Agenda 10/11/2011 Item #10C10/11/2011 Item 10:C.
EXECUTIVE SUMMARY
Recommendation to approve the renewal of the Group Dental Insurance program
through Cigna Dental Plan, Inc. with no increase in the rates or change in terms
for a one year period effective January 1, 2012 in the amount of $1,730,521
OBJeCTIVE: To gain Board approval to purchase Group Dental Insurance through Cigna
Dental Plan effective January 1, 2012.
CONSIDERATIONS: The Board of Commissioners through its Risk Management Department
administers the group benefit program for the County Manager's agency and participating
Constitutional Officers. Group Dental' Insurance is offered as part of the program. Coverage is
provided by Cigna Dental Plan, Inc. under a fully insured PPO arrangement.
In preparation for the FY 2012 budget, staff requested a renewal proposal from Cigna in May,
2011. Staff coordinated the process through the County's contracted benefits broker, Willis, .Inc.
Cigna presented a renewal proposal in June, 2011 which contained a 3.8% rate increase. The
staff of Risk Management and Willis reviewed the prior twelve month claim history and
requested that CIGNA agree to retain the existing rates and terms for the 2012 policy year.
Cigna agreed to no rate increase in 2012 and to continue existing terms.
Claims adjudication has been prompt and Cigna has been responsive to service issues as they
arise. further, Cigna has made efforts to expand the provider network in Collier County over
the past seven years. The number of providers in network has grown from twenty -eight (28)
providers in 2005 to one hundred, twenty -six providers (126) in 2011.
There are no other changes to the terms and conditions of the program.
FISCAL IMPACT: The estimated cost of the program in calendar year 2012 based upon
average enrollment of 1,870 employees is $1,730,521. These costs include both the employer
and employee contributions. Final cost is dependent upon enrollment by plan and tier (single,
family). The employer portion of the premium is approximately 53 % of the total cost. Sufficient
funds are available within Fund 517, Group Health and Life Insurance for this purchase.
GROWTH MANAGEMENT IMPACT: ,There is no growth management impact associated with
this item.
LEGAL CONSIDERATIONS: This , item has been reviewed the County Attorney's Office,
requires majority vote and is legally sufficient for Board action. - CMG
RECOMMENDATION: That the Board approves the purchase of Group Dental Insurance from
Cigna Dental Plan, Inc. with an effective date of January 1, 2012 through December 31, 2012.
PREPARED BY: Jeffrey A. Walker, CPCU, ARM, Director; Risk Management
Packet Page -490-
10/11/2011 Item 10.C.
COLLIER COUNTY
Board of County Commissioners
Item Number: 1O.C.
Item Summary: Recommendation to approve the renewal of the Group Dental Insurance
program through Cigna Dental. Plan, Inc. with no increase in the rates or change in terms for a
one year period effective January 1, 2012 in the amount of $1,730,521.
Meeting Date: 10/11/2011
Prepared By
Name: WalkerJefl'
Title: Director - Risk Management,Risk Management
9/15/20119:36:14 AM
Submitted by
Title: Director Risk Management,Risk Management
Name: WalkerJeff
9/15/20119:36:15 AM
Approved By
Name: SmithKristen
Title: Administrative Secretary,Risk Management
Date: 9/15/20113:29:43 PM
Name: GreeneColleen .
Title: Assistant County Attorney,County Attorney
Date: 9/19/20119:581:53 AM
Name: PriceLen
Title: Administrator - Administrative. Services,
Date: 9/23/20115:39: 18 PM
Name: KlatzkowJeff
Title: County Attorney,
Date: 9/29/20114:47:29 PM
�1
Packet Page -491-
Name: FinnEd
Date: 10/3/20113:06:15 PM
Name: OchsLeo
Title: County Manager
Date: 10/3/20115:53:08 PM
Packet Page -492-
10/11/2011 Item 10.C.
10/11/2011 Item 10.C.
From: Buell, Stephen [mailto:buell_st @willis.com]
Sent: Friday, September 23, 201112:48 PM
To: Walkerleff
Cc: Wiesing, Sue
Subject: FW: Dental Rates for 2012
Jeff,
As per previous discussions regarding the dental renewal, CIGNA agreed to no change in the current
rates for 2012. This was part of the negotiations on the medical plan and subsequent placement with
Allegiance.
Ken Munkel's note below will confirm that CIGNA is not changing rates.
Let me know if you need anything else.
Stephen J. Buell
Account Executive/Vice President
7205 th Avenue South, Suite 203
Naples, FL 34102
Tel 239 - 659 -4500 ext. 8
Steohen.buello-willis.com
See what we stand for and how we serve our clients at www.vAllis.comlwilliscause
Click here for a FLIMP message
From: Munkel, Kenneth W (Ken) 338 [ mailto: Kenneth. Munkel @CIGNA.com]
Sent: Friday, September 02, 20112:01 PM
To: 'ToppeAlice'; Buell, Stephen
Subject: RE: Dental Rates for 2012
Alice - for 2012, rates for the current Dental PPO plans would not change from current (2011) rates.
The Dental PPO rates will stay the same irrespective of whether the Dental HMO is offered.
Let me know if you need anything further. Thanks.
P.S. Enjoy your Labor Day weekend!
Ken Munkel
CIGNA HealthCare
Phone 404 -443 -8880
ken.munkel @cigna.com
From: ToppeAlice [mailto:AliceToppe @colliergov.net]
Sent: Thursday, September 01, 20119:31 AM
To: Munkel, Kenneth W (Ken) 338; Buell, Stephen
Subject: Dental Rates for 2012
Packet Page -493-
10/11/2011 Item 10.C.
Just checking to see if our rates are staying the same or changing for 1/1/12 whether or not we go with the HMO
option.
Irk.
Group Insurance Manager
Risk Ma♦
alicetoppe@colIiergov.net
Office: 239-252-8966
r'
ok:
HIPAA Disclosure- The information contained in this message may be privileged and /or confidential and
protected from disclosure. If the reader of this message is not the intended recipient or agent responsible for
delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution or
copying of this communication is strictly prohibited. if you have received this communication in error, please
notify the sender immediately by replying to this message and deleting the material from any computer.
Packet Page -494-
-
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10/11/2011 Item 10-C.
Collier County Board of
Commissioners
CIGNA DENTAL PREFERRED
PROVIDER INSURANCE
(Basic Plan)
EFFECTIVE DATE: January 1, 2009
This document printed in February. 2010 takes the place ofany documents previously issued to you which
described your benefits.
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10/11/2011 Item 10.C.
Table of Contents
FederalRequirements .................................................................................... .............................17
Notice of Provider Directory' Networks ................................................................................... .............................17
Qualified Medical Child Support Order (QMCSO) . ....... ............. ... ....... ............ ........................... ................. -.... 17
Effect of-Section 125 Tax Regulations on This Plan ............................................................... .............................18
Eligibility for Coverage for .Adopted Chil dren ........................................................................ .............................18
Federal Tax Implications for Dependent Coverage ................................................................. .............................19
Croup Plan Coverage Instead of Medicaid .............................................................................. .............................19
Requirements of Medical Leave Act of 1993 ( FMLA) ................................................. ............................... 19
Uniformed Services Employment and Re- Employment Rights Act of 1494 ( USERRA) ....... .............................19
Noticeof an Appeal or a Grievance ....................................................._.............-...........,...,... ......,,,.,..................20
WhenYou Have a Complaint or an Appeal ................... .......................... .............................20
Definitions........................................................................................................ .............................21
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Certification ..............:....................................................................................... ........................,.....4
Iow To File Your Claim ................................................................................. ..............................6
Accidentand Health Provisions ...................................................................... ..............................6
Eligibility— Effective Date ............................................................................... ..............................6
WaitinuPeriod ...................... ..................................................................................................................................
7
EmployeeInsurance...... .... ......................... ................................................
.............................................. ...7
DependentInsurance... ........ ...............................................................................................................
...... 7
CIGNADental Preferred Provider Insurance .............................................. ..............................8
TheSchedule ....... .. ...................... .................. ..... ........... _ ................................................
........................... . .......... ,8
CoveredDental Expense .........................................................................................................
.............................10
Dental PPO - Participating and Non- Participating Providers ...........................
- ........... ......... .................. ....,...... 10
ExpensesNot Covered ............................................................................................................
.............................12
GeneralLimitations ........................................................................................
.............................12
Dental B enefits .................................................. ............................ .................................._
...
......................._....... 12
Coordinationof Benefits .....................................................................
............................... ......13
Expenses For Which A Third Party May lie Liable ....................................
.............................15
Paymentof Benefits ........................................................................................
.............................15
Terminationof Insurance ................................................................................
............................1.5
Employees....... ....... ..................................... .......... .............. .... - .....................
..................................... ........... 15
Dependents... ... ,........... .,. .......... .............................................................................................
............................... 16
Special Continuation of Dental insurance for Dependents of Military Reservists ............................. ..................16
DentalBenefits Extension ...............................................................................
.............................17
FederalRequirements .................................................................................... .............................17
Notice of Provider Directory' Networks ................................................................................... .............................17
Qualified Medical Child Support Order (QMCSO) . ....... ............. ... ....... ............ ........................... ................. -.... 17
Effect of-Section 125 Tax Regulations on This Plan ............................................................... .............................18
Eligibility for Coverage for .Adopted Chil dren ........................................................................ .............................18
Federal Tax Implications for Dependent Coverage ................................................................. .............................19
Croup Plan Coverage Instead of Medicaid .............................................................................. .............................19
Requirements of Medical Leave Act of 1993 ( FMLA) ................................................. ............................... 19
Uniformed Services Employment and Re- Employment Rights Act of 1494 ( USERRA) ....... .............................19
Noticeof an Appeal or a Grievance ....................................................._.............-...........,...,... ......,,,.,..................20
WhenYou Have a Complaint or an Appeal ................... .......................... .............................20
Definitions........................................................................................................ .............................21
Packet Page -497-
10/11/2011 Item 10.C.
1pyine bllaon?field. Connecticut
Mailing Address: ljariford Connecticut 06152
( 4)NNECTICUT GENERAL LIFE INSURANCE COMPANY
a C IGNA company (called CG) certifies that it insures certain Employees for the benefits provided by the
collowinc, policy(s):
I*()1ACVHOLDER- Collier County Board of Commissioners
6,ROUP POLICY(S) -- COVERAGE
3215448-DPPOB CIGNA DENTAL PREFERRED PROVIDER IN St.] RANCE
EFFECTIVE DATE: January 1, 2009
CERTIFICATEHOLDER:
THE DENTAL BENEFITS IN THIS CERTIFICATE CONTAIN A DEDUCTIBLE PROVISION.
This certificate describes the main features of the insurance- It does not waive or alter any of the terms of
the policv(s). If questions arise, the policy(4) will s--yovern.
111is cert'ificate takes the place of any other issued to you on a prior date which described the insurance.
L,
Deborah Young, Cor-porate -Vecl'etall'
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10/11/2011 Item 10.C.
Explanation of Terms
You will find terms starting with capital letters throughout your certificate. To help you understand your benefits, most of these terms
are defined in the Definitions section oi'your certificate.
The Schedule
The Schedule is a brief outline of your maximum benefits which may be payable under your insurance. For a full description
of each benefit, refer to the appropriate section listed in the Table of''Contents.
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10/11/2011 Item 10.C.
"..a
:�,(.;NA 1jealthCare
does not get these claim forms within 15 days after CG
receives notice of claim, fie will be considered to meet the
How To File Your Claim
proof of loss requirements of the policy if he submit,, written
The prompt filing of any required claim form will result in
proof of loss within 90 days after the date of loss. This proof
describe the occurrence, character and extent of the loss
faster payment of your claim.
the required claim forms from your Benefit Pian
must
for which claim is made.
You may get
Administrator. All fully completed claim forms and bills
Proof of Loss
should be sent directly to your servicing CG Claim office.
Written proof of loss must be given to CG within 90 days after
the date of the loss for which claim is made. if written proof of
Dental Expenses
The first Dental Claim should be filed as soon as you have
loss is not given in that time, the claim will not be invalidated
or reduced if it is shown that written proof of loss was given as
incurred covered expenses. itemized copies of your bills
be sent with the claim form. If you have any additional
soon as was reasonably possible.
should
bills after the first treatment, file them periodically.
Physical Examination
us Predetermination of Benefits procedure
You must follow the Predetermin,
nine any
CG, at its own expense, will have the right to examine
for -whom claim is pending as often as it may
when it is necessary for dental forms.
person
CLAIM REMINDERS:
reasonably require.
BE SURE TO USE YOUR MEMBER ID AND
Legal Actions
ACCOUNTNUMBER WHEN YOU FILE CG'S CLAIM
Where CG has, followed the terms of the policy, no action at
FORMS, OR WHEN YOU CALL YOUR CG CLAIM
law or in equity will be brought to recover on the policy until
OFFICE.
at least 60 days after proof of loss has been filed with CG. No
YOUR MEMBER ID IS THE ID SHOWN ON YOUR
action will be brought at all unless brought within 3 years after
tile tirrievvithin which proof of loss is required.
BENEFIT IDENTIFICATION CARD.
YOUR ACCOUNT NUMBER IS THE 7 -DIGIT POLICY
NUMBER SHOWN ON YOUR BENEFIT
GM6000 CLA43V6
IDENTIFICATION CARD.
PROMPT FILING OF ANY REQUIRED CLAIM FORMS
RESULTS IN FASTER PAYMENT OF YOUR CLAIMS.
Eligibility — Effective Date
WARNINC: Any pet-son who knowingly presents a false or
Eligibility for Employee Insurance
fraudulent claim for payment of loss or benefit is guilty of a
You will become eligible for insurance oil the day you
crime and may be subject to fines and confinement in prison.
complete the waiting period if-,
• you are in a Class of Eligible Employees-, and
GN16000C119 CLAHVIO
• you are an eligible. full-time Employee; and
• you normally work at least 30 hours a week.
Accident and Health Provisions
If you were previously insured and your insurance ceased, you
must satisfy the waiting period to become insured again. If
Claims
your insurance ceased because you were no longer employed
Notice of Claim
in a Class of Eligible Employees, you are not required to
if - again become a member of
Written notice of claim must be given to CG within 30 days
after the occurrence or start of the loss on which clairn is
satisfy any waiting period you
Class of Eligible Employees within one year after your
based. If notice is not given in that time., the claim will not be
insurance ceased.
invalidated or reduced if it is shown that written notice was
Eligibility for Dependent Insurance
given as soon as was reasonably possible.
ter
You will become eligible for Dependent insurance on the later
Claim Forms
of'.
When CG receives the notice of claim, it will give to the
* the day you become eligible for yourself, or
claimant, or to the Policyholder for the claimant, the claim
- the day you acquire your first Dependent.
forms which it uses for Filing proof of loss. If the claimant
6 rnVC C.NAXOT
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02A
CIGNA HealtbCare
Waiting Period
If the date of hire is the first day of the
month, then coverage begins oil the date of hire.
If the date of hire is other than the first dav of the month- then
coverage begins on the first day of the month following the
date of'hire.
Classes of Eligible Employees
Each Employee as reported to the insurance company by your
Employer.
(A16000 1, 1, 1
Einployce Insurance
V-32
FL16 hi
This plan is offered to you as an Employee. To be insured, you
will have to pay part of the cost.
Effective Date of Your Insurance
You will become insured on the date you elect the insurance
by signing all approved payroll deduction form, but no earlier
than the date you become eligible. If you are a Late Entrant,
your insurance will not become effective until CG agrees to
insure you.
You will become insured on your first day of eligibility,
hollowing your election, if you are in Active Service on that
date, or if you are not in Active Service on that date due to
your health status. I lowever, you will not be insured for ,my
loss of life, dismemberment or loss of income coverage until
you are in Active Service.
Late Entrant — Employee
You are a Late Entrant if-
you elect the insurance more than 30 days after you become
eli-I= ible, or
you again elect it after you cancel your payroll deduction.
CC may require evidence of good health to be provided at
your expense if you are a Late Entrant.
10/11/2011 Item 10.C.
Late Entrant — Employee Waiting Period for Major
Treatment
bate Entrant means your enrollment forill is received by CC,
30 days after your date of eligibility. Ifyou area Late Entrant,
your coverage will become effective on the date Your
enrollment form is received. During the first 12 consecutive
months of coverage, your dental benefits will be limited to
"Preventive Services" on the list of procedures shown on the
"Dental Services Schedule."
However, if you incur expenses for a Covered Dental In i jury
more than 90 days after VOLT become a late applicant, benefits
will be paid for that Covered Dental Injury subjJect to all other
dental plan provisions.
("Motor EF I EI-17VS2
Dependent Insurance
For your Dependents to be insured, you will have to pay part
of the cost of Dependent Insurance.
Effective Date of Dependent Insurance
Insurance for your Dependents will become effective oil the
(late you elect it by signing an approved payroll deduction
form, but no earlier than the day you become eligible for
Dependent Insurance. All of your Dependents as defined will
be included. A newborn child will be covered for the first 31
days of life even if you fail to enroll the child, Coverage for an
adopted child will becorne effective from the date of
placement in Your home or from birth even if VOLT Phil to enroll
the child_
If you are a Late Entrant for Dependent Insurance, the
insurance for each of your Dependents wilt not become
effective until CG agrees in writing to insure that Dependent.
Your Dependents will be insured only if you are insured.
Late Entrant — Dependent
You are a Late Entrant for Dependent Insurance if:
• you elect that insurance more than 30 days after you
become eligible for it, or
• you again elect it after you cancel Your payroll deduction.
CG inay require evidence of your Dependents good health at
Your expense if you are a Late Entrant.
FF , E111 V3
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10/11/2011 Item 10.C.
�! IGNA HeaEltltC;are
I
CIl�IA Denfial Pareferred Provider Insuranr� ;
The S herlu[e
for You and Your Dependents - -YI
The Dental Benefits Plan offered by your Employer includes Participating and Non - Participating Providers. If you
select a Participating Provider, your cost will be less than if you select a Non - Participating Provider.
Emergency- Services
The Benefit Percentage payable for Emergency Services charges made by a Non - Participating Provider is the same
Benefit Percentage as for Participating Provider Charges. Dental Emergency services are required immediately to either
alleviate pain or to treat the sudden onset of an acute dental condition. These are usually minor procedures performed in
response to serious symptoms, which temporarily relieve significant pain, but do not effect a definitive cure_ and which,
if not rendered, will likely result in a more serious dental or medical complication.
Deductibles
Deductibles are expenses to be paid by you or your Dependent. Deductibles are in addition to any Coinsurance. O rce
the Deductible maximum in The Schedule has been reached you and your family need not satisfy any further dental
deductible for the rest of that year.
Participating Provider Payment �_ - .---- - - - - -- - '
Participating Provider services are paid based on the Contracted Fee agreed upon by the provider and CG.
Non- Participating Provider Payment
Non- Participating Provider services are paid based on the Maximum Reimbursable Charge. For this plan, the Maximum
Reimbursable Charge is calculated at the 95th percentile of all provider charges in the geographic area.
Simultaneous Accumulation of Amounts
Expenses incurred for either Participating or non - Participating Provider charges will be used to satisfy both tine
Participating and non - Part icipating Provider Deductibles shown in the Schedule.
Benefits paid for Participating and non - Participating Provider services will be applied toward both the Participating and
non - Participating Provider maximum shown in the Schedule.
e ..
.. 6
..O I
V DER A
Classes 1, 11, 111 Combined $1000
Calendar Year Maximum I
Class V Lifetime Maximum $1000 � $1000
_ _..__.- ..- ..._._._.. - --
Calendar Year Deductible
Individual $50 per person
Family Maximum — _ $150 per family
Class I
Preventive Care � 100% 100
i
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10/11/2011 Item 10.C.
CIGNA HeaitbC are
mvC"IGNA.com
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n11
CIGNA Healtll(;are
Covered Dental Expense
Covered Dental Expense means that portion of a Dentist's
charge that is payable for a service delivered to a covered
person provided:
• the service is ordered or prescribed by a Dentist-,
• is essential for the Necessary care of teeth;
• the service is within the scope of coverage limitations;
• the deductible amount in The Schedule has been met;
• the maximum benefit in The Schedule has not been
exceeded;
• for Class 1. 11 or III the service is started and completed
while coverage is in effect, except for services described in
the "Benefits Extension" section.
ON16000 DFNI 1 (10
Predetermination of Benefits
Predetermination of Benefits is a voluntary review of a
Dentist's proposed treatment plan and expected charges. It is
not preauthorization of service and is not required.
The treatment plan should include supporting pre-operative x-
rays and other diagnostic materials as requested by CG's
dental consultant. Ifthere is a change in the treatment plan, a
revised plan should be Submitted.
C(.j will determine covered dental expenses for the proposed
treatment plan. If there is no Predetermination of Benefits, CG
will determine covered dental expenses when it receives a
claim.
Review of proposed treatment is advised whenever extensive
dental work is recommended when charges exceed $200.
Predetermination of Benefits is not a guarantee of a set
payment. Payment is based on the services that are actually
delivered and the coverage in force at the time services are
completed.
GM6000 DFIN161 r17
10/11/2011 Item 10.C.
Covered Services
The following section lists covered dental services. CG may
agree to cover expenses for a service not listed. To be
considered the service should be identified using the American
Dental Association I Jmform Code ot'Dental Procedures and
Nomenclature, or by description and then submitted to CG.
GM6000 DFNI I 66V'
Dental PPO — Participating and Non-
Participating Providers
Non -
Participating
Pavment for a service delivered by a Participating Provider is
the Contracted Fee, times the benefit percentage that applies to
the class of service, as specified in the Schedule.
The covered person is responsible for the balance of the
Contracted Fee.
Pavment for a service delivered by a non- Participating
Provider is the Maximum Reimbursable Charge times the
benefit percentage that applies to the class of service, as
specified in the Schedule.
The covered person is responsible for the balance of the
provider's actual charge.
(i%460CA) DES426
Class I Services — Diagnostic And Preventive
Clinical oral examination — Only 2 per person per 12
consecutive months.
X-rays --- Complete series — Only one per person, including
Panoramic filin, in any 60 consecutive months.
Bitewing x-rays -- Only one set of 4 files per III consecutive
months.
Panoramic (Panorex) x-ray -- Only one per person in any 60
Consecutive months.
Prophylaxis (Cleaning) — Only 2 per person per calendar year.
periodontal maintenance procedures (following active therapy,
Periodontal Prophylaxis — Only 2 per pet-son per calendar
year.
Topical application of fluoride (excluding prophylaxis) --
Limited to persons less than 14 years old.
Only one per person
per 12 consecutive months.
IIE
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10/11/2011 Item 10.C.
CIGNA HealthCare
Topical application of sealant, per tooth, on a posterior tooth when administered in conjunction with complex oral surgical
for a person less than 14 years old — Only one treatment per procedures which are covered tinder this plan.
tooth per lifetime.
Space Maintainers, fixed unilateral -- Limited to OW100 DES�98 %I V7
nonorthodontic treatment,
GNUI(ftl DESNIV5
Class 11 Services — Basic Restorations, Enclodontics,
Periodontics, Prosthodontic Maintenance And Oral
Surgery
Palliative (emergency) treatment of dental pain, minor
procedures, when no other definitive Dental Services are
performed. (Any x-ray, taken in connection with such
treatment is a separate Dental Service.)
Amalgam Filling
Composite/Resin Filling
Root Canal Therapy -- Any x-ray, test, laboratory exam or
fol low-up care is part of the allowance for root canal therapy
and not a separate Dental Service — re-treatment: one per 24
consecutive months if necessity demonstrated.
Osseous Surgery - f1ap entry and closure is part of7the
allowance for osseous surgery and not a separate Dental
Service.
Periodontal Scaling and Root Planing -, Entire Mouth
Routine Extractions
Surgical Removal of Erupted Tooth Requiring Elevation of
Mucopericisteal Flap and Removal of Bone and/or Section of'
Tooth
Removal of impacted Tooth, Soft Tissue
Removal of Impacted Tooth, Partially Bony
Removal of Impacted Tooth. Completely Bony
Local anesthetic, analgesic and routine postoperative care for
extractions and other oral surgery procedures are not
separately reimbursed but are considered as part of the
submitted fee for the global Surgical procedure.
General Anesthesia — Paid as a separate benefit only when
Medically or Dentally Necessanw, as determined by CG, and
when administered in conjunction with complex oral surgical
procedures which are covered under this plan.
1. V. Sedation -- Paid as a separate benefit only when
Medically orDentally Necessary, as determined by CG, and
when administered in conjunction with complex oral surgical
procedures which are covered tinder this plan.
Nitrous Oxide — Paid as a separate benefit only when
Medically or Dentally Necessary., as determined by CG, and
Class III Services - Major Restorations, Dentures and
Bridgework
Adjustments -- Complete Denture
Adjustments only covered one time in any 12 consecutive
month period, and only if'performed more than 12
consecutive months after the insertion of the denture.
Rebasing and Relining
Relining Dentures, Rebasing Dentures - Limited to relining
or rebasing done more than 12 consecutive months after the
initial insertion. and then not more than one time in any
consecutive 36-month period.
Recement Bridge
Repair, to Dentures and Bridges
Repairs to Full and Partial Dentures - Limited to repairs
performed more than 12 consecutive months after initial
insertion.
Recenient Fixed Partial Denture - Limited to repairs
performed more than 12 consecutive months after initial
insertion.
Fixed partial Denture Repair, by Report — Limited to repairs
performed more than 12 consecutive months after initial
insertion.
Crowns
Note: Crown restorations are Dental Services only when the
tooth, as a result of extensive caries or fracture, cannot be
restored with amalgam, compositeiresin, silicate, acrylic or
plastic restoration.
Porcelain Fused to High Noble Metal
Full Cast, High Noble Metal
Threc-Fourths Cast, Metallic
Removable Appliances
Complete (Full) Dentures, tipper or Lower
Partial Dentures
Lower, Cast Metal Base with Resin Saddles (including any
conventional clasps, rests and teeth)
Lipper, Cast Metal Base with Resin Saddles (including any
conventional clasps rests and teeth)
Fixed Appliances
Bridge Poritics - Cast High Noble Metal
Bridge Pontics - Porcelain Fused to High Noble Metal
mvCIGNA.com
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"�WA
I CICTNA HealtbCare
Bridge Pontics - Resin with High Noble Metal
Retainer Crowns - Resin with High Noble Metal
Retainer Cro,,vns - Porcelain Fused to High Noble Metal
Retainer Crowns - Full Cast High Noble Metal
implants — Covered Dental Expenses include: the surgical
placement of the implant body or framework of any type; any
device, index, or surgical template guide used for implant
surgery-, prefabricated or custom implant abutments; or
removal of an existing implant. Implant removal is covered
only if the implant is not serviceable and cannot be repaired.
Prosthesis Over implant — A prosthetic device, supported by
an implant or implant abutment. is a Covered Expense.
Replacement of any type of prosthesis with a prosthesis
supported by an implant or implant abutment is only payable
if the existing prosthesis is at least 60 consecutive months old,
is not serviceable and cannot be repaired.
(j,06000 DES3fY2 V5 M
Class V Services - Ternporomandibular Joint Dysfunction
Only the Dental Services listed below will be considered
covered expenses for the treatment of Temporornandibular
Joint Dysfunction.
Office Visit - Adjustment to Appliance
No more than 6 adjustments in 6 consecutive months after
seating or placement of appliance.
Transcutaneous Electro-neural Stimulation
No More than 4 treatments in a 6 -month period.
Trigger Point Injection of Local Anesthetic into Muscle
Fascia
No more than 4 treatments in a 6-month period.
Mandibular Orthopedic Repositioning Appliance
Only one appliance per person in any 5 year period.
DEP&M
Expenses Not Covered
(.','overed Expenses will not include, and no payment will be
made for:
• service,,,, performed solely for cosmetic reasons;
• replacement of a lost or stolen appliance,,
• replacement of a bridge, crown or denture within 5 years
after the date it was originally installed unless: a) the
replacement is made necessary by the placement of an
original opposing full denture or the necessary extraction of
natural teeth-, or (b) the bridge., crown or denture, while in
l2
10/11/2011 Item 10.C.
the mouth, has been damaged beyond repair as a result of an
injury received while a person is insured for these benefits,
• any replacement of a bridge, crown or denture which is or
can be made useable according to common dental standards;
• procedures, appliances or restorations (except full dentures)
whose main purpose is to: (a) change vertical dimension; (b)
dimmose or treat conditions or dysfunction of the
temporomandibular joint except as shown in The Schedule:
(c) stabilize periodontally involved teeth-, or (d) restore
occlusion;
• porcelain or acrylic veneers of crowns or pontics on, or
replacing the tipper and lower first. second and third molars,
• bite registrations; precision or serniprecision attachments; or
splinting.
(W16000 DEN, I K" M
• instruction for plaque control, oral hygiene and diet;
• dental services that do not meet common dental standards;
• services that are deemed to be medical services;
• services and supplies received from a Hospital',
• orthodontic treatment;
services for which benefits are not payable according to the
"General Limitations" section.
GM6000 DEN 186
General Limitations
Dental Benefits
No payment will be made for expenses incurred for you or any
one of your Dependents:
• far services related to an Injury or Sickness paid and/or
received under workers' compensation, occupational disease
or similar laws;
• for charges made by a Hospital owned or operated by or
which provides care or performs services for, the United
States Government, if such charges are directly related to a
military-service-connected condition;
• services or supplies received as a result of'dental disease,
defect or injury due to an act of war, declared or undeclared-.
• to the extent that payment is unlawful where the person
resides when the expenses are incurred;
• For charges which the person is not legally required to pay:
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CIGNA flealthCare
• for charges which would not have been made if the person
had no insurance,
• to the extent that billed charges exceed the rate of
reimbursement as described in the Schedule;
• for charges for unnecessary care, treatment or surgery;
V I
• to the extent that you or any of your Dependents is in any
way paid or entitled to payment for those expenses by or
through a public program, other than Medicaid;
• for or in connection with experimental procedures or
treatment methods not approved by the American Dental
Association or the appropriate dental specialty society.
(4,46000 UEN I 16V"
Coordination of Benefits
'Phis section applies if you or anN1 one of your Dependents is
covered under more than one Plan and determines how
benefits payable from all such Plans will be coordinated. You
should file all claims with each Plan.
Definitions
For the purposes of this section, the following terms have the
meanings set forth below:
Plan
Any of the following that provides benefits or services for
dental care or treatment:
(1) Group insurance and/or group -type coverage, whether
insured or self-insured which neither can be purchased by
the general public. nor is individually underwritten,
including, closed panel coverage.
(2) Governmental benefits as permitted by law., excepting
Medicaid. Medicare and Medicare supplement policies.
(3) Medical benefits coverage of group, group-type, and
individual automobile contracts.
Each Plan or part of a Plan which has the right to coordinate
benefits will be considered a separate Plan.
Closed Panel Plan
A Plan that provides medical or dental benefits primarily in
the form of services through a parcel of employed or
contracted providers, and that I imits or excludes benefits
provided by proyiders outside of the panel. except in the case
of emergency or if referred by a provider within the panel.
Primary Plan
ne Plan that determines and provides or pays benefits
Without taking into consideration the existence of any other
Plan.
13
10/11/2011 Item 10.C.
Secondary Plan
A Plan that deten-nines, and may reduce its benefits after
taking into consideration, the benefits provided or paid by the
Primary Plan. A Secondary Plan may also recover from the
Primary Plan the Reasonable Cash Value of any services it
provided to you.
GM6()00 COB I I
Allowable Expense
M
A necessary, reasonable and customary service or expense,
including deductibles, coinsurance or . copayments, that is
covered in full or in part by any Plan covering you. When a
Plan provides benefits in the form of services, the Reasonable
Cash Value of each service is the Allowable Expense and is a
paid benefit.
Examples of expenses or services that are not Allowable
Expenses include, but are not limited to the following:
(1) An expense or service or a portion of an expense or
service that is not covered by any of the Plans is not an
Allowable Expense.
(2) If you are covered by two or more Plans that provide
services or supplies on the basis of reasonable and
customary fees, any amount in excess of the highest
reasonable and customary fee is not an Allowable
Expense.
(3) If you are covered by one Plan that provides services or
supplies on the basis of reasonable and customary fees
and one Plan that provides services and supplies on the
basis of negotiated fees, the Primary Plan's fee
arrangement shall be the Allowable Expense.
(4) 1 f your benefits are reduced under the Primary Plan
(through the imposition of a higher copa.yment amount,
higher coinsurance percentage, a deductible and' 'or a
penalty) because you did not comply with Plan provisions
or because you did not use a preferred provider, the
amount of the reduction is not an A I lowable Expense.
Such Plan provisions include second surgical opinions
and precertification of admissions or services.
Claim Determination Period
A calendar year, but does not include any part of a year during
which you are not covered under this policy or any date before
this section or any similar provision takes effect.
01146,0001 COB 12
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CIGNA HealthCare
Reasonable Cash Value
An amount which a duly licensed provider of health care
services usually charges patients and which is within the range
of fees usually charged for the same service by other health
care providers located within the immediate geographic area
where the health care service is rendered under similar or
comparable circumstances.
Order of Benefit Determination Rules
A Plan that does not have a coordination of benefits rule
consistent with this section shall always be the Primary Plan.
If the Plan does have a coordination of benefits rule consistent
with this section, the first of-the following rules that applies to
the situation is the one to use:
(1) The Plan that covers you as an enrollee or an employee
shalt be the Primary Plan and the Plan that covers you as a
Dependent shall be the Secondary Plan;
(2) If you are a Dependent child whose parents are not
divorced or legally separated, the Primary Plan shall be
the Plan which covers the p<u•ent whose birthday falls first
in the calendar year as an enrollee or employee;
(3) If you are the Dependent of divorced or separated parents,
benefits for the Dependent shall be determined in the
following., order:
(a) first, if a court decree states that one parent is
responsible for the child's healthcare expenses or
health coverage and the flan for that parent has actual
knowledge of tine terms of the order, but only from
the time of actual knowledge;
(b) then, the Plan of the parent with custody of the child:
(c) then, the Plan of the spouse of the parent with custody
of the child;
(d) then, the Plan of the parent not having custody of the
child, and
(c) finally, the Plan of the spouse of the parent not having
custody of the child.
61400(x, rou i
(4) The Plan that covers you as an active employee (or as that
employee's Dependent) shall be the Primary Plan and the
['Ian that covers you as laid -off or retired employee (or as
that employee's Dependent) shall be the secondary Plan.
If the other Plan does not have a similar provision and, as
a result, the Plans cannot agree on the order of benefit
determination, this paragraph shall not apply.
(5) The Plan that covers you under a right of continuation
which is provided by federal or state law shall be the
Secondary Pian and the Plan that covers you as an active
employee or retiree (or as that employee's Dependent)
14
10/11/2011 Item 1O.C.
shall be the Primary Plan. if the other Plan does not have
a similar provision and, as a result, the Plans cannot agree
on the order of benefit determination. this paragraph shall
not apply.
(6') If one of the Plans that covers you is issued out of the
state whose laws govern this Policy, and determines the
order of benefits based upon the gender of a parent, and as
a result, the Plans do not agree on the order of benefit
determination, the Plan with the gender rules shall
determine the order of benefits.
I f none of the above rules determines the order of benefits, tfre
Plan that has covered you for the longer period of time shall
be primary.
Effect on the Benefits of This Plan
If this Plan is the Secondary Plan, this Plan may reduce
benefits so that the total benefits paid by all Plans during a
Claim Determination Period are not more than 100°,'0 of the
total of all Allowable Expenses.
'The difference between the amount that this Plan would have
paid if this Plan had been the Primary Plan, and the benefit
payments that this Plan had actually paid as tine Secondary
Plan, will be recorded as a benefit reserve for you. C(} will use
this benefit reserve to pay any Allowable Expense not
otherwise paid during the Claim Determination Period.
M
(7 M6(N)Cl 0.011 i d
As each claim is submitted, CCi will determine the following:
(1) CG's obligation to provide services and supplies under
this policy;
(2) whether a benefit reserve has been recorded for you; and
(3) whether there are any unpaid Allowable Expenses during
the Claims Determination Period.
If there is a benefit reserve, CC; will use the benefit reserve
recorded for you to pay up to 100°-�is of the total of al
Allowable Expenses. At the end of the Claim Determination
Period, your benefit reserve will return to zero and a new
benefit reserve will be calculated for cacti new Claim
Determination Period.
l;ecovery of Excess Benefits
if CG pays charges for benefits that should have been paid by
the Primary Plan, or if c(i pays charges in excess of those for
which we are obligated to provide under the Policy, CCs will
have the right to recover the actual payment made or the
Reasonable Cash Value of any services.
CG will have sole discretion to seek such recovery from any
person to, or for whom, or• with respect to whom. such
services were provided or such payments made by any
insurance company, healthcare plan or other organization. If
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we request, you must execute and deliver to us such
instruments and documents as we determine are necessary, to
SCCLII'e the right of recovery.
Rialit to Receive and Release information
CG, without consent or notice to you, may obtain information
from and release information to any other Plan with respect to
you in order to coordinate your benefits pursuant to this
section. You must provide us with any information we request
in order to coordinate your benefits pursuant to this section.
This request may occur in connection with a submitted claim;
if SO, VOU will be advised that the "other coverage"
information, (including an Explanation of Benefits paid under
the Primary Plan) is required before the claim will be
processed for payment. If no response is received within 90
days of the request, the claim will be denied. If the requested
information is subsequently received, the clairn will be
processed.
OM600000T315
Expenses For Which A Third Party May
Be Liable
This policy (foes riot cover expenses for which another party
may be responsible as a result of having caused or contributed
to the Injury or Sickness. If you incur a Covered Expense for
which, in the opinion of CG, another party may be liable:
L CG shall, to the extent permitted by law, be subrogated to
all rights, claims or interests which you may have against
such party and shall automatically have a lien upon the
proceeds of any recovery by you from such party to the
extent of any benefits paid under the Policy. You or your
representative shall execute such documents as may be
required to secure CG's subrogation rights.
2. Alternatively, CG May, at its sole discretion, pay the
benefits otherwise payable tinder the Policy. However, you
must First agree in writing to refund to CG the lesser of.
a. the amount actually paid for such Covered Expenses by
CG, or
b. the amount you actually receive from the third party for
such Covered Expenses,
at the time that the third party's liability is determined and
satisfied, whether by settlement, Judgment, arbitration or
award or otherwise.
C(T7 U( L7
ti
10/11/2011 Item 10.C.
Payment of Benefits
To Whom Payable
All Dental Benefits are payable to you. However, at the option
of CG and with the consent of the Policyholder, all or any part
of them may be paid directly to the person or institution on
whose charge claim is based.
If any person to whom benefits are payable is a minor or., in
the opinion of CG, is not able to give a valid receipt for any
payment due him, such payment will be made to his legal
guardian. If no request for payment has been made by his legal
guardian, CG may, at its option, make payment to the person
or institution appearing to have assumed his custody and
support.
If you die while any of these benefits remain unpaid, CG may
choose to make direct payment to any of your following living
relatives: spouse, mother, father, child or children, brothers or
sisters-, or to the executors or administrators of your estate.
Payment as described above will release CG from all liability
to the extent of any payment made,
Time of Payment
Benefits will be paid by CG when it receives due proof of loss.
Recovery of Overpayment
When an overpayment has been made by CG, CG will have
the right at any time to: (a) recover that overpayment from the
person to whom or on whose behalf it was made, or (b) Offset
the arnount of that overpayment from a future claim payment.
(W60001011 I Z MIT 115V 16
Miscellaneous
If you are a CIGNA Dental plan member as well as a member
o(a CIGNA medical plan, you may be eligible for additional
dental benefits durint, certain episodes of care. For example,
certain frequency limitations for dental services may be
relaxed for pregnant women, diabetics or those with cardiac
disease. Please review your plan enrollment materials for
details.
6111Sii()() 11011h
Termination of Insurance
Employees
Your insurance will cease on the earliest date below:
• the date you cease to be in a Class of Eligible Employees or
cease to qualify for the insurance.
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0 the last day for Which VOU have made any required
contribution for tile insurance.
• the date the policy is canceled.
• the last day of the calendar month in which your Active
Set-vice end,, except as described below.
Any continuation of insurance must be based on a plan which
precludes individual selection.
Temporary Layoff or Leave of Absence
if your Active Service ends due to temporary layoff or leave
of absence. your insurance will be continued until the date
your Employer: (a) stops paying premium for you, or (b)
otherwise cancels your insurance' 'However, your insurance
will not be continued for more than 60 days past the date your
Active Service ends.
Injury or Sickness
117your Active Service ends due to an Injury or Sickness. Your
insurance will be continued while you remain totally and
continuously disabled as a result of the Injiury or Sickness.
However, the insurance will not continue past the date your
Employer stops paying premium lor you or otherwise cancels
the insurance,
Retirement
If Your Active Service ends because you retire, your insurance
will be continued until the date on which your Employer stops
paying premium for you or otherwise cancels the insurance.
(;�,,J�,Ooo 'I R\1 I W44
Dependents
Your insurance for all Of your Dependents will cease on the
earliest date below:
• the date your insurance ceases.
• the date you cease to be eligible for Dependent Insurance-
• the last day for which you have made any required
contribution for the insurance.
• the date Dependent Insurance is canceled.
The insurance for any one of your Dependents will cease oil
the date that Dependent no longer qualities as a Dependent.
(WO)OO rRN1301
16
10/11/2011 Item 10.C.
Special Continuation of Dental Insurance for
Dependents of Military Reservists
If Your insurance ceases because you are called to active
military duty in: (a) the Florida National Guard; or (b) the
elect to continue
I..)nited States military reserves, you maN., ,
Dependent insurance, You must pay the required premiums to
the Policyholder if you choose to continue Dependent
insurance. In no event will coverage be continued beyond the
earliest of the following dates:
• the expiration of 30 days from the date the Employee's
military service ends;
• the last day for which the required contribution for
Dependent insurance has been made.
• the date the Dependent becomes eligible for insurance Linder
another group Policy. Coverage under the Civilian Health
and Medical Program of the Uniformed Services
(C) IA MPUS) is excluded from this provision.;
• the date the Dependent becomes eligible for Medicare;
• the date the group Policy cancels;
• the date the Dependent ceases to be an eligible Dependent.
IRMIgivi
CMORW ITAIII
Reinstatement of Dental insurance — Employees and
dependents
tjpo,, completion of your- active military duty in: (a) the
Florida National Guard-, or (b) the United States military
reserves, you are entitled to the reinstatement of your
insurance and that of your Dependents il'continuation of
Dependent insurance was not elected. Such reinstatement will
be without the application of: (a) any new waiting periods, or
(b) the Pre-existing Condition Limitation to any new condition
that you or your Dependent may have developed during the
period that coverage was interrupted due to active military
duty,
Provisions Applicable to Reinstatement
• You Must notif,\, your Employer, before reporting for
military duty, that you intend to return to Active Set-vice
with that Employer: and
• You must . notify Your Employer that you elect such
reinstatement within 30 days after returning to Active
Service with that Employer and pay any required premium.
(i M(,()UU I E106
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Dental Benefits Extension
An expense incurred in connection with a Dental Service that
is completed after a person's benefits cease for any reason
other than the person's failure to pay premiums will be deemed
to be incurred while he is insured if:
• the course of treatment was recommended in writing by the
physician and began while the person was insured for dental
benefits; and
• the Dental Service is other than a routine examination,
prophylaxis, x -ray, sealants or orthodontic services., and
• the Dental Service is performed within 90 days after his
insurance ceases.
The terms of this Dental Benefits Extension will not apply to a
person who becomes insured under another group policy for
similar dental benefits.
t;M6000 BEe 9EX 13 1 vz
Federal Requirements
The following; pages explain your rights and responsibilities
under federal laws and regulations. Some states may have
similar requirements. If similar provision appears elsewhere
in this booklet, the provision which provides the better benefit
will apply.
rumi,.i V2
Notice of Provider Directory /Networks
Notice Regarding Provider Directories and Provider
Networks
If your Plan utilizes a network of Providers, you will
automatically and without charge, receive a separate listing of
Participating Providers.
You may also have access to a list of Providers who
participate in the network by visiting www.eigna.com;
mycigna.com or by calling the toll -free telephone- number on
your ID card.
Your Participating Provider network consists of a group of
local dental practitioners, of varied specialties as well as
general practice, who are employed by or contracted with
CIGNA HealthCare or CIGNA Dental Health.
WHIM
10/11/2011 Item 10.C.
Qualified Medical Child Support Order
(QMCSO)
A. Eligibility for Coverage Under a QMCSO
If a Qualified Medical Child Support Order (QMCSO) is
issued for your child, that child will be eligible for coverage as
required by the order and you will not be considered a Late
Entrant for Dependent Insurance.
You must notify your Employer and elect coverage for that
child and yourself, if you are not alreadv enrolled, within 31
days of the QMCSO being issued.
B. Qualified Medical Child Support Order Defined
A Qualified Medical Child Support Order is a judgment,
decree or order (including approval of a settlement agreement)
or administrative notice, which is issued pursuant to a state
domestic relations law (including a community property law),
or to an administrative process, which provides for child
support or provides for health benefit coverage to such child
and relates to benefits under the group health plan, and
satisfies all of the following:
I. the order recognizes or creates a child's right to receive
group health benefits for which a participant or beneficiary
is eligible;
2. the order specifies your name and last known address, and
the child's name and last known address, except that the
name and address of an official of a state or political
subdivision may be substituted for the child's mailing
address;
3. the order provides a description of the coverage to be
provided, or the manner in which the type of coverage is to
be determined;
4. the order states the period to which it applies; and
5. if the order is a National Medical Support Notice
completed in accordance with the Child Support
Performance and Incentive Act of 1998, such Notice meets
the requirements above.
The QMCSO may not require the health insurance policy to
provide coverage for any type or form of benefit or option not
otherwise provided under the policy, except that an order may
require a plan to comply with State laws regarding health care
coverage.
1?
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C. Payment of Benefits
Any payment of benefits in reimbursement for Covered
Expenses paid by the child, or the child's custodial parent or
legal guardian, shall be made to the child, the child's custodial
Parent or legal guardian, or a state official whose name and
address have been substituted for the name and address of the
child.
V1
Effect of Section 125 Tax Regulations on This
Plan
Your Employer has chosen to administer this Plan in
accordance with Section 125 regulations of the Internal
Revenue Code. Per this regulation, you may agree to a pretax
salary reduction put toward the cost of your benefits.
Otherwise. VOL) will receive your taxable earnings as cash
(salary),
A. Coverage Elections
Per Section 125 regulations, You are generally allowed to
enroll for or change coverage only before each annual benefit
period. However, exceptions are allowed if your Employer
0—N agrees arid you enroll for or change coverage within 30 days
of (lie following:
the date you meet the criteria shown in the following
Sections B through F.
B. Change of Status
A change in status is defined as:
I , change in legal marital status due to marriage, death of
spouse, divorce, annulment or legal separation-,
2, change in number of Dependents due to birth, adoption,
placement for adoption, or death of a Dependent;
3, change in employment status or Employee, spouse Or
Dependent due to termination or start of employment,
strike, lockout, beginning or end of unpaid leave of
absence, including tinder the Family and Medical Leave
Act (['MLA), or change in worksite,
4, changes in employment status of Employee, spouse or
Dependent resulting in eligibility or ineligibility for
coverage:
5. change in residence of Employee. spouse or Dependent to
a location outside of the Employer's network service
area, and
6. chances which Cause a Dependent to become eligible or
ineligible for coverage.
19
10/11/2011 Item 10-C.
C. Court Order
A change in coverage due to and consistent with a court order
Of the Employee or other person to cover a Dependent.
D. Medicare or Medicaid E ligibil ity/En title men t
The Employee, spouse or Dependent cancels or reduce.,,
coverage due to entitlement to Medicare or Medicaid, or
enrol Is or increases coverage due to loss of Medicare or
Medicaid eligibility.
E. Change in Cost Of Coverage
If the cost of benefits increases or decreases during a benefit
period, your Employer may, in accordance with plan terms,
automatically change your elective contribution.
When the change in cost is significant, you may either
increase your contribution or elect less-costly coverage. When
a significant overall reduction is made to the benefit option
you have elected, you may elect, another available benefit
option. When a new benefit option is added, you may change
your election to the new benefit option.
F. Changes in Coverage of Spouse or Dependent Under
Another Employer's Plan
You may make a coverage election change if the plan of your
spouse or Dependent: (a) incurs a change such as adding or
deleting a benefit option; (b) allows election changes due to
Change in Status, Court Order or Medicare or Medicaid
Eligibility /Entitlement; or (c) this Plan and the other plan have
different periods of coverage or open enrollment periods.
fj)1z1_7t)
Eligibility for Coverage for Adopted Children
Any child under the age of 18 who is adopted by you,
including a child who is placed with you for adoption, will be
eligible for Dependent Insurance upon the date of placement
With You. A child will be considered placed for adoption when
you become legally Obligated to support that child, totally or
partially, prior to that child's adoption.
I I'a child placed for adoption is DOL adopted, all health
Coverage ceases when the placement ends, arid will not be
continued.
The provisions in the "Exception for Newborns- section of
this document that describe requirements for enrollment and
effective date of insurance will also apply to an adopted child
or a child placed with you for adoption.
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Federal Tax Implications for Dependent
Coverage
Premium payments for Dependent health insurance are usually
exempt from federal income tax. Generally, if you can claim
an individual as a Dependent for purposes of federal income
tax, then the premium for that Dependent's health insurance
coverage will not be taxable to you as income. However, in
the rare instance that you cover an individual tinder your
health insurance who does not meet the federal definition of a
Dependent, the premium may be taxable to you as income. If
you have questions concerning your specific situation, you
should consult your own tax consultant or attorney.
FIAL7
Group Plan Coverage Instead of Medicaid
If your income does not exceed 100% of the official poverty
line and your liquid resources are at or below twice the Social
Security income level, the state may decide to pay premiums
for this coverage instead of for Medicaid, if it is cost effective.
This includes premiums for continuation coverage required by
federal law.
12P111-10
Requirements of Medical Leave Act of 1993
(FM LA)
Any provisions of the policy that provide for: (a) continuation
Of insurance during a leave of absence; and (b) reinstatement
of insurance following a return to Active Service, are modified
by the following provisions of the federal Family and Medical
I-eave Act of 1993, where applicable:
A. Continuation of Health Insurance During Leave
Your health insurance will be continued during a leave of
absence if-
• that leave qualifies as a leave of absence tinder the Family
and Medical Leave Act of 1993; and
• you are an eligible Employee under the terms of that Act.
The cost of your health insurance during such leave must be
paid, whether entirely by your Employer or in part by you and
your Employer.
B. Reinstatement of Canceled Insurance Following Leave
Upon your return to Active Service following a leave of
absence that qualifies under the Family and Medical Leave
19
10/11/2011 Item 10.C.
Act of 1993, any canceled insurance (health, life or disability)
will be reinstated as of the date of your return.
You will not be required to satisfy any eligibility or benefit
waiting period or the requirements of any Pre-existing
Condition limitation to the extent that they had been satisfied
prior to the start of such leave of absence.
Your Employer will give you detailed information about the
Farnily and Medical Leave Act of 1993.
1, D Ril 0,
Uniformed Services Employment and Re-
Employment Rights Act of 1994 (USERRA)
The Uniformed Services Employment and Re- employment
Rights Act of 1994 (USERRA) sets requirements for
continuation of health coverage and re- employment in regard
to an Employee's military leave of absence. These
requirements apply to medical and dental coverage for You
and your Dependents. They do not apply to any Life. Short-
term or Long -tern Disability or Accidental Death &
Dismemberment coverage You may have.
A. Continuation of Coverage
For leaves of less than 31 days, coverage will continue as
described in the Termination section regarding Leave of
Absence.
For leaves of 31 days or more, you may continue coverage for
yourself and y out-Dependents as follows:
You may continue benefits by paying the required premium to
your Employer, until the earliest of the following:
C,
* 24 months from the last day of employment with the
Employer.
* the day after you fail to return to work; and
* the date the policy cancels,
Your Employer may charge you and your Dependents up to
102% of the total premium.
Following continuation of health coverage per USERRA
requirements, you may convert to a plan of individual
coverage according to any "Conversion Privilege" shown in
your certificate.
B. Reinstatement of Benefits (applicable to all coverages)
If your coverage ends during the leave of absence because you
do not elect USERRA or an available conversion plan at the
expiration of USERRA and you are reemployed by your
current Employer, coverage for you arid your Dependents may
be reinstated if (a) you pave your Employer advance written or
verbal notice of your military service leave, and (b) the
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CIC,T-JA HeatflICAtte
duration of all military leaves while you are employed with
your current Employer does not exceed 5 years.
You and your Dependents will be subject to only the balance
of a Pre-Existing- Condition Limitation ([,Cl,) or waiting
period that was not yet satisfied before the leave began.
However, if an Injury or Sickness occurs or is aggravated
during the military leave, full Plan limitations will apply.
Any 63-day break in coverage rule regarding credit for time
accrued toward a PCI.., waiting period will be waived.
If your coverage under this plan terminates as a result of your
eligibility for military medical and dental coverage and your
order to 'active duty is canceled before your active dutti, service
commences, these reinstatement rights will continue to apply.
MIR1,58
Notice of an Appeal or a Grievance
'Hle appeal or grievance provision in this certificate may be
superseded by the law of your state. Please see your
explanation ofbenefits for the applicable appeal or grievance
procedure.
(;NJf,0tK) N101111)
The Followinff Will Apply To Residents of
Florida
When You Have a Complaint or an
Appeal
For the purposes of this section, any reference to "you your"
or "Member" also refers to a representative or provider
designated by you to act on your behalf'. unless otherwise
rioted.
we want you to be completely satisfied with the care you
receive. That is why we have established a process for
addressing your concerns and solving your problems.
Start with Member Services
We are here to listen and help. if you have a concern regarding
;.i person. a -service, the quality of care, or contractual benefits.
you can call cur toll-free number and explain your concern to
one Of Our Customer Service representatives. You can also
express that concern In writing. Please call or write to us at the
following: :
Customer Services Toll-Free Number or address that
appears on your Benefit Identification card, explanation
of benefits or claim fOrM.
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10/11/2011 Item 10.C.
We will do our best to resolve the matter on your initial
contact. if we need more time to review or investigate your
concern, we will get back to you as soon as possible, but in
any case within 30 days.
If you are not satisfied with the results of a coverage decision,
you can start the appeals procedure.
Appeals Procedure
CG has a two step appeals procedure for coverage decisions.
,I,o initiate an appeal, you must submit a request for an appeal
in writing within 365 days of receipt of a denial notice. You
should state the reason why you feel your appeal should be
approved and include any information Supporting your appeal
if you are unable or choose not to write, you may ask to
register your appeal by telephone. Call or write to us at the
toll-free number or address on your Benefit Identification
card, explanation of'beriefits or claim form.
"I
coNW00 APL610
Level One Appeal
Your appeal will be reviewed and the decision made by
someone not involved in the initial decision. Appeals
involving Medical Necessity or clinical appropriateness will
be considered by a health care profession,].
For level one appeals, we will respond in writing with a
decision within 30 calendar days after we receive an appeal
for a postserviec coverage determination. If more time or
information is needed to make the determination, we will
notify you in writing to request an extension of up to 15
calendar days and to specify any additional information
needed to complete the review.
Level Two Appeal
if you are dissatisfied with our level one appeal decision, you
may request a. second review. To start a level two appeal,
follow the same process required for a level one appeal.
Most requests for a second review will be conducted by the
Appeals Committee, which consists of at least three people.
Anvone involved in the prior decision may not vote on the
Committee. For appeals involving Medical Necessity Or
clinical appropriateness, the Committee will consult with at
least one Dentist reviewer in the same or similar specialty as
the care under consideration, as determined by C.Gs Dentist
reviewer. You may present your situation to the Committee in
person or by conference call.
V2
9 'ININXIO AN 611
For level two appeals we will acknowledge in writing that we
have received your request and schedule a Committee review.
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CIGNA HealtbCare,
For postservice claims, the Committee review will be
completed within 30 calendar days. If more time or
information is needed to make the determination, we will
notify You in writing to request an extension of up to 15
calendar days and to specify any additional information
needed by the Committee to complete the review. You will be
notified in writing of the Committee's decision Within five
working days after the Committee meeting, and within the
Committee review time frames above if the Committee does
not approve the requested coverage.
C,M6()()O AP1,612 V1
Appeal to the State of Florida
You have the right to contact the state regulators for assistance
at any time. The state regulators may be contacted at the
following addresses and telephone numbers:
The Statewide Provider and Subscriber Assistance Panel
Fort Knox Building One, Room 303
2727 Mahan Drive
Tallahassee, FL 32308
1-888-419-3456 or 850-92 1-5458
The Agency for Health Care Administration
Fort Knox Building One, Room 303
2727 Mahan Drive
Tallahassee, FL 32308
1-888-419-3456
The Department of Insurance
State Treasurer's Off-tee
State Capitol, Plaza Level Eleven
Tallahassee, FL 32308
1-800-342-2762
ON10000APt-W V1
Notice of Benefit Determination on Appeal
Every notice of a determination On appeal will be provided in
writing or electronically and, if an adverse determination, will
include: ( I) the specific reason or reasons for the adverse
determination; (2) reference to the specific plan provisions, on
�,vhich the determination is based, (3) a statement that the
claimant is entitled to receive, upon request and free of charge,
reasonable access to and copies of all documents, records, and
other Relevant 161brination as defined- (4) a statement
describinc, any voluntary appeal procedures offered by the
plan and the claimant's right to bring an action tinder ERISA
section 502(a).- (5) upon request and free of charge. a copy of
any internal rule, guideline, protocol or other similar criterion
that was relied upon in making the adverse determination
regarding your appeal, and an explanation of the scientific or
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10/11/2011 Item 10.C.
clinical judgment for a determination that is based on a
M
Medical Necessity, experimental treatment or other Simi lar
exclusion or limit.
You also have the ri - alit to bring a civil action Linder Section
502(a) of ERISA if you are not satisfied with the decision on
review. You or your plan may have other voluntary alternative
dispute resolution options such as Mediation. One way to find
Out what may be available is to contact your local U.S.
Department of Labor office and your State insurance
regulatory agency. You may also contact the Plan
Administrator.
Relevant Information
Relevant Information is any document, record, or other
information which (a) was relied upon In making the benefit
determination; (b) 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; (c)
demonstrates compliance with the administrative processes
and safeguards required by federal law in making the benefit
determination; or (d) constitutes a statement of policy or
guidance with respect to the plan concerning the denied
treatment option or benefit or the claimant's diagnosis, without
regard to whether such advice or statement was relied upon in
making the benefit determination.
Legal Action
If your plan is governed by ERISA, you have the right to bring
a civil action under Section 502(a) of ERISA if you are not
satisfied with the outcome of the Appeals Procedure. In most
instances, you may not initiate a legal action against CG until
you have completed the Level One and Level "Two Appeal
processes. I f your Appeal is expedited, there is no need to
complete the Level Two process prior to bringing legal action.
CAM00 AN (,, 14
Definitions
Active Service
You will be considered in Active Service:
• on any of your Employer's scheduled work days if you are
performing the regular duties of your work- on a full-time
basis on that day either at your Employer's place of business
or at some location to which you are required to travel for
your Employer's business.
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CIGNA HealthCare
• on a day which is riot one of your Employer's scheduled
work days ifVOU were in Active Service on the preceding
scheduled work day.
EM
Coinsurance
The teen Coinsurance means the percentage of charges for
Covered Expenses that an insured person is required to pay
under the Plan.
D171,17
Contracted Fee - CIGNA Dental Preferred Provider
The tenn Contracted Fee refers to the total compensation level
that a provider has agreed to accept as payment for dental
procedures and services performed on an Employee or
Dependent, according to the Employee's dental benefit plan.
Di S 1217
Dentist
The term Dentist means a person practicing dentistry or oral
surgery Within the scope of his license. It will also include a
physician operating within the scope of his license when he
performs any of the Dental Services described in the policy.
I AISN
Dependent - For Dental Insurance
Dependents are:
• your lawful spouse, and
• anv child Of yours Who is
- less than 19 years old.,
from 19 years until the end of the calendar year in which
the child reaches age 25, provided the child is both
primarily supported by you and either, living in your
household or enrolled as a full-time or part-time Student.
CG may require proof at least once each year until the end
of the carendar year lie attains age 25-,
1 or more years old and primarily supported by you and
incapable Of'Self-SLIstaining employment by reason of
mental or physical handicap. Proof of the child's condition
and dependence is not required to be submitted to CG as a
condition of coverage after the date the child ceases to
qualify above. However, if a claim is denied, prooFmust
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10/11/2011 Item 10.C.
be submitted by the Policyholder that the child is and has
continued to be mentally or physically handicapped.
A child includes a legally adopted child, including that child
from the date of placement in the home or from birth provided
that a writ en agreement to adopt such child has been entered
into prior to the birth of such child. Coverage for a legally
adopted child will include the necessary care and treatment of
an Injury or a Sickness existing prior to the date of placement
or adoption. Coverage is not required if the adopted child is
ultimately not placed in your home. It also includes:
a stepchild who lives with you;
• a child born to an insured Dependent child of yours until
such child is 18 months old.
Anyone who is eligible as an Employee will not be
considered as a Dependent.
No one may be considered as a Dependent of more than one
Employee.
UP S1903
1903
Employee
The term Employee means a full-time employee of the
Employer. The term does not include employees who are part-
time or temporary or who normally work less than 30 hours a
week for the Employer.
DI 5211
Employer
The term Employer means the Policyholder and all Affiliated
Employers.
PFS2 11
Maximum Reimbursable Charge - Dental
The Maximum Reimbursable Charge is [fie lesser of:
1. the provider's nonnal charge for a similar service or
supply, or
2. the policvholdet--selected percentile of all charges made
by providers of such service or supply in the geographic
area where it is received.
To determine if a charge exceeds the Maximum Reimbursable
Charge, the nature and severity of the Injury or Sickness may
be considered.
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CG uses the Ingenix Prevailing Health Care System database
to determine the charges made by providers in an area. The
database is updated semiannually.
The percentile used to determine the Maximum Reimbursable
Charge is listed in the Schedule.
Additional information about the Maximum Reimbursable
Charge is available upon request.
G1,16060 DFS IS 14V I
Medicaid
(DEN)
The term Medicaid means a state program of medical aid for
needy persons established under Title XIX of the Social
Security Act of 1965 as amended.
DFS191
Medicare
The term Medicare means the program of medical care
benefits provided Linder Title XVI 11 of the Social Security Act
of 1965 as amended.
DC'S W
Participating Provider- CIGNA Dental Preferred
Provider
The term Participating Provider means: a dentist, or a
professional corporation, professional association, partnership,
or other entity which is entered into a contract with CG to
provide dental services at predetermined fees.
The providers qualifying as Participating Providers may
change from time to time. A list of the current Participating
Providers will be provided by your Employer.
DF 1i 17 13
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