice our recovery rights.
4. Refraining from designating all (or any disproportionate part) of any recovery as exclusively for "pain
and suffering."
If you fail to cooperate, we will collect from you any payments we made.
m
Right of subrogation
You agree to transfer any rights to us that you have to recover any expenses paid under this policy. We
will be subrogated to these recovery rights from any funds paid or payable.
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We may enforce our subrogation rights by asserting a claim to any coverage to which you may be entitled.
« If we are precluded from exercising our subrogation rights, we may exercise our right of reimbursement.
Right of reimbursement
If we pay benefits and you later recover payment from the liable party, we have the right to recover from
you the amount we paid. You must notify us in writing within 31 days of any settlement, compromise or
judgment. If you waive or impair our right to reimbursement, we will suspend payment of past or future
services until all outstanding lien(s) are resolved.
If you recover payments from and release any legally responsible party from future expenses relating to a
sickness or bodily injury, we have a continuing right to seek reimbursement from you. This right,
however, will apply only to the extent allowed by law. This reimbursement obligation exists regardless of
whether a settlement, compromise or judgment designates that the recovery includes or excludes dental
expenses.
E= Assignment of recovery rights
If your claim against the other insurer is denied or partially paid, we will process the claim according to
the terms and conditions of this policy. If we make payment on your behalf you agree that any right for
expenses you have against the other insurer for expenses we pay will be assigned to us.
If benefits are paid under this policy and you recover under any automobile, homeowners, premises or
similar coverage, we have the right to recover from you an amount equal to the amount we paid.
Limitations to recovery rights
_ Any such Right of Subrogation or Reimbursement provided to us under this policy shall not apply or shall
be limited to the extent that the Florida Statutes or the Courts of Florida eliminate or restrict such rights.
O FL -70146 -HC L 1/14 11
Claims
Worker's Compensation
If we pay benefits but determine that the benefits were for the treatment of bodily injury or sickness that
arose from or was sustained in the course of any occupation or employment for compensation, profit or
gain, we have the right to recover that payment. We will exercise our right to recover against you.
The recovery rights will be applied even though:
I. The Workers' Compensation benefits are in dispute or are made by means of settlement or
compromise.-
2.
ompromise:2. No final determination is made that bodily injury or sickness was sustained in the course of, or
resulted from, your employment;
3. The amount of Workers' Compensation due to medical or health care is not agreed upon or defined by
you or the Workers' Compensation carrier; or
4. Medical or health care benefits are specifically excluded from the Workers' Compensation settlement
or compromise.
You agree that, in consideration for the coverage provided by the policy, we will be notified of any
Workers' Compensation claim that you make, and you agree to reimburse us as described above.
FL -70146 -HC L 1/14 12
Eligibility
Definitions
The following terms are used in this section:
Late applicant: If you enroll or are enrolled more than 31 days after your eligibility date or .special
enrollment date, you will be considered a late applicant and your henefits will only cover Preventive
services for the first 12 months of coverage.
Special enrollment date means:
• The date of change in family status after the initial eligibility date as follows:
- Date of marriage;
- Date of divorce;
- Date specified in a Qualified Medical Child Support Order (QMCSO);
- Date specified in a National Medical Support Notice (NMSN);
- Date of birth of a natural born child; or
- Date of adoption of a child or date of placement of a child with the employee for the purpose of
adoption; or
• The date of termination of coverage under a group dental plan or other dental insurance coverage, as
specified under the "Special Enrollment" provision.
Eligibility date
Employee eligibility date
The employee is eligible for coverage on the date:
• The eligibility requirements stated in the Employer Group Application, or as otherwise agreed to by
us and the policyholder, are satisfied; and
• The employee is in an active status.
Dependent eligibility date
Each dependent is eligible for coverage on:
The date the employee is eligible for coverage, if he or she has dependents who may be covered on
that date;
• The date of the employee's marriage for any dependents (spouse or child) acquired on that date;
FL -70146 -HC L 1/14
13
Eligibility
• The date of birth of the employee's natural-born child;
• The date of placement of the child for the purpose of adoption by the employee;
• The date a foster child is placed in the employee's home;
• The date any child for whom the employee is the legal guardian, who is dependent on the employee
for health care coverage pursuant to a valid court order, or who lives with the employee in a normal
parent-child relationship and qualifies for the dependent exemption as defined in the Internal Revenue
Code and Federal Tax Regulations. We have the right to request proof of the child's dependency
status at any time; or
• The date specified in a Qualified Medical Child Support Order (QMCSO) or National Medical
Support Notice (NMSN) for a child, or a valid court or administrative order for a spouse, which
requires the employee to provide coverage for a child or spouse as specified in such orders.
The employee may cover his or her dependents only if the employee is also covered.
A dependent child who enrolls for other group coverage through any employment is no longer eligible for
group coverage under the policy. If a dependent child becomes an employee of the employer, he or she is
no longer eligible as a dependent and must make application as an eligible employee.
Employee enrollment
The employee must enroll as agreed by the policyholder and us. Depending on the total number of
employees covered by the employer's policy, we may require any employee to provide evidence of health
status whenever enrolling as permitted by laws, rules, or regulations.
If the employee enrolls more than 31 days after the employee's eligibility date or more than 31 days after
the employee's special enrollment date, the employee is a late applicant.
Dependent enrollment
Check with the employer immediately on how to enroll for dependent coverage. The employee must
enroll for dependent coverage and enroll additional dependents as agreed by the policyholder and us.
Depending on the total number of employees covered by the employer's policy, we may require any
dependent to provide evidence of health status whenever enrolling as permitted by laws, rules, or
regulations.
A dependent enrolled more than 31 days after the dependent's eligibility date or the special enrollment
date will be a late applicant.
Newborn dependent enrollment
An employee who already has dependent child coverage in force phor to the newborn's date of birth is not
required to complete an enrollment form for the newborn child. However, the employee must notify us of
the birth.
FL -70146 -HC L 1/14 14
Eligibility
An employee who does not have dependent child coverage must enroll the newborn dependent, as agreed
by the policyholder and us, within 31 days after the date of birth.
Newborn dependent effective date
• If we receive enrollment on, prior to, or within 2 years of the newborn's date of birth, dependent
coverage is effective on the first of the month following receipt of the enrollment.
• If we receive enrollment between 2 years and 2 years and 31 days after the newborn's date of birth,
dependent coverage is effective on the child's second birth date.
• If we receive enrollment more than 2 years and 31 days after the newborn's date of birth, the newborn
is considered a late applicant.
Foster Child effective date
Coverage for a foster child or a child otherwise placed in the employee or covered spouse's custody by a
court order, prior to the child's eighteenth birthday, will be provided from the date of placement if, on the
date of placement, the employee had dependent coverage. No coverage will be provided under this
provision for the child who is not ultimately placed in the employee's home. For a child in the employee's
custody, coverage will terminate the date the employee no longer has legal custody.
Special Enrollment
Loss of other coverage
If you are an employee or dependent who was previously eligible for coverage under the policy and had
waived coverage, you may be eligible for special enrollment under the policy.
You will not be considered a late applicant, if the following applies:
• You declined enrollment under the policy at the time of initial enrollment because:
You were covered under a group dental plan at the time of eligibility and your coverage
terminated as a result of:
— Termination of employment or eligibility;
— Reduction in number of hours of employment;
— Divorce, legal separation or death of a spouse; or
— Termination of your employer's contribution for the coverage; or
You had COBRA continuation coverage under another plan at the time of eligibility and such
coverage has since been exhausted; and
— You stated, at the time of initial enrollment, that coverage under the group dental plan, or
COBRA continuation was your reason for declining enrollment; and
FL -70146 -HC L 1/14
15
Eligibility
— You were covered under an alternate plan provided by the employer and you are replacing
coverage with the policy;
• You apply for coverage within 31 days after termination of coverage under the group dental plan or
COBRA.
Dependent special enrollment period
The dependent Special Enrollment Period is a 31 -day period from the special enrollment date.
If dependent coverage is available under the employer's policy or added to the policy, an employee who is
a covered person can enroll eligible dependents during the Special Enrollment Period. An employee, w•hc
is otherwise eligible for coverage and had waived coverage under the policy when eligible, can enroll
himself/herself and eligible dependents during the Special Enrollment Period. The employee or
dependent enrolling within 31 days from the special enrollment date will not be considered a late
applicant.
Effective date
Employee effective date
The employee's effective date provision is stated in the Employer Group Application. It may be the date
immediately following, or the first of the month following, completion of the waiting period or the
special enrollment date.
If the employee enrolls more than 31 days after his or her eligibility date or special enrollment date, he or
she is a late applicant. The effective date of coverage will be the first of the month following the receipt
of the enrollment form.
Employee delayed effective date
If the employee is not in active status on the eligibility date, coverage will be effective the day after the
employee returns to active status. The employer must notify us in writing of the employee's return to
active Stands.
Dependent effective date
The dependent's effective date will be determined as follows:
• If we receive enrollment on, prior to, or within 31 days of the dependent's eligibility date that
dependent is covered on the date he or she is eligible.
• If we receive enrollment on, prior to, or within 31 days of the dependent's special enrollment date,
that dependent's coverage is effective on the special enrollment date.
• If we receive enrollment more than 31 days after the dependent's eligibility date, or the special
enrollment date, that dependent is considered a late applicant. The of jective date of coverage will be
the first of the month following the receipt of the enrollment form.
However, no dependent's effective date will be prior to the employee's effective date of coverage.
FL -70146 -HC L 1/14 16
Eligibility
Benefit changes
Benefit changes will become effective on the date specified by us.
Incontestability: After you have been insured for two years, we cannot contest the validity of coverage
except for nonpayment of premium. Absent of fraud, all statements made by you will be deemed
representations and not warranties. Statements you make cannot be contested unless they are in writing
with your signature. A copy of the form must then be given to you.
Retired employee coverage
Retired employee eligibility date
Retired employees are an eligible class of employees if requested on the Employer Group Application and
if approved by us. An employee who retires while insured under this policy is considered eligible for
retired employee dental coverage on the date of retirement if the eligibility requirements stated in the
Employer Group Application are satisfied.
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Notification of the employee's retirement must be submitted to us by the employer within 31 days of the
date of retirement. If we receive the notification more than 31 days after the date of retirement, you will
be considered a late applicant.
Retired employee effective date
The effective date of coverage for an eligible retired employee is the date of retirement for an employee
who retires after the date we approve the employer's request for a retiree classification, provided we
receive notice of the retirement within 31 days. If we receive notice more than 31 days after retirement,
the effective date of coverage will be the date we specify.
Retired employee benefit changes
Additional or increased insurance or a decrease in insurance will become effective on the approved date
of change.
FL -70146 -HC L 1/14
17
Eligibility
Terminating coverage
Your insurance coverage may end at any time, as stated below and in the Employer Group Application.
Coverage terminates on the earliest of the following events:
1. Termination date listed in the policy;
2. Failure to pay premium by the required due date;
3. The date the employer stops participating in the policy;
4. The date you enter the military fulltime;
5. The dateyou no longer are eligible for coverage as outlined in the Employer Group Application:
6. The date You terminate employment with the employer;
7. For a dependent, the date the employee's insurance terminates;
8. For a dependent, the end of the month he/she no longer meets the definition of a dependent;
9. The date an employee requests that insurance be terminated for the employee and/or dependents;
10. An employee's retirement date unless the Employer Group Application provides coverage for
retirees; or
11. For any benefit that may be deleted from the policy, the date it is deleted.
Special provisions for active status
If the employer continues coverage under this policy, your coverage remains in force for no longer than:
1. Three consecutive months if the employee is temporarily laid off, in part-time status or on approved
non-medical leave of absence; or
2. Six consecutive months if the employee is totally disabled.
If this coverage terminates and the employee returns to an active status, the employee will be considered a
new employee and must re -enroll for insurance coverage.
Continuation of coverage during military leave
An employee called to active duty or state active duty is eligible for continuation if they are:
1. A member of the Florida National Guard; or
2. A Florida resident and a member of any branch of the United States military reserves.
Any employee's dependents who have coverage under this plan immediately prior to the date of the
employee's covered absence are also eligible to elect continuation.
You or an appropriate military authority, must notify your employer of your intent to continue coverage
under this section. Notification must occur prior to reporting to active duty or state active duty, unless
such notice is precluded by military necessity or if such notice is impossible or unreasonable.
FL -70146 -HC L 1/14 18
Eligibility
Coverage available under any insurance sponsored by the Department of Defense will be coordinated
with benefits available under this plan, as allowed by the Department of Defense.
Premium payment
If continuation coverage is elected under this section, coverage will have the same premium in effect as
for other members under this same plan, unless the employee requests coverage changes that might alter
the premium in effect prior to such activation.
Reinstatement
We will reinstate coverage for the members who elected not to continue coverage under this plan while on
active duty or state active duty:
1. After receipt of that person's request for reinstatement upon return from active duty or state active
duty; and
2. If reinstatement is requested within 30 days after returning to work with the same employer.
Upon reinstatement of coverage, no additional waiting period will be applied for any condition that
N existed at the time the member was called to active duty or state active duty
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Other information
o Employees should contact their employer with any questions regarding coverage normally available
N during a military leave of absence or continuation coverage and notify the employer of any changes in
marital status, or a change of address.
EL -70146 -HC L 1/14
19
Eligibility
Replacement provisions
Applicability: This provision applies only if.
1. You are eligible for dental coverage on your employer's effective date under this policy; and
2. You were covered on the final day of coverage on your employer's previous group dental plan (Prior
Plan).
Delayed effective date: We will waive the Delayed Effective Date provision if it applies to you when
you would othern ise be eligible for dental coverage on your employer's effective date under this policy.
Dental coverage is provided to you until the earlier of the following dates:
1. 90 days after your employers effective date under this plan.
2. The date your dental coverage would otherwise terminate according to the Terminating coverage
section in the certificate.
If you satisfy the Delayed Effective Date provision before either of these dates, your dental coverage will
continue uninterrupted.
Deductible amount: Any expense incurred while you were covered under the Prior Plan maybe used to
satisfy your deductible amount under this dental plan. These expenses must qualify as covered expenses
that would have been applied to the deductible amount for the calendar year that this dental plan becomes
effective.
Prior plan extension of benefits: Any benefits that you are entitled to receive during an extension period
under your Prior Platt arc not considered payable benefits under this plan.
Teeth extracted prior to effective date: We will not pay for a prosthetic device to replace any teeth lost
before you became insured under this plan unless the device also replaces one or more natural teeth lost or
extracted after you became insured under this plan.
Modification of policy
This plan may be modified at any time by agreement between us and the policyholder without the consent
of any member. Modifications will not be valid unless approved by our president, vice president,
secretary or other authorized officer. The approval must be endorsed on, or attached to, the policy. No
agent has the authority to modify the policy, waive any of the policy provisions, extend the time for
premium payment, make or alter any contract, or waive any of the 6mpanv's other rights or
responsibilities.
FL -70146 -HC L 1/14 20
Disclosures
Discount/access disclosure
From time to time, we may offer or provide you with access to discount programs. In addition, we may
arrange for third -party service providers such as optometrists, dentists and laboratories to provide you
with discounts on goods and services. Some of these third -party service providers may make payments to
us when these discount programs are used. These payments offset the cost to its of making these programs
available and may help reduce the costs ofyour plan administration.
Who has responsibility for these discounts?
Although we have arranged for third parties to offer discounts on these goods and services, these discount
programs are not insured benefits under this certificate. The third -party providers are solely responsible
for providing the goods and/ or services. We are not responsible for any goods and/ or services nor are we
liable if vendors refuse to honor such discounts. Further, we are not liable for the negligent provision of
such goods and/ or services by third -party service providers.
t Discount programs may not be available to people who 'opt out' of marketing communications, or where
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FL -70146 -HC L 1/14 21
Disclosures
Shared Savings Program
We have a Shared Savings Program that provides you with savings when we obtain discounts from
dentists. When we are able to obtain these discounts, your deductible and coinsurance will be calculated
at the discounted amount.
You do not need to inquire in advance about a dentist's status. When processing your claim, we
automatically will determine if the dentist was participating in the program at the time treatment was
provided, and we will calculate your deductible and coinsurance on the discounted amount. Your
Explanation of Benefits statement will reflect any savings received.
However, you may inquire in advance to determine if a dentist participates in the Shared Savings Program
by calling 1-800-2334013. Dentist arrangements in the Shared Savings Program change constantly. We
cannot guarantee that a dentist who is in the Shared Savings Program at the time of your inquiry will still
be in the program at the time treatment is received. Discounts depend on availability on a claim by claim
basis. Therefore, availability and discount amounts cannot be guaranteed.
We make no representations about the dentists participating in the Shared Savings Program. Additionally,
we reserve the right to modify, amend or discontinue the Shared Savings Program at any time.
FL -70146 -HC L 1/14 22
Definitions
Accidental injury: Damage to the mouth, teeth and supporting tissue due directly to an accident. It does
not include damage to the teeth, appliances or prosthetic devices that results from chewing or biting food
or other substances.
Active status: The employee performs all of his or her duties on a regular full-time basis for the required
number of hours per week shown on the employer's group application for 48 weeks per year. Active
status applies to employees whether they perform their duties at the employer's business establishment or
at another location when required to travel for job purposes; on each regular paid vacation day; and any
regular non -working holiday if the employee is not totally disabled on his or her effective date of
coverage. An employee is considered in active status if he or she was in active status on his or her last
regular working day.
Benefit: The amount payable in accordance with the provisions of this plan.
Bodily injury: An injury due directly to an accident.
Clinical review: The determination of benefit eligibility based on the review of clinical documentation by
a licensed dentist.
Coinsurance: The percent of covered expense that is payable as benefits after the deductible is satisfied
up to the maximum benefit. The applicable coinsurance percentage rate is shown in the Summary of
your benefits.
Cosmetic: Services provided by a dentist primarily for the purpose of improving appearance.
Covered expense: The reimbursement limit for a covered service.
Covered person: the employee and/or dependent who is covered under the Policy.
Covered service: A dental service that is:
I. Ordered by a dentist;
2. For the benefits described, subject to any maximum benefit, as well as all other terms, provisions,
limitations and exclusions of the policy; and
3. Incurred when a member is insured for that benefit under the policy on the expense incurred date.
Deductible: The amount of covered expenses you must incur and pay before we pay benefits.
Dental emergency means a sudden, serious dental condition caused by an accident or dental disease that,
if not treated immediately, would result in serious harm to the dental health of the covered person.
Dentist: An individual who is duly licensed to practice dentistry or perform oral surgery and is acting
within the lawful scope of his or her license.
Dependent: A covered employee's:
1. Lawful spouse; and
FL -70146 -HC L 1/14 23
Definitions
2. Natural blood related child, stepchild, foster child or legally adopted child whose age is less than the
limiting age. Each child must qualify as a dependent as defined by the U.S. Internal Revenue Code.
This child must receive at least 50 percent support and maintenance from the covered employee; or
Covered dependent's newborn child. Coverage for such child terminates 18 months after the date of
birth or the date as determined by the Terminating coverage provision, whichever is earlier.
The limiting age for each dependent child is:
1. 30 years; or
2. 30 years if such child is dependent upon the employee for support and:
• Living in the household of the employee; or
• In regular full -tune or part-time attendance at an accredited secondary school, college or
university. A dependent continues to be eligible for coverage for up to four months after the close
of a school term only if enrolled as a full-time or part-time student for the next school term.
A covered dependent child who becomes an employee eligible for other group coverage no longer is
eligible for coverage under this policy.
A covered dependent child who reaches the limiting age while insured under this policy remains eligible
for dental expense benefits if:
1. Mental Iv or physically disabled;
2. Incapable of self-sustaining employment;
3. Dependent on the covered employee for at least 50 percent of support and maintenance.
If a claim is denied, you must furnish satisfactory proof to us that the above conditions continuously
existed on and after the date the limiting age was reached. We may not request proof more often than
annually after two years from the date the first proof was furnished. If we do not receive satisfactory
proof, the child's coverage ends on the date proof is due.
Emergency: A sudden, serious dental condition caused by an accident or dental disease that, if not
treated immediately, would result in serious harm to the dental health of the member. Coverage for an
emergency is limited to palliative care only.
Employee: The person who is regularly employed and paid a salary or earnings and is in active status at
the employer's place of business. If the employer is a union, the employee must be in good standing and
eligible for insurance according to the union's rules of eligibility.
Employer: The policyholder of the Group Insurance Plan, or any subsidiary described in the Employer
Group Application.
Expense incurred: The amount you are charged for a service.
Expense incurred date: The date on which:
1. The teeth are prepared for fixed bridges, crowns, inlays or onlays;
2. The final impression is made for dentures or partials;
3. The pulp chamber of a tooth is opened for root canal therapy,
4. Periodontal surgery is performed;
5. The service is performed for services not listed above.
FL -70146 -HC L 1/14 24
Definitions
Family member: Anyone related to you by blood, marriage or adoption.
Health care practitioner: Someone who is professionally licensed by the appropriate state agency to
diagnose or treat a bodily injury or sickness, and who provides services within the scope of that license. A
health care practitioner's services are not covered if he/she lives in your home or is a family member.
Late applicant: An employee or an employee's eligible dependent who enrolls or is enrolled for dental
coverage more than 31 days after his/her eligibility date.
Maximum benefit: The maximum amount that may be payable for each member for covered services.
The applicable maximum benefit is shown in the Summary of your benefits. No further benefits are
payable after the maximum benefit is reached.
Maximum family deductible: The total deductible applied to one family in a year, as defined on the
Summary of your benefits.
Medical necessity/medically necessary: The extent of services required to diagnose or treat a bodily
injury or.sickness that is known to be safe and effective by most health care practitioners who are
licensed to diagnose or treat that bodily injury or sickness. Such services must be:
I. The least costly setting procedure required by your condition;
2. Not provided primarily for the convenience of you or the health care practitioner;
3. Consistent with your symptoms or diagnosis of the sickness or bodily injury under treatment;
4. Furnished for an appropriate duration and frequency in accordance with accepted medical practices,
and appropriate for your symptoms, diagnosis, or sickness or bodily injury; and
5. Substantiated by the records and documentation maintained by the provider of service.
Palliative: Treatment used in an emergency to relieve, ease or alleviate the acute severity of dental pain,
swelling or bleeding. Palliative treatment usually is performed for, but not limited to, the following acute
conditions:
1. Toothache;
2. Localized infection;
3. Muscular pain; or
4. Sensitivity and irritations of the soft tissue.
Services are not considered palliative when used in association with any other covered services except X-
rays and/or exams.
Policy: The group policy issued to the policyholder.
Policyholder: The legal entity named on the face page of the policy.
Reimbursement limit is the maximum fee for a covered service. It is the lesser of:
1. The fee most often charged in the geographical area where the service was performed;
2. The fee most often charged by the provider;
3. The fee that is recognized as reasonable by a prudent person;
4. The fee determined by comparing usual and customary charges for similar services to a national
database adjusted to the geographical area where the services or procedures were performed;
FL -70146 -HC L 1/14
25
Definitions
5. At our choice the fee determined by using a national Relative Value Scale. Relative Value Scale
means a methodology that values procedures and services relative to each other that includes, but is
not limited to, a scale in terms of difficulty, work, risk, as well as the material and outside costs of
providing the service, as adjusted to the geographic area where the services or procedures were
performed;
6. In the case of services rendered by providers with whom we have agreements, the fee or maximum
allowable charge that we have negotiated with that provider;
7. The fee or maximum allowable charge that we negotiated with one or more participating providers in
the geographic area for the same or similar services;
8. The fee based on the provider's costs for providing the same or similar services as reported by the
provider in the most recent, publicly available Medicare cost report submitted annually to the Centers
for Medicare and Medicaid Services; or
9. The fee based on a percentage of the fee Medicare allows for the same or similar services provided in
the same geographic area.
Charges billed by a provider that exceed the reimbursement limit will not apply to the member's
deductible or coinsurance.
Services: Dental procedures, surgeries, exams, consultations, advice, diagnosis, referrals, treatment, tests,
supplies, drugs, devices or technologies.
Sickness: A disturbance in function or structure of your body causing physical signs or symptoms that, if
left untreated, will result in deterioration of your health.
Total disability/totally disabled. An employee or employed covered spouse who, during the first 12
months of a disability, is prevented by bodily injury or sickness from performing all aspects of his or her
respective job or occupation. After 12 months, total disability/totally disabled means the person is
prevented by bodily injury or sickness from engaging in any paid job or occupation that he/she is
reasonably qualified for by education, training or experience.
For any member who is not employed, total disability means a disability preventing him/her from
performing the usual and customary activities of someone in good health of the same age and gender.
A totally disabled individual may not engage in any paid job or occupation.
Treatment plan: A written report on a form satisfactory to us and completed by the dentist that includes:
1. A list of the services to be performed, using the American Dental Association nomenclature and
codes;
2. Your dentist's written description of the proposed treatment;
3. Supporting pretreatment x-rays showing your dental needs;
4. Itemized cost of the proposed treatment: and
5. Any other appropriate diagnostic materials as requested by us.
We, us and our: Humana Insurance Company.
Year means the period of time which begins on any January I st and ends on the following December
31st. When you first become covered by the policy, the first year begins for you on the effective date of
Your insurance and ends on the following December 31st.
You and your: Any covered person.
FL -70146 -HC L 1/14 26
Humana
Humana.com
Toll Free 800-2334013
1100 Employers Blvd
Green Bay WI 54344
Insured by Humana Insurance Company
In Kentucky, insured by The Dental Concern, Inc.
FL -70146 -HC L 1/14
27
Benefits
Policyholder: CITY OF SEBASTIAN
Group Number: 771470
Coverage Effective Date: 10/01/2016
Summary of Your Benefits
This summary provides an overview of plan benefits. Refer to the Your plan benefits and Waiting
periods provisions for detailed descriptions, including additional limitations or exclusions. Paid benefits
are based on the reimbursement limit.
Dental benefits
Individual maximum benefit:
$1,000 per near per covered person for Preventive, Basic, and Major Services.
Individual extended maximum benefit: When a covered person has reached his or her Individual
Maximum Benefit covered expenses for Preventive. Basic and Major services will be paid at 30% for the
remainder of that vear. Coverage of these services will be subject to all provisions of this Certificate,
including but not limited to, the eligibility of the covered person, the reimbursement limit, and all
limitations and exclusions. The Individual Extended Maximum Benefit does not apply to, and no
additional benefits are available for Orthodontic services.
Individual deductible:
$50 per year per covered person for Basic and Major Services.
Maximum family deductible:
Covered expenses applied to the plan deductible of each covered person are combined to a year maximum
of $150.
Orthodontic lifetime maximum benefit:
$1,000 per each covered dependent child age 18 and under.
Preventive Services:
Benefits are paid at 100%.
• Routine teeth cleaning (prophylaxis)
• Topical fluoride treatment
• Sealants
• X-rays
• Oral examinations
• Space maintainers
FL -70146 -HC SCI L 1/14 28 TRP
Benefits
Basic Services:
Benefits are paid at 80% after the deductible.
• Fillings (amalgam and composite restorations)
• Non-surgical extractions
• Non-surgical residual root removal
• Oral Surgery
• Non -cast prefabricated crowns
• Emergency exam and palliative care for pain relief
• Harmful habits and thumb -sucking appliances
Major Services:
Benefits are paid at 50% after the deductible.
• Crowns
• Inlays and onlays
• Removable or fixed bridgework
r • Partial or complete dentures
r
a • Denture relines or rebases
• Partial and denture repairs and adjustments
o
Periodontics (gum disease)
• Endodontics (root canals)
N
k
Orthodontic Services:
Benefits are paid at 50%.
Please refer to the Orthodontic Services Rider of your certificate to determine who is eligible for coverage
under this benefit.
C
C
C
FL -70146 -HC SCI L 1/14 29
Benefits
Waiting periods:
This provision describes to the employer the waiting period criteria that will apply to members before
benefits are available for covered services. Dependents added after the effective date of the employee
may be subject to a separate waiting period. Please call us for the waiting period that applies to those
dependents.
Any member who is a late applicant, is subject to a 12 -month waiting period before he or she is eligible
for coverage for any service except Preventive .services.
If a member enrolls timely, Major and Orthodontic services MAY be subject to a 12 -month waiting
period before they are eligible for coverage. This 12 -month waiting period can be decreased by the
amount of time the member had prior dental coverage immediately before his or her coverage with us.
If a member has continuous dental coverage without a break of more than 63 days between the
termination of creditable coverage and his or her enrollment date under the policy, any period of time that
was satisfied under the prior plan will be applied to the appropriate waiting periods under the policy, if
any. The employee will then be eligible for benefits under the policy when the balance of the waiting
period has been satisfied, whether the member is timely or a late applicant.
Please see your Summary of Benefits for waiting period provisions that are specific to you.
Preventive Services:
No waiting periods apply to Preventive services.
Basic Services:
No waiting periods apply to Basic services, unless the member is a late applicant.
If a member is a late applicant, he or she must be insured under this policy for a period of 12 continuous
months before Basic services will be covered.
Major Services:
For Major Services, coverage is effective as follows:
Groups with fewer than 10 dental lives with no prior dental coverage, coverage is effective 12 months
after the effective date of coverage.
Groups with fewer than 10 dental lives with prior dental coverage, coverage is effective on the effective
date of coverage.
Groups with more than 10 dental lives with or without prior dental coverage, coverage is effective on the
effective date of coverage.
For a late applicant added after the group's effective date under this policy, he or she MUST be insured
under this policy for a period of 12 consecutive months before Major services will be covered.
FL -70146 -HC SCI L 1/14 30 TRP
Benefits
Orthodontic Services:
Groups with fewer than 10 dental lives with no prior orthodontia coverage --orthodontia coverage is
effective 24 months after the effective date of coverage.
Groups with fewer than 10 dental lives with prior dental and orthodontia coverage --orthodontia coverage
is effective on the effective date of coverage.
Groups with fewer than 10 dental lives -orthodontic coverage is effective 24 months after the effective
date of the covered dependent added after the effective date of the group's Policy.
Groups with more than 10 dental lives --orthodontia coverage is effective on the effective date of
coverage.
FL -70146 -HC SCI L 1/14 31
if Y;1,
Benefits
Your plan benefits
We pay benefits on covered expenses as explained in the How your plan works section. Benefits for
covered services explained below are limited to the maximum benefit shown in the Summary of your
benefits.
Preventive services
1. Oral evaluations
• Periodic exam — two per year;
• Limited or problem focused exam— one per year;
• Comprehensive exam — one every three years. Periodontal and comprehensive exams not in
conjunction with each other.
2. Periodontal evaluations — one every three years.
3. Cleaning (prophylaxis), including all scaling and polishing procedures —two per year.
4. Adjunctive test to aid in oral cancer screening for covered persons age 40 and older— one per year.
5. Intra -oral complete series X-rays, or panoramic X-ray - once every five years for covered persons 12
years of age or older. If the total cost of periapical and bitewing x-rays exceeds the cost of a complete
series of x-rays, the plan will consider these as a complete series.
6. Bitewing X-rays — one set of films per year for covered persons under age 10 and four films per year
for covered persons age 10 and older.
7. Other x-rays, including intra -oral periapical and occlusal and extra -oral x-rays. Limited to x-rays
necessary to diagnose a specific treatment.
8. Topical application of fluoride or fluoride varnish — provided to covered persons age 14 and younger.
Service is payable once per year.
9. Sealants — application provided to covered persons age 14 years and younger to the occlusal surface of
permanent molars that are free of decay and restorations. Service is payable once per tooth per lifetime.
10. Space maintainers for retaining space when a primary tooth is prematurely lost. Services are payable
only for covered persons age 14 and younger for the installation of the initial appliance. Separate
adjustment expenses will not be covered.
Basic services
1. Amalgam restorations (fillings) — limited to one per tooth per surface in a two year period. Multiple
restorations on one surface are considered one restoration.
2. Composite restorations (fillings) on anterior teeth -limited to one per tooth per surface in a two year
period. Composite restorations on molar and bicuspid teeth are considered an alternate service and
will be payable as a comparable amalgam filling. You will be responsible for the remaining expense
incurred. Multiple restorations on one surface are considered one restoration.
FL -70146 -HC BEN L 1/14 32
Benefits
3. Gold foil restorations on molar and bicuspid teeth are considered an alternate service and will be
payable as a comparable amalgam filling. You will be responsible for the remaining expense
incurred. Limited to a maximum of one per tooth every two years.
4. Recementing of inlays, onlays, crowns and bridges;
5. Non -cast pre -fabricated crowns on primary teeth that cannot be adequately restored with amalgam or
composite restorations.
6. Treatment for the initial palliative care of pain and/or injury. Services include palliative procedures
for treatment to the teeth and supporting structures. We will consider the service as a separate benefit
only if no other service is provided during the same visit.
7. Fixed and removable appliances to inhibit thumb sucking and other harmful habits. Services are
payable only for covered persons age 14 and younger for the installation of the initial appliance.
Separate adjustment expenses will not be covered.
Simple Oral surgery services
1. Extractions - coronal remnants of a primary tooth
0
2. Extraction - erupted tooth or exposed root.
0
0
Complex Oral surgery services
N
1. Surgical extractions.
2. Bone Smoothing.
3. Trim or Remove over growth or non vital tissue or bone.
4. Removal of tooth or root from sinus and closing opening between mouth and sinus.
5. Surgical access of an unerupted tooth.
6. Mobilization of erupted or malpositioned tooth to aid eruption; or, surgical reposition of teeth.
7. Excision or removal of benign oral cysts or tumors.
8. Bone, cartilage, or synthetic grafts.
9. General anesthesia when based on review of clinical documentation provided and administered by a
dentist in conjunction with a covered oral surgical procedure.
Major/Prosthodontic services
1. Repairs of bridges; full or partial dentures, and crowns.
2. Denture adjustments when done by a dentist other than the one providing the denture, or adjustments
performed by the dentist providing the denture after initial installation - only after 6 months after
initial installation.
FL -70146 -HC BEN L 1/14 33
Benefits
Initial placement of laboratory -fabricated restorations for a permanent tooth when the tooth, as a
result of extensive decay or traumatic injury, cannot be restored with a direct placement filling
material. Covered services include inlays, onlays, crowns, veneers, core build-ups and posts. Inlays
are considered an alternate service and will be payable as a comparable amalgam filling. We will not
cover the expense incurred for pin retention when done in conjunction with core build-up.
4. Initial placement of bridges, complete dentures, immediate dentures only if the functioning tooth
(excluding third molars or teeth not fully in occlusion with an opposing tooth or prosthesis) was
extracted while you are covered under this plan. We will not cover replacement of congenitally
missing teeth.
5. Replacement of bridges, partial dentures, complete dentures, inlays, onlays, crowns, veneers, core
build ups and posts or other laboratory -fabricated restorations. Covered services include the
replacement of the existing prosthesis if
It has been at least five years since the prior insertion and is not, and cannot be made, serviceable;
It is damaged beyond repair as a result of an accidental injury (non -chewing injury) while in the
oral cavity; or
Extraction of functioning teeth, excluding third molars or teeth not fully in occlusion with an
opposing tooth or prosthesis, necessitates the replacement of the prosthesis.
These services are covered only on permanent teeth.
6. Denture relines or rebases — once in a three year period after 6 months from installation.
7. Post and core build-up in addition to partial denture retainers with or without core build up.
8. Implant related services, subject to clinical review. Dental implant prosthetics including implant
supported crowns, bridges, complete dentures or partial dentures. Implant supported complete or
partial dentures are limited to a maximum of one every five years. All other services limited to a
maximum of one every five years. Implant prosthetics noted above will be payable at the same level
of benefits as the corresponding non -implant prosthetic. You will be responsible for the remaining
expense incurred.
Periodontic services
1. Periodontal scaling and root planing, available at a maximum of once per quadrant in a three year
period. Benefits payable for a maximum of two quadrants on the same date of service. Additional
quadrants are allowed after seven days or as allowed based on clinical review.
2. Periodontal maintenance (following periodontal therapy) —procedure available four times per year
for covered persons with periodontal history.
3. Periodontal surgery, available at a maximum of once per quadrant in a three-year period.
4. Occlusal adjustments when performed in conjunction with periodontal surgery — available at a
maximum of once per quadrant in a three year period.
Endodontic services
1. Root canal therapy, including root canal treatments and root canal fillings for permanent teeth -
limited to one per tooth per lifetime.
FL -70146 -HC BEN L 1114 34
Benefits
2. Root canal retreatment, including root canal treatments and root canal fillings - limited to one per
tooth per lifetime.
3. Apicoectomy - procedure available for permanent teeth only.
4. Partial pulpotomy for apexogenesis — procedure available for permanent teeth only.
5. Vital pulpotomy — procedure available for primary teeth,
6. Apexification/recalcification.
Integral service
The following services are considered integral to the dental service. A separate fee for these services is
not considered a covered expense.
1. Local anesthetics;
2. Bases;
3. Pulp caps;
4. Additional charges related to materials or equipment used in the delivery of dental care;
5. Study models/diagnostic casts;
6. Treatment plans;
7. Occlusal (biting or grinding surfaces of molar and bicuspid teeth) adjustments;
8. Nitrous oxide;
9. Irrigation;
10. Tissue preparation associated with impression or placement of a restoration.
11. Any test, intraoperative, x-rays, laboratory, removal of existing posts, filling material, Thermafill
carriers, and any other follow-up care is considered integral to root canal therapy.
Additional benefits for newborns
If the employee's has dependent coverage, a child born to the employee's or any of the employee's
covered dependents while this policy is in effect is covered from the moment of birth for the same
benefits and under the same terms and conditions that are applicable for other children covered as
dependents under the policy.
Coverage for such newborn child consists of benefits for services which are a dental necessity for the
treatment of a bodily injury or sickness, including the necessary care and treatment of medically
diagnosed congenital defects, birth abnormalities, or premature birth; and transportation costs, not to
exceed $1,000 to and from the nearest available facility appropriately staffed and equipped to treat the
newborn's condition. The transportation must be certified by the attending physician as necessary to
protect the health and safety of the newborn child, and is subject to the reimbursement limit.
Coverage for the newborn child to an employee's covered dependent terminates 18 months after the
child's date of birth or according to the Terminating coverage provision in the certificate, whichever is
earliest.
Ifyou are an employee with single coverage currently in force, refer to the When you are eligible for
coverage provision for information on addition dependent coverage.
FL -70146 -HC BEN L 1/14
35
Benefits
Limitations & exclusions (all services)
In addition to the limitations and exclusions listed in Your plan benefits section, this policy does not
provide benefits for the following:
1. Any expenses arising from or sustained in the course of any occupation or employment for
compensation, profit or gain for which benefits are paid under any Workers' Compensation or
Occupational Disease Act or Law.
2. Services:
• That are free or that you would not be required to pay for ifyou did not have this insurance,
unless charges are received from and reimbursable to the U.S. government or any of its agencies
as required by law;
• Furnished by, or payable under, any plan or law through any government or any political
subdivision (this does not include Medicare or Medicaid); or
• Furnished by any U.S. government-owned or operated hospital/institution/agency for any service
connected with sickness or bodily injury.
3. Any loss caused or contributed by:
• War or any act of war, whether declared or not, excluding terrorism;
• Any act of international anned conflict; or
• Any conflict involving armed forces of any international authority.
4. Any expense arising from the completion of forms.
5. Your failure to keep an appointment with the dentist.
6. Any service we consider cosmetic unless it is necessary as a result of an accidental injury sustained
while you are covered under this policy. We consider the following cosmetic procedures to include,
but are not limited to:
• Facings on crowns or pontics (the portion of a fixed bridge between the abutments) posterior to
the second bicuspid.
• Any service to correct congenital malformation;
• Any service performed primarily to improve appearance;
• Characterizations and personalization of prosthetic devices; or
• Any procedure to change the spacing and/or shape of the teeth.
FL -70146 -HC LE L 1/14 36
Benefits
7. Charges for:
• Any type of implant and all related services, including crowns or the prosthetic device attached to
it.
• Precision or semi -precision attachments;
• Overdentures and any endodontic treatment associated with overdentures;
• Other customized attachments;
• Any service for 3D imaging (cone beam images);
• Temporary and interim dental services;
• Additional charges related to material or equipment used in the delivery of dental care.
• Charges rendered for treatment in a clinical or dental facility sponsored or maintained by the
employer;
• The removal of any implants unless specified in the Summary of Your Benefits section of this
certificate.
8. Any service related to:
• Altering vertical dimension of teeth;
• Restoration or maintenance of occlusion;
• Splinting teeth, including multiple abutments, or any service to stabilize periodontally weakened
teeth;
• Replacing tooth structures lost as a result of abrasion, attrition, erosion or abfraction; or
• Bite registration or bite analysis.
9. Infection control, including but not limited to sterilization techniques.
10. Fees for treatment performed by someone other than a dentist except for scaling and teeth cleaning,
and the topical application of fluoride that can be performed by a licensed dental hygienist. The
treatment must be rendered under the supervision and guidance of the dentist in accordance with
generally accepted dental standards.
11. Any hospital, surgical or treatment facility, or for services of an anesthesiologist or anesthetist.
12. Prescription drugs or pre -medications, whether dispensed or prescribed.
13. Any service not specifically listed in Your plan benefits.
FL -70146 -HC LE L 1/14
37
Benefits
14. Any service that:
• Is not eligible for benefits based upon clinical review;
• Does not offer a favorable prognosis:
• Does not have uniform professional acceptance; or
• Is deemed to be experimental or investigational in nature.
15. Orthodontic services unless specified in your Summary of your benefits. Only the services
specified in the orthodontic rider will be covered orthodontic benefits under this plan.
16. Any expense incurred before your effective date or after the date your coverage under this policy
terminates (unless the .service is eligible under Extension of benefits).
17. Services provided by someone who ordinarily lives in your home or who is afamily member.
18. Charges exceeding the reimbursement limit for the service.
19. Treatment resulting from any intentionally self-inflicted injury or bodily illness.
20. Local anesthetics, irrigation, nitrous oxide, bases, pulp caps, study models, treatment plans, occlusal
adjustments, or tissue preparation associated with the impression or placement of a restoration when
charged as a separate service. These services are considered an integral part of the entire dental
service.
21. Temporary dental services.
22. Repair and replacement of orthodontic appliances.
23. Any surgical or nonsurgical treatment for any jaw joint problems, including any temporomandibular
joint disorder, craniomaxillary, craniomandibular disorder or other conditions of the joint linking the
jaw bone and skull; or treatment of the facial muscles used in expression and chewing functions, for
symptoms including, but not limited to, headaches.
24. The oral surgery benefits under this plan does not include:
a. Any services for orthognathic surgery;
b. Any services for destruction of lesions by any method;
c. Any services for tooth transplantation.,
d. Any services for removal of a foreign body from the oral tissue or bone;
e. Any services for reconstruction of surgical, traumatic, or congenital defects of the facial bones;
f Any separate fees for pre and post-operative care.
FL -70146 -HC LE L 1/14 38
Benefits
25. General anesthesia or conscious sedation is not a covered service unless it is based on clinical review
of documentation provided and administered by a dentist or health care practitioner in conjunction
with covered oral surgical procedures, periodontal and osseous surgical procedures, or periradicular
surgical procedures for covered services.
General anesthesia or conscious sedation administered due, but not limited to, the following reasons
are not covered:
1. Pain control unless a documented allergy to local anesthetic is provided.
2. Anxiety.
3. Fear of pain.
4. Pain management.
5. Emotional inability to undergo surgery.
N
26. Preventive control programs including, but not limited to, oral hygiene instructions, plaque control,
0
take-home items, prescriptions and dietary planning.
0
27. Replacement of any lost, stolen, damaged, misplaced or duplicate major restoration, prosthesis or
appliance.
28. Any caries susceptibility testing, laboratory tests, saliva samples, anaerobic cultures, sensitivity
testing or charges for oral pathology procedures.
29. Separate fees for pre- and post-operative care and re-evaluation within 12 months are not considered
covered services under the surgical periodontic services in this plan.
30. We do not cover services that generally are considered to be medical services except those
specifically noted as covered in this certificate.
FL -70146 -HC LE L 1/14
CM
Supplemental Dental Expense Benefit
Orthodontic Services
This Supplemental Dental Expense Benefit is part of the certificate. The benefits outlined will be
effective the latter of:
1. The effective date of vour certificate; or
2. Completion of any applicable waiting period.
Please refer to the Waiting Periods provision to verify if an orthodontic waiting period applies to you.
Benefits are available only to covered dependent children age 18 and under at the time treatment begins.
We pay benefits based on our reimbursement limits and your orthodontic maximum benefit. Except as
modified below, all plan terms, conditions and limitations apply.
Covered services for orthodontia treatment
Covered services for orthodontic treatment include those that are:
1. For the treatment of --and appliances for --tooth guidance, interception and correction; and
2. Related to covered orthodontic treatment including:
• X-rays;
• Exams;
• Space regaincm and/or
• Study models.
How benefits will be paid if treatment begins after you are eligible for orthodontic
benefits with us.
In order to have the full orthodontic treatment be considered for benefits under this plan, bands and
appliances must be inserted after:
1. Your effective date under this plan; and
2. Exhaustion of any orthodontic waiting period.
If services are eligible under this plan at the time orthodontic appliances or bands are initially inserted, we
will pay the lesser of.
1. 25 percent of the total treatment plan charge;
2. 25 percent of the total maximum benefit payable; or
3. The dentist's initial fee.
We will pay the remaining installments at the end of each quarter while you are covered for orthodontic
benefits under this plan, if for any reason the treatment plan is terminated before treatment is completed,
we will not pay further benefits.
FL -70146 -HC ORTHO L 1/14 40
Supplemental Dental Expense Benefit
How benefits will be paid if treatment was started before you were eligible for
orthodontic benefits with us.
Services for orthodontic treatment received prior to your effective date, or prior to exhaustion of the
orthodontic waiting period, are not covered services.
Benefits are available only for the portion of the treatment after:
1. Your effective date under this plan; and
2. Exhaustion of any orthodontic waiting period.
Benefits will be prorated to account for the portion of treatment completed prior to orthodontic eligibility.
Additionally, ifyou had orthodontic coverage under your prior dental plan, any benefits paid by your
prior plan, will be applied to the Orthodontic Lifetime Maximum Benefit of this plan.
To obtain more information about your coverage, please feel free to contact our Customer Service
Department at:
Humana Insurance Department
1100 Employers Blvd
Green Bay, WI 54344
1-800-233-4013
FL -70146 -HC ORTHO L 1/14
Bruce Broussard
President
41
Open Enrollment Rider
Change in Plan Rider:
Coverage for Open Enrollment
Your certificate is amended to include this plan rider. The effective date of the rider is the latter of the
effective date of your certificate or the date this rider is added to your certificate. Benefits are subject to
all policy terms, conditions and limitations, including waiting periods.
Open enrollment period
The open enrollment period is the annual period during which eligible employees may apply for coverage
for themselves and their eligible dependents as outlined in the Employer Group Application (see your
employer for details).
To enroll for coverage
The employee must complete the enrollment/change form provided by its, carefully listing each person to
be covered. Enrollment during the open enrollment period will be allowed if we receive the completed
forms within the open enrollment period. Any reference to late applicants within the Eligibility section of
your certificate and/or Policy is removed. Late applicants are not eligible for coverage, and must wait
until the following open enrollment periods to apply.
When you are eligible for coverage section in your certificate is amended as follows:
The eligibility date of coverage is amended as follows:
Employee Coverage:
The employee is eligible for coverage on the date:
1. The eligibility requirements stated in the Employer Group Application, oras otherwise agreed to
by us and the policyholder, are satisfied;
2. The employee is in an active status. or;
3. The employer's annual anniversary date.
FL -70146 -HC OE L 1/14 42
Open Enrollment Rider
Dependent coverage
Each dependent is eligible for coverage on the date:
1. The employee is eligible for coverage, if he or she has dependents who may be covered on that
date;
2. Of the employee's marriage for any dependents (spouse or child) acquired on that date;
3. Of birth of the employee's natural-born child;
4. Of placement of the child for the purpose of adoption by the employee; Coverage shall begin from
the moment of birth, if a written agreement to adopt such child has been entered into by the
employee prior to the birth of such child, whether or not the agreement is enforceable;
5. The date a child underage 18 is placed in the employee's home as a foster child;
6. Specified in a Qualified Medical Child Support Order (QMCSO) or National Medical Support
Notice (NMSN) for a child, or a valid court or administrative order for a spouse, which requires
the employee to provide coverage for a child or spouse as specified in such orders; or
7. Of the employer's annual anniversary date.
Please check the Summary of Your Benefits for waiting periods that may apply to you.
To obtain more information about your coverage, please feel free to contact our Customer Service
Department at:
Humana Insurance Department
1100 Employers Blvd
Green Bay, WI 54344
1-800-233-4013
0
FL -70146 -HC OE L 1/14
Bruce Broussard
President
43
Implant Rider
Change in Plan Rider:
Coverage for Implants
Your certificate is amended to include this plan rider. The effective date of the rider is the latter of the
effective date of your certificate or the date this rider is added to your certificate. Benefits are subject to
all policy terms, conditions and limitations.
The following Implant benefit is added to your certificate as follows:
Implants services, subject to clinical revieir, including dental implant placement and related services.
Implants will be allowed as a benefit payable under Major services on your Summary of Your Benefits
subject to the individual maximum benefit. Implants and implant supported prostheses covered under
this plan are limited to the replacement of permanent teeth extracted while insured under this plan, or for
replacement of a prior prosthesis if it has been at least five years since the prior insertion, and is not, and
cannot be made serviceable.
To obtain more information about your coverage, have inquiries, or need assistance in resolving
complaints, please feel free to contact our Customer Service Department at:
Humana Insurance Company
1100 Employers Blvd
Green Bay, WI 54344
1-800-2334013
i
Bruce Broussard
President
FL -70146 -HC Implant L 1/14 44
Florida Notice:
Effective July 1, 1994, certain victims of violent crime do not have to meet the deductible or copayment
provision of any insurance policy for the treatment of their crime -related injuries pursuant to the Florida
Crimes Compensation Act, excluding 960.28. Eligibility under the Florida Crimes Compensation Act is
determined when victims of violent crime apply for services with the Office of the Attorney General,
Division of Victim Services. When victims are determined eligible, they are given written notification
which references their insurance exemption. If you are eligible under the Florida Crimes Compensation
Act, please forward a copy of such written notification to us to report your status.
Notices
The following pages contain important information about certain federal laws. There may be
differences between the Certificate of Insurance and this Notice packet. There may also be
differences between this notice packet and state law. You are eligible for the rights more beneficial
to you, unless preempted by state or federal law.
This section includes notices about:
Claim procedures
Federal legislation
Medical child support orders
Continuation of coverage for full-time students during medical leave of absence
General notice of COBRA continuation of coverage rights
Family and Medical Leave Act (FMLA)
Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA)
Your Rights under ERISA
Claim procedures
The Employee Retirement Income Security Act of 1974 (ERISA) established minimum requirements for
claims procedures. Humana complies with these standards. Covered persons in insured plans subject to
ERISA should also consult their insurance benefit plan documents (e.g., the Certificate of Insurance or
Evidence of Coverage). Humana complies with the requirements set forth in any such benefit plan
document issued by it with respect to the plan unless doing so would prevent compliance with the
requirements of the federal ERISA statute and the regulations issued thereunder. The following claims
procedures are intended to comply with the ERISA claims regulation, and should be interpreted consistent
with the minimum requirements of that regulation. Covered persons in plans not subject to ERISA should
consult their benefit plan documents for the applicable claims and appeals procedures.
Discretionary authority
With respect to paying claims for benefits or determining eligibility for coverage under a policy issued by
Humana, Humana as administrator for claims determinations and as ERISA claims review fiduciary, shall
have full and exclusive discretionary authority to:
1. Interpret plan provisions;
2. Make decisions regarding eligibility for coverage and benefits; and
3. Resolve factual questions relating to coverage and benefits.
Claim procedures
Definitions
Adverse determination: means a decision to deny benefits for a pre -service claim or a post -service claim
under a group health and/or dental plan.
Claimant: A covered person (or authorized representative) who files a claim.
Concurrent -care Decision: A decision by the plan to reduce or terminate benefits otherwise payable for
a course of treatment that has been approved by the plan (other than by plan amendment or termination)
or a decision with respect to a request by a Claimant to extend a course of treatment beyond the period of
time or number of treatments that has been approved by the plan.
Group health plan: an employee welfare benefit plan to the extent the plan provides dental care to
employees or their dependents directly (self insured) or through insurance (including HMO plans),
reimbursement or otherwise.
Health insurance issuer: the offering company listed on the face page of your Certificate of Insurance or
Certificate of Coverage and referred to in this document as "Humana."
Post -service Claim: Any claim for a benefit under a group health plan that is not a Pre -service Claim.
Pre -service Claim: A request for authorization of a benefit for which the plan conditions receipt of the
benefit, in whole or in part, on advance approval.
Urgent -care Claim (expedited review): A claim for covered services to which the application of the
time periods for making non -urgent care determinations:
could seriously jeopardize the life or health of the covered person or the ability of the covered person to
regain maximum function; or
in the opinion of a physician with knowledge of the covered person's medical condition, would subject the
covered person to severe pain that cannot be adequately managed without the service that is the subject of
the claim.
Humana will make a determination of whether a claim is an Urgent -care Claim. However, any claim a
physician, with knowledge of a covered person's medical condition, determines is a " Urgent -care Claim"
will be treated as a "claim involving urgent care."
Submitting a claim
This section describes how a Claimant files a claim for plan benefits
A claim must be filed in writing and delivered by mail, postage prepaid, by FAX or e-mail. A request for
pre -authorization may be filed by telephone. The claim or request for pre -authorization must be
submitted to Humana or to Humana's designee at the address indicated in the covered person's benefit
plan document or identification card. Claims will be not be deemed submitted for purposes of these
procedures unless and until received at the correct address.
Claims submissions must be in a format acceptable to Humana and compliant with any legal
requirements. Claims not submitted in accordance with the requirements of applicable federal law
respecting privacy of protected health information and/or electronic claims standards will not be accepted
by Humana.
Claims submissions must be timely. Claims must be filed as soon as reasonably possible after they are
incurred, and in no event later than the period of time described in the benefit plan document.
Claims submissions must be complete and delivered to the designated address. At a minimum they must
include:
• Name of the covered person who incurred the covered expense.
• Name and address of the provider
• Diagnosis
• Procedure or nature of the treatment
• Place of service
• Date of service
• Billed amount
A general request for an interpretation of plan provisions will not be considered a claim. Requests of this
type, such as a request for an interpretation of the eligibility provisions of the plan, should be directed to
the plan administrator.
Procedural defects
If a Pre -service Claim submission is not made in accordance with the plan's requirements, Humana will
notify the Claimant of the problem and how it may be remedied within five (5) days (or within 24 hours,
in the case of an Urgent -care Claim). If a Post -service Claim is not made in accordance with the plan's
requirement, it will be returned to the submitter.
Authorized representatives
A covered person may designate an authorized representative to act on his or her behalf in pursuing a
benefit claim or appeal. The authorization must be in writing and authorize disclosure of health
information. If a document is not sufficient to constitute designation of an authorized representative, as
determined by Humana, the plan will not consider a designation to have been made. An assignment of
benefits does not constitute designation of an authorized representative.
• Any document designating an authorized representative must be submitted to Humana in advance or
at the time an authorized representative commences a course of action on behalf of the covered
person. Humana may verify the designation with the covered person prior to recognizing authorized
m
representative status.
rn
r
• In any event, a health care provider with knowledge of a covered person's medical condition acting in
connection with an Urgent -care Claim will be recognized by the plan as the covered person's
x authorized representative.
Covered persons should carefully consider whether to designate an authorized representative.
Circumstances may arise under which an authorized representative may make decisions independent of
the covered person, such as whether and how to appeal a claim denial.
Claims decisions
After a determination on a claim is made, Humana will notify the Claimant within a reasonable time, as
follows:
Pre -service claims
Humana will provide notice of a favorable or adverse determination within a reasonable time appropriate
to the medical circumstances but no later than 15 days after the plan receives the claim.
This period may be extended by an additional 15 days, if Humana determines the extension is necessary
due to matters beyond the control of the plan. Before the end of the initial 15 -day period, Humana will
notify the Claimant of the circumstances requiring the extension and the date by which Humana expects
to make a decision.
If the reason for the extension is because Humana does not have enough information to decide the claim,
the notice of extension will describe the required information, and the Claimant will have at least 45 days
from the date the notice is received to provide the necessary information.
Urgent -care claims (expedited review)
Humana will determine whether a particular claim is an Urgent -care Claim. This determination will be
based on information furnished by or on behalf of a covered person. Humana will exercise its judgment
when making the determination with deference to the judgment of a physician with knowledge of the
covered person's condition. Humana may require a Claimant to clarify the medical urgency and
circumstances supporting the Urgent -care Claim for expedited decision-making.
Notice of a favorable or adverse determination will be made by Humana as soon as possible, taking into
account the medical urgency particular to the covered person's situation, but not later than 72 hours after
receiving the Urgent -care Claim.
If a claim docs not provide sufficient information to determine whether, or to what extent, services are
covered under the plan, Humana will notify the Claimant as soon as possible, but not more than 24 hours
after receiving the Urgent -care Claim. The notice will describe the specific information necessary to
complete the claim. The Claimant will have a reasonable amount of time, taking into account the covered
person's circumstances, to provide the necessary information - but not less than 48 hours.
Humana will provide notice of the plan's Urgent -care Claim determination as soon as possible but no
more than 48 hours after the earlier of.
• The plan receives the specified information; or
• The end of the period afforded the Claimant to provide the specified additional information
Concurrent -care decisions
Humana will notify a Claimant of a Concurrent -care Decision involving a reduction or termination of pre -
authorized benefits sufficiently in advance of the reduction or termination to allow the Claimant to appeal
and obtain a determination.
Humana will decide Urgent -care Claims involving an extension of a course of treatment as soon as
possible taking into account medical circumstances. Humana will notify a Claimant of the benefit
determination, whether adverse or not, within 24 hours after the plan receives the claim, provided the
claim is submitted to the plan 24 hours prior to the expiration of the prescribed period of time or number
of treatments.
Post -service claims
Humana will provide notice of a favorable or adverse determination within a reasonable time appropriate
to the medical circumstances but no later than 30 days after the plan receives the claim.
This period may be extended an additional 15 days, if Humana determines the extension is necessary due
to matters beyond the plan's control. Before the end of the initial 30 -day period, Humana will notify the
affected Claimant of the extension, the circumstances requiring the extension and the date by which the
plan expects to make a decision.
If the reason for the extension is because Humana does not have enough information to decide the claim,
the notice of extension will describe the required information, and the Claimant will have at least 45 days
from the date the notice is received to provide the specified information. Humana will make a decision on
the earlier of the date on which the Claimant responds or the expiration of the time allowed for
submission of the requested information.
Initial denial notices
Notice of a claim denial (including a partial denial) will be provided to Claimants by mail, postage
prepaid, by FAX or by e-mail, as appropriate, within the time frames noted above. With respect to
adverse decisions involving Urgent -care Claims, notice may be provided to Claimants orally within the
time frames noted above. If oral notice is given, written notification must be provided no later than 3
days after oral notification.
A claims denial notice will convey the specific reason for the adverse determination and the specific plan
provisions upon which the determination is based. The notice will also include a description of any
additional information necessary to perfect the claim and an explanation of why such information is
necessary. The notice will disclose if any internal plan rule, protocol or similar criterion was relied upon
to deny the claim. A copy of the rule, protocol or similar criterion will be provided to Claimants, free of
charge, upon request.
The notice will describe the plan's review procedures and the time limits applicable to such procedures,
including a statement of the Claimant's right to bring a civil action under ERISA Section 502(a) following
an adverse benefit determination on review.
If an adverse determination is based on medical necessity, experimental treatment or similar exclusion or
limitation, the notice will state that an explanation of the scientific or clinical basis for the determination
will be provided, free of charge, upon request. The explanation will apply the terms of the plan to the
o covered person's medical circumstances.
M
r
In the case of an adverse decision of an Urgent -care Claim, the notice will provide a description of the
plan's expedited review procedures
N
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Appeals of Adverse determinations
A Claimant must appeal an adverse determination within 180 days after receiving written notice of the
denial (or partial denial). An appeal may be made by a Claimant by means of written application to
Humana, in person, or by mail, postage prepaid.
A Claimant, on appeal, may request an expedited appeal of an adverse Urgent -care Claim decision orally
or in writing. In such case, all necessary information, including the plan's benefit determination on
review, will be transmitted between the plan and the Claimant by telephone, facsimile, or other available
similarly expeditious method, to the extent permitted by applicable law
Determination of appeals of denied claims will be conducted promptly, will not defer to the initial
determination and will not be made by the person who made the initial adverse claim determination or a
subordinate of that person. The determination will take into account all comments, documents, records,
and other information submitted by the Claimant relating to the claim.
On appeal, a Claimant may review relevant documents and may submit issues and comments in writing.
A Claimant on appeal may, upon request, discover the identity of medical or vocational experts whose
advice was obtained on behalf of the plan in connection with the adverse determination being appealed,
as permitted under applicable law.
If the claims denial is based in whole, or in part, upon a medical judgment, including determinations as to
whether a particular treatment, or other service is experimental, investigational, or not medically
necessary or appropriate, the person deciding the appeal will consult with a health care professional who
has appropriate training and experience in the field of medicine involved in the medical judgment. The
consulting health care professional will not be the same person who decided the initial appeal or a
subordinate of that person.
Time periods for decisions on appeal
Appeals of claims denials will be decided and notice of the decision provided as follows:
Urgent -care Claims
As soon as possible but no later than 72 hours after Humana
receives the appeal request.
Pre -service Claims
Within a reasonable period but no later than 30 days after
Humana receives the appeal request.
Post -service Claims
Within a reasonable period but no later than 60 days after
Humana receives the appeal request.
Concurrent -care
Within the time periods specified above depending on the type of
Decisions
claim involved.
Appeals denial notices
Notice of a claim denial (including a partial denial) will be provided to Claimants by mail, postage
prepaid, by FAX or by e-mail, as appropriate, within the time periods noted above.
A notice that a claim appeal has been denied will include:
• The specific reason or reasons for the adverse determination;
• Reference to the specific plan provision upon which the determination is based;
• If any internal plan rule, protocol or similar criterion was relied upon to deny the claim. A copy of the
rale, protocol or similar criterion will be provided to the Claimant, free of charge, upon request;
• A statement describing any voluntary appeal procedures offered by the plan and the claimant's right
to obtain the information about such procedures, and a statement about the Claimant's right to bring
an action under section 502(a) of ERISA;
• If an adverse determination is based on medical necessity, experimental treatment or similar
exclusion or limitation, the notice will state that an explanation of the scientific or clinical basis for
the determination will be provided, free of charge, upon request. The explanation will apply the
terms of the plan to the covered person's medical circumstances.
In the event an appealed claim is denied, the Claimant will be entitled to receive without charge
reasonable access to, and copies of, any documents, records or other information that:
• Was relied upon in making the determination;
• Was submitted, considered or generated in the course of making the benefit determination, without
regard to whether such document, record or other information was relied upon in making the benefit
determination;
• Demonstrates compliance with the administrative processes and safeguards required in making the
determination.
• Constitutes a statement of policy or guidance with respect to the plan concerning the denied treatment
option or benefit for the claimant's diagnosis, without regard to whether the statement was relied on in
making the benefit determination.
Exhaustion of remedies
Upon completion of the appeals process under this section, a Claimant will have exhausted his or her
administrative remedies under the plan. If Humana fails to complete a claim determination or appeal
within the time limits set forth above, the claim shall be deemed to have been denied and the Claimant
may proceed to the next level in the review process.
After exhaustion of remedies, a Claimant may pursue any other legal remedies available, which may
include bringing civil action under ERISA section 502(a) for judicial review of the plan's determination.
Additional information may be available from the local U.S. Department of Labor Office.
Legal actions and limitations
No lawsuit may be brought with respect to plan benefits until all remedies under the plan have been
exhausted.
No lawsuit with respect to plan benefits may be brought after the expiration of the applicable limitations
period stated in the benefit plan document. If no limitation is stated in the benefit plan document, then no
such suit may be brought after the expiration of the applicable limitations under applicable law.
Medical child support orders
An individual who is a child of a covered employee shall be enrolled for coverage under the group health
plan in accordance with the direction of a Qualified Medical Child Support Order (QMCSO) or a National
Medical Support Notice (HMSO).
A QMCSO is a state -court order or judgment, including approval of a settlement agreement that:
• provides for support of a covered employee's child;
• provides for health care coverage for that child;
• is made under state domestic relations law (including a community property law);
• relates to benefits under the group health plan; and
• is "qualified," i.e., it meets the technical requirements of ERISA or applicable state law.
QMCSO also means a state court order or judgment enforcing state Medicaid law regarding medical child
support required by the Social Security Act § 1908 (as added by Omnibus Budget Reconciliation Act of
1993).
An NMSO is a notice issued by an appropriate agency of a state or local government that is similar to a
QMCSO requiring coverage under the group health plan for a dependent child of a non-custodial parent
who is (or will become) a covered person by a domestic relations order providing for health care
coverage.
Procedures for determining the qualified status of medical child support orders are available at no cost
upon request from the plan administrator.
Continuation of coverage for full-time students during medical leave of absence
A dependent child who is in regular full-time attendance at an accredited secondary school, college or
university, or licensed technical school continues to be eligible for coverage for until the earlier of the
following if the dependent child takes a medically necessary leave of absence:
- Up to one year after the first day of the medically necessary leave of absence; or
- The date coverage would otherwise terminate under the plan.
We may require written certification from the dependent child's health care practitioner that the
dependent child has a serious bodily injury or sickness requiring a medically necessary leave of absence.
General notice of COBRA continuation coverage rights
Introduction
You are getting this notice because you recently gained coverage under a group health and/or dental plan
(the Plan). This notice has important information about your right to COBRA continuation coverage,
which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation
coverage, when it may become available to you and your family, and what you need to do to protect
your right to get it. When you become eligible for COBRA, you may also become eligible for other
coverage options that may cost less than COBRA continuation coverage.
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus
Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to
you when you would otherwise lose your group health and/or dental coverage. It can also become
available to you and other members of your family when group health coverage would otherwise end.
For more information about your rights and obligations under the Plan and under federal law, you should
review the Plan's Summary Plan Description or contact the Plan Administrator.
What is COBRA continuation coverage?
COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because
of a life event. This is also called a "qualifying event." Specific qualifying events are listed later in this
notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a
"qualified beneficiary." You, your spouse, and your dependent children could become qualified
beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified
beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.
If you are an employee, you will become a qualified beneficiary if you too lose your coverage under the
Plan because of the following qualifying events:
• Your hours of employment are reduced; or
• Your employment ends for any reason other than your gross misconduct
If you are the spouse of an employee, you will become a qualified beneficiary if you too lose your
coverage under the Plan because of the following qualifying events:
• Your spouse dies;
• Your spouse's hours of employment are reduced;
• Your spouse's employment ends for any reason other than his or her gross misconduct;
• Your spouse becomes entitled to Medicare benefits (under Part A, Part B or both); or
• You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because
of the following events:
• The parent -employee dies;
• The parent -employee's hours of employment are reduced;
• The parent -employee's employment ends for any reason other than his or her gross misconduct;
• The parent -employee becomes entitled to Medicare benefits (Part A, Part B or both);
• The parents become divorced or legally separated; or
• The child stops being eligible for coverage under the plan as a "dependent child."
Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying
event. If a proceeding in bankruptcy is filed with respect to the employer, and that bankruptcy results in
the loss of coverage of any retired employee covered under the Plan, the retired employee will become a
qualified beneficiary. The retired employee's spouse, surviving spouse, and dependent children will also
become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.
When is COBRA coverage available?
The plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan
Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan
Administrator of the following qualifying events:
• the end of employment or reduction of hours of employment;
• death of the employee;
• commencement of a proceeding in bankruptcy with respect to the employer; or
• the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both).
For allother qualifying events (divorce or legal separation of the employee and spouse or a
dependent child's losing eligibility for coverage as a dependent child), you must notify the Plan
Administrator within 60 days after the qualifying event occurs.
How is COBRA Coverage Provided?
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation
coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an
independent right to elect COBRA continuation coverage. Covered employees may elect COBRA
continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage
on behalf of their children.
COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months
due to employment termination or reduction of hours of work. Certain qualifi ing events or a second
qualifying event during the initial period of coverage may permit a beneficiar} to receive a maximum of
36 months of coverage. There are also ways in which this 18 -month period of COBRA continuation
coverage can be extended:
Disability extension of 18 -month period of
continuation coverage - If you or anyone in your family covered under the Plan is determined by
Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your
entire family may be entitled to get up to an additional I I months of COBRA continuation coverage,
for a maximum of 29 months. The disability would have to have started at some time before the 6e
day of COBRA continuation coverage and must last at least until the end of the 18 -month period of
COBRA continuation coverage
Second qualifying event extension of 18 -month period of
continuation coverage - If your family experiences another qualifying event during the 18 months of
COBRA continuation coverage, the spouse and dependent children in your family can get up to 18
additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is
properly notified about the second qualifying event. This extension may be available to the spouse
and any dependent children getting COBRA continuation coverage if the employee or former
employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or
legally separated; or if the dependent child stops being eligible under the Plan as a dependent child.
This extension is only available if the second qualifying event would have caused the spouse or
dependent child to lose coverage under the Plan had the first qualifying event not occurred.
If You Have Questions
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the
contact or contacts identified below. For more information about your rights under ERISA, including
COBRA, or other laws affecting your group heath and/or dental plans, contact the nearest Regional or
District Office of the U.S. Department of Labor's Employee Benefits Security Administration (EBSA) in
your area or visit at www.dol.gov/cbsa. (address and phone numbers of Regional and District EBSA
Office are available through EBSA's website.)
Keep your plan informed of address changes
To protect your family's rights, let the Plan Administrator know about any changes in the addresses of
family members. You should also keep a copy, for your records, of any notices you send to the Plan
Administrator.
Plan contact information:
Humana
Billing/Enrollment Department
101 E Main Street
Louisville, KY 40201
1-800-872-7207
Family and Medical Leave Act (FMLA)
If an employee is granted a leave of absence (Leave) by the employer as required by the Federal Family
and Medical Leave Act, s/he may continue to be covered under the plan for the duration of the Leave
o under the same conditions as other employees who are currently employed and covered by the plan. If
o the employee chooses to terminate coverage during the Leave, or if coverage terminates as a result of
'e nonpayment of any required contribution, coverage may be reinstated on the date the employee returns to
F work immediately following the end of the Leave. Charges incurred after the date of reinstatement will
be paid as if the employee had been continuously covered.
Uniformed Services Employment and Reemployment Rights Act of 1994
Continuation of benefits
Effective October 13, 1994, federal law requires health plans offer to continue coverage for employees
that are absent due to service in the uniformed services and/or dependents.
Eligibility
An employee is eligible for continuation under USERRA if he or she is absent from employment because
of voluntary or involuntary performance of duty in the Armed Forces, Army National Guard, Air National
Guard, or commissioned corps of the Public Health Service. Duty includes absence for active duty, active
duty for training, initial active duty for training, inactive duty training and for the purpose of an
examination to determine fitness for duty.
An employee's dependents that have coverage under the plan immediately prior to the date of the
employee's covered absence are eligible to elect continuation under USERRA.
If continuation of Plan coverage is elected under USERRA, the employee or dependent is responsible for
payment of the applicable cost of coverage. If the employee is absent for not longer than 31 days, the cost
will be the amount the employee would otherwise pay for coverage. For absences exceeding 30 days, the
cost may be up to 102% of the cost of coverage under the plan. This includes the employee's share and
any portion previously paid by the employer.
Duration of coverage
If elected, continuation coverage under USERRA will continue until the earlier of.
• 24 months beginning the first day of absence from employment due to service in the uniformed
services; or
• The day after the employee fails to apply for a return to employment as required by USERRA, after
the completion of a period of service.
Under federal law, the period coverage available under USERRA shall run concurrently with the COBRA
period available to an employee and/or eligible dependent.
Other information
Employees should contact their employer with any questions regarding coverage normally available
during a military leave of absence or continuation coverage and notify the employer of any changes in
marital status, or change of address.
Your Rights Under the Employment Rights Income Security Act of 1974 (ERISA)
Under ERISA, all plan participants covered by ERISA are entitled to certain rights and protections, as
described below. Notwithstanding anything in the group health plan or group insurance policy, following
are a covered person's minimum rights under ERISA. ERISA requirements do not apply to plans
maintained by governmental agencies or churches.
Information about the plan and benefits
Plan participants may:
• Examine, free of charge, all documents governing the plan. These documents are available in the
plan administrator's office.
• Obtain, at a reasonable charge, copies of documents governing the plan, including a copy of any
updated summary plan description and a copy of the latest annual report for the plan (Form 5500), if
any, by writing to the plan administrator.
• Obtain, at a reasonable charge, a copy of the latest annual report (Form 5500) for the plan, if any, by
writing to the plan administrator.
As a plan participant, you will receive a summary of any material changes made in the plan within 210
days after the end of the plan year in which the changes are made unless the change is a material
reduction in covered services or benefits, in which case you will receive a summary of the material
reduction within 60 days after the date of its adoption.
If the plan is required to file a summary annual financial report, you will receive a copy from the plan
administrator.
Responsibilities of plan fiduciaries
In addition to creating rights for plan participants, ERISA imposes duties upon the people who are
responsible for the operation of the plan. These people, called 'fiduciaries" of the plan, have a duty to act
prudently and in the interest of plan participants and beneficiaries.
No one, including an employer, may discharge or otherwise discriminate against a plan participant in any
way to prevent the participant from obtaining a benefit to which the participant is otherwise entitled under
the plan or from exercising ERISA rights.
Continue group health plan coverage
Participants may be eligible to continue health care coverage for themselves, their spouse or dependents if
there is a loss of coverage under the group health plan as a result of a qualifying event. You or your
dependents may have to pay for such coverage. Review the COBRA notice in this document regarding
the rules governing COBRA continuation coverage rights.
Claims determinations
N If a claim for a plan benefit is denied or disregarded, in whole or in part, participants have the right to
know why this was done, to obtain copies of documents relating to the decision without charge and to
0
appeal any denial within certain time schedules.
a
a
N Enforce your rights
Under ERISA, there are steps participants may take to enforce the above rights. For instance:
• if a participant requests a copy of plan documents and does not receive them within 30 days, the
participant may file suit in a Federal court. In such a case, the court may require the plan
administrator to provide the materials and pay you up to $ 110 a day until the participant receives the
materials, unless the materials were not sent because of reasons beyond the control of the plan
administrator;
• if a claim for benefits is denied or disregarded, in whole or in part, the participant may file suit in a
state or Federal court:
• if the participant disagrees with the plan's decision, or lack thereof, concerning the qualified status of
a domestic relations order or a medical child support order, the participant may file suit in Federal
Court;
• if plan fiduciaries misuse the plan's money, or if participants are discriminated against for asserting
their rights, they may seek assistance from the U.S. Department of Labor, or may file suit in a Federal
_ court.
The court will decide who should pay court costs and legal fees. If the participant is successful, the court
may order the person sued to pay costs and fees. If the participant loses, the court may order the
participant to pay the costs and fees.
e Assistance with questions
• Contact the group health plan human resources department or the plan administrator with questions
C about the plan;
• For questions about ERISA rights, contact the nearest area office of the Employee Benefits Security
Administration, U.S. Department of Labor, listed in your telephone directory or:
C
The Division of Technical Assistance and Inquiries
Employee Benefits Security Administration
U.S. Department of Labor
200 Constitution Avenue N.W.
Washington, D.C. 20210;
• Call the publications hotline of the Employee Benefits Security Administration to obtain publications
about ERISA rights.