Table of Contents Important Information..................................................................................................................4 Important Notices..........................................................................................................................6 How To File A Claim.....................................................................................................................7 Eligibility - Effective Date.............................................................................................................8 Covered Dental Expenses............................................................................................................10 Cigna Dental Preferred Provider Insurance.............................................................................11 The Schedule..........................................................................................................................................................11 Covered Dental Services..............................................................................................................13 General Limitations and Expenses Not Covered......................................................................16 Coordination of Benefits..............................................................................................................19 Expenses For Which A Third Party May Be Responsible.......................................................21 Payment of Benefits.....................................................................................................................22 Termination of Insurance............................................................................................................23 Dental Benefits Extension............................................................................................................23 Miscellaneous................................................................................................................................24 Definitions .....................................................................................................................................25 Federal Requirements.................................................................................................................30 Notice of Provider Directory/Networks.................................................................................................................30 Qualified Medical Child Support Order (QMCSO)...............................................................................................30 Effect of Section 125 Tax Regulations on This Plan.............................................................................................31 Eligibility for Coverage for Adopted Children......................................................................................................32 Group Plan Coverage Instead of Medicaid............................................................................................................32 Requirements of Family and Medical Leave Act of 1993 (as amended) (FMLA)................................................32 Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA).....................................32 Claim Determination Procedures under ERISA....................................................................................................33 Appointment of Authorized Representative..........................................................................................................34 Dental - When You Have a Complaint or an Appeal............................................................................................34 COBRA Continuation Rights Under Federal Law................................................................................................35 ERISA Required Information................................................................................................................................38
HCDFB-TOC28
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