Mid-America Apartments, L.P.
CIGNA DENTAL PREFERRED PROVIDER INSURANCE High Plan
EFFECTIVE DATE: January 1, 2020
ASO23 3332254
This document printed in March, 2020 takes the place of any documents previously issued to you which described your benefits.
Printed in U.S.A.
Table of Contents
Important Information..................................................................................................................4
Important Notices ..........................................................................................................................6
How To File Your Claim ...............................................................................................................7
Eligibility - Effective Date .............................................................................................................7 Employee Insurance ...............................................................................................................................................7 Waiting Period........................................................................................................................................................8 Dependent Insurance ..............................................................................................................................................8 Cigna Dental Preferred Provider Insurance ...............................................................................9 The Schedule ..........................................................................................................................................................9 Covered Dental Expense ......................................................................................................................................11 Dental PPO – Participating and Non-Participating Providers ..............................................................................11 Expenses Not Covered .........................................................................................................................................13
General Limitations .....................................................................................................................13
Dental Benefits .....................................................................................................................................................13
Coordination of Benefits..............................................................................................................14
Expenses For Which A Third Party May Be Responsible .......................................................16
Payment of Benefits .....................................................................................................................17
Termination of Insurance............................................................................................................18 Employees ............................................................................................................................................................18 Dependents ...........................................................................................................................................................18
Dental Benefits Extension............................................................................................................18
Federal Requirements .................................................................................................................18 Notice of Provider Directory/Networks................................................................................................................18 Qualified Medical Child Support Order (QMCSO) .............................................................................................19 Effect of Section 125 Tax Regulations on This Plan ............................................................................................19 Eligibility for Coverage for Adopted Children.....................................................................................................20 Group Plan Coverage Instead of Medicaid...........................................................................................................20 Requirements of Family and Medical Leave Act of 1993 (as amended) (FMLA) ...............................................20 Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA) ....................................20 Claim Determination Procedures under ERISA ...................................................................................................21 Dental - When You Have a Complaint or an Appeal ...........................................................................................22 COBRA Continuation Rights Under Federal Law ...............................................................................................22 ERISA Required Information ...............................................................................................................................26
Definitions.....................................................................................................................................27
Important Information THIS IS NOT AN INSURED BENEFIT PLAN. THE BENEFITS DESCRIBED IN THIS BOOKLET OR ANY RIDER ATTACHED HERETO ARE SELF-INSURED BY MID-AMERICA APARTMENTS, L.P. WHICH IS RESPONSIBLE FOR THEIR PAYMENT. CIGNA HEALTH AND LIFE INSURANCE COMPANY (CIGNA) PROVIDES CLAIM ADMINISTRATION SERVICES TO THE PLAN, BUT CIGNA DOES NOT INSURE THE BENEFITS DESCRIBED. THIS DOCUMENT MAY USE WORDS THAT DESCRIBE A PLAN INSURED BY CIGNA. BECAUSE THE PLAN IS NOT INSURED BY CIGNA, ALL REFERENCES TO INSURANCE SHALL BE READ TO INDICATE THAT THE PLAN IS SELF-INSURED. FOR EXAMPLE, REFERENCES TO "CIGNA," "INSURANCE COMPANY," AND "POLICYHOLDER" SHALL BE DEEMED TO MEAN YOUR "EMPLOYER" AND "POLICY" TO MEAN "PLAN" AND "INSURED" TO MEAN "COVERED" AND "INSURANCE" SHALL BE DEEMED TO MEAN "COVERAGE."
HC-NOT89
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 of 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.
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Important Notices Discrimination is Against the Law
HC-NOT96
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Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Cigna: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as Qualified interpreters Information written in other languages If you need these services, contact customer service at the toll- free phone number shown on your ID card, and ask a Customer Service Associate for assistance. If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance by sending an email to ACAGrievance@cigna.com or by writing to the following address: Cigna Nondiscrimination Complaint Coordinator P.O. Box 188016 Chattanooga, TN 37422 If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)
Proficiency of Language Assistance Services English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711). Chinese – 注意：我們可為您免費提供語言協助服務。 對於 Cigna 的現有客戶，請致電您的 ID 卡背面的號碼。 其他客戶請致電 1.800.244.6224 （聽障專線：請撥 711 ）。 Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của Cigna, vui lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1.800.244.6224 (TTY: Quay số 711). Korean – 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 현재 Cigna 가입자님들께서는 ID 카드 뒷면에 있는 전화번호로 연락해주십시오. 기타 다른 경우에는 1.800.244.6224 ( TTY : 다이얼 711 )번으로 전화해주십시오. Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711). Russian – ВНИМАНИЕ: вам могут предоставить бесплатные услуги перевода. Если вы уже участвуете в плане Cigna, позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки участника плана. Если вы не являетесь участником одного из наших планов, позвоните по номеру 1.800.244.6224 (TTY: 711).
French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele nimewo ki
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dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711).
of-Network claims can be submitted by the provider if the provider is able and willing to file on your behalf. If the provider is not submitting on your behalf, you must send your completed claim form and itemized bills to the claims address listed on the claim form. You may get the required claim forms from the website listed on your identification card or by calling Member Services using the toll-free number on your identification card. CLAIM REMINDERS BE SURE TO USE YOUR MEMBER ID AND ACCOUNT/GROUP NUMBER WHEN YOU FILE CIGNA’S CLAIM FORMS, OR WHEN YOU CALL YOUR CIGNA CLAIM OFFICE. YOUR MEMBER ID IS THE ID SHOWN ON YOUR BENEFIT IDENTIFICATION CARD. YOUR ACCOUNT/GROUP NUMBER IS SHOWN ON YOUR BENEFIT IDENTIFICATION CARD. BE SURE TO FOLLOW THE INSTRUCTIONS LISTED ON THE BACK OF THE CLAIM FORM CAREFULLY WHEN SUBMITTING A CLAIM TO CIGNA. Timely Filing of Out-of-Network Claims Cigna will consider claims for coverage under our plans when proof of loss (a claim) is submitted within one year (365 days) after services are rendered. If services are rendered on consecutive days, such as for a Hospital Confinement, the limit will be counted from the last date of service. If claims are not submitted within one year, the claim will not be considered valid and will be denied. WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information; or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act.
French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre
carte d’identité. Sinon, veuillez appeler le numéro 1.800.244.6224 (ATS : composez le numéro 711).
Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso contrário, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711). Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711). Japanese – 注意事項：日本語を話される場合、無料の言語支援サー ビスをご利用いただけます。現在の Cigna の お客様は、 ID カード裏面の電話番号まで、お電話にてご 連絡ください。その他の方は、 1.800.244.6224 （ TTY: 711 ）まで、お電話にてご連絡ください。 Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali, chiamare il numero sul retro della tessera di identificazione. In caso contrario, chiamare il numero 1.800.244.6224 (utenti TTY: chiamare il numero 711). German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung. Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711).
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Eligibility - Effective Date
Employee Insurance This plan is offered to you as an Employee. Eligibility for Employee Insurance
HC-NOT97
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How To File Your Claim There’s no paperwork for In-Network care. Just show your identification card and pay your share of the cost, if any; your provider will submit a claim to Cigna for reimbursement. Out-
You will become insured on the date you elect the insurance by completing the Employer’s specified enrollment process,
but no earlier than the date you become eligible. you are in a Class of Eligible Employees; and
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you are an eligible full-time Employee; and you normally work at least 30 hours a week; and you pay any required contribution.
Effective Date of Dependent Insurance Insurance for your Dependents will become effective on the date you elect it by completing the Employer’s specified enrollment process, but no earlier than the day you become eligible for Dependent Insurance. All of your Dependents as defined will be included. 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 31 days after you become eligible for it; or you again elect it after you cancel your payroll deduction (if required).
If you were previously insured and your insurance ceased, you must satisfy the New Employee Group Waiting Period to become insured again. Initial Employee Group: You are in the Initial Employee Group if you are employed in a class of employees on the date that class of employees becomes a Class of Eligible Employees as determined by your Employer. New Employee Group: You are in the New Employee Group if you are not in the Initial Employee Group. Eligibility for Dependent Insurance Insurance for your Dependents will become effective on the date you elect it by completing the Employer’s specified enrollment process, but no earlier than the day you become eligible for Dependent Insurance.
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the day you become eligible for yourself; or the day you acquire your first Dependent.
Waiting Period First of the Month on or after 30 days of active service. Classes of Eligible Employees Each Employee as reported to the insurance company by your Employer. Effective Date of Employee Insurance You will become insured on the date you elect the insurance by completing the Employer’s specified enrollment process, but no earlier than the date you become eligible. You will become insured on your first day of eligibility, following 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. Late Entrant - Employee You are a Late Entrant if: you elect the insurance more than 31 days after you become eligible; or you again elect it after you cancel your payroll deduction (if required). Dependent Insurance For your Dependents to be insured, you will have to pay the required contribution, if any, toward the cost of Dependent Insurance.
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Cigna Dental Preferred Provider Insurance
The Schedule
For You and Your Dependents
The Dental Benefits Plan offered by your Employer includes Participating Provider 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. Once 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 that is agreed to by the provider and Cigna. Based on the provider’s Contracted Fee, a higher level of plan payment may be made to a Participating Provider resulting in a lower payment responsibility for you. To determine how your Participating Provider compares refer to your provider directory. Provider information may change annually; refer to your provider directory prior to receiving a service. You have access to a list of all providers who participate in the network by visiting www.mycigna.com. 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 90th percentile of all provider charges in the geographic area.
Simultaneous Accumulation of Amounts
Benefits paid for Participating Provider and non-Participating Provider services will be applied toward both the Participating Provider and non-Participating Provider maximum shown in the Schedule. Expenses incurred for either Participating Provider or non-Participating Provider charges will be used to satisfy both the Participating Provider and non-Participating Provider Deductibles shown in the Schedule. .
NON-PARTICIPATING PROVIDER
BENEFIT HIGHLIGHTS
PARTICIPATING PROVIDER
Classes I, II, III Combined Calendar Year Maximum
$2,500
$2,500
$2,500
Class IV Lifetime Maximum
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NON-PARTICIPATING PROVIDER
BENEFIT HIGHLIGHTS
PARTICIPATING PROVIDER
Calendar Year Deductible
Individual
$50 per person
Not Applicable to Class I
Family Maximum
$150 per family
Not Applicable to Class I
. Class I
Preventive Care
100%
100%
Class II
Basic Restorative
80% after plan deductible
80% after plan deductible
Class III
Major Restorative
60% after plan deductible
60% after plan deductible
Class IV
Orthodontia
50%
50%
. Class IX
Implants
50% after plan deductible
50% after plan deductible
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considered the service should be identified using the American Dental Association Uniform Code of Dental Procedures and Nomenclature, or by description and then submitted to Cigna.
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; the charge does not exceed the amount allowed under the Alternate Benefit Provision; for Class I, II or III the service is started and completed while coverage is in effect, except for services described in the “Benefits Extension” section. Alternate Benefit Provision If more than one covered service will treat a dental condition, payment is limited to the least costly service provided it is a professionally accepted, necessary and appropriate treatment. If the covered person requests or accepts a more costly covered service, he or she is responsible for expenses that exceed the amount covered for the least costly service. Therefore, Cigna recommends Predetermination of Benefits before major treatment begins. 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 Cigna's dental consultant. If there is a change in the treatment plan, a revised plan should be submitted. Cigna will determine covered dental expenses for the proposed treatment plan. If there is no Predetermination of Benefits, Cigna 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. Covered Services The following section lists covered dental services. Cigna may agree to cover expenses for a service not listed. To be
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Dental PPO – Participating and Non- Participating Providers Plan payment for a covered service delivered by a
Participating Provider is the Contracted Fee for that procedure, 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. Plan payment for a covered service delivered by a non- Participating Provider is the Maximum Reimbursable Charge for that procedure, 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 non- Participating Provider’s actual charge.
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Class I Services – Diagnostic and Preventive Clinical oral examination – Only 2 per person per calendar year. 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.) X-rays – Complete series or Panoramic (Panorex) – Only one per person, including panoramic film, in any 36 consecutive months. Bitewing x-rays – Only 2 charges per person per calendar year. Prophylaxis (Cleaning), including Periodontal maintenance procedures (following active therapy) – Only 2 per person per calendar year.
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Topical application of fluoride (excluding prophylaxis) – Limited to persons less than 19 years old. Only 2 per person per calendar year. Topical application of sealant, per tooth, on a posterior tooth for a person covered to age 16 years old - Only 1 treatment per tooth in any 36 consecutive months Space Maintainers, fixed unilateral – Limited to persons less than 19 years old. Limited to nonorthodontic treatment.
I.V. Sedation – Paid as a separate benefit only when medically or dentally necessary, as determined by Cigna, and when administered in conjunction with complex oral surgical procedures which are covered under this plan.
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Class III Services - Major Restorations, Dentures and Bridgework Crowns Note: Crown restorations are Dental Services only when the tooth, as a result of extensive caries or fracture, cannot be restored with amalgam, composite/resin, silicate, acrylic or plastic restoration. Porcelain Fused to High Noble Metal Full Cast, High Noble Metal Three-Fourths Cast, Metallic Removable Appliances Complete (Full) Dentures, Upper or Lower Partial Dentures Lower, Cast Metal Base with Resin Saddles (including any conventional clasps, rests and teeth) Upper, Cast Metal Base with Resin Saddles (including any conventional clasps rests and teeth) Fixed Appliances Bridge Pontics - Cast High Noble Metal Bridge Pontics - Porcelain Fused to High Noble Metal Bridge Pontics - Resin with High Noble Metal Retainer Crowns - Resin with High Noble Metal Retainer Crowns - Porcelain Fused to High Noble Metal Retainer Crowns - Full Cast High Noble Metal 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.
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Class II Services – Basic Restorations, Periodontics, Endodontics, Oral Surgery, Prosthodontic Maintenance Amalgam Filling Composite/Resin Filling Root Canal Therapy – Any x-ray, test, laboratory exam or follow-up care is part of the allowance for root canal therapy and not a separate Dental Service. Osseous Surgery – Flap entry and closure is part of the allowance for osseous surgery and not a separate Dental Service. Periodontal Scaling and Root Planing – Entire Mouth Adjustments – Complete Denture Any adjustment of or repair to a denture within 6 months of its installation is not a separate Dental Service. Recement Bridge Routine Extractions Surgical Removal of Erupted Tooth Requiring Elevation of Mucoperiosteal 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 necessary, as determined by Cigna, and when administered in conjunction with complex oral surgical procedures which are covered under this plan.
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Class IV Services - Orthodontics Each month of active treatment is a separate Dental Service.
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Covered Expenses include: Orthodontic work-up including x-rays, diagnostic casts and treatment plan and the first month of active treatment including all active treatment and retention appliances. Continued active treatment after the first month. Fixed or Removable Appliances - Only one appliance per person for tooth guidance or to control harmful habits. Periodic observation of patient dentition to determine when orthodontic treatment should begin, at intervals established by the dentist, up to four times per calendar year. The total amount payable for all expenses incurred for orthodontics during a person’s lifetime will not be more than the orthodontia maximum shown in the Schedule. Payments for comprehensive full-banded orthodontic treatment are made in installments. Benefit payments will be made every 3 months. The first payment is due when the appliance is installed. Later payments are due at the end of each 3-month period. The first installment is 25% of the charge for the entire course of treatment. The remainder of the charge is prorated over the estimated duration of treatment. Payments are only made for services provided while a person is insured. If insurance coverage ends or treatment ceases, payment for the last 3-month period will be prorated.
replacement of a bridge, crown or denture within 60 consecutive months after the date it was originally installed unless: the replacement is made necessary by the placement of an original opposing full denture or the necessary extraction of natural teeth; or the bridge, crown or denture, while in 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: change vertical dimension; diagnose or treat conditions or dysfunction of the temporomandibular joint; stabilize periodontally involved teeth; or restore occlusion; porcelain or acrylic veneers of crowns or pontics on, or replacing the upper and lower first, second and third molars; bite registrations; precision or semiprecision attachments; or splinting; 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; services for which benefits are not payable according to the “General Limitations” section.
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Class IX Services – 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. Implant coverage may have a separate deductible amount, yearly maximum and/or lifetime maximum as shown in The Schedule.
V1
General Limitations Dental Benefits No payment will be made for expenses incurred for you or any one of your Dependents: for or in connection with an injury arising out of, or in the course of, any employment for wage or profit; for or in connection with a Sickness which is covered under any workers' compensation or similar law; 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;
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Expenses Not Covered Covered Expenses will not include, and no payment will be made for: services performed solely for cosmetic reasons; replacement of a lost or stolen appliance;
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for charges which the person is not legally required to pay. For example, if Cigna determines that a provider is or has waived, reduced, or forgiven any portion of its charges and/or any portion of copayment, deductible, and/or coinsurance amount(s) you are required to pay for a Covered Service (as shown on the Schedule) without Cigna’s express consent, then Cigna in its sole discretion shall have the right to deny the payment of benefits in connection with the Covered Service, or reduce the benefits in proportion to the amount of the copayment, deductible, and/or coinsurance amounts waived, forgiven or reduced, regardless of whether the provider represents that you remain responsible for any amounts that your plan does not cover. In the exercise of that discretion, Cigna shall have the right to require you to provide proof sufficient to Cigna that you have made your required cost share payment(s) prior to the payment of any benefits by Cigna. This exclusion includes, but is not limited to, charges of a Non- Participating Provider who has agreed to charge you or charged you at an in-network benefits level or some other benefits level not otherwise applicable to the services received; charges arising out of or relating to any violation of a healthcare-related state or federal law or which themselves are a violation of a healthcare-related state or federal law; 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; 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.
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 medical or dental care or treatment: 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. Governmental benefits as permitted by law, excepting Medicaid, Medicare and Medicare supplement policies. 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 panel of employed or contracted providers, and that limits or excludes benefits provided by providers outside of the panel, except in the case of emergency or if referred by a provider within the panel. Primary Plan The Plan that determines and provides or pays benefits without taking into consideration the existence of any other Plan. Secondary Plan A Plan that determines, 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. Allowable Expense The amount of charges considered for payment under the plan for a Covered Service prior to any reductions due to coinsurance, copayment or deductible amounts. If Cigna contracts with an entity to arrange for the provision of Covered Services through that entity’s contracted network of health care providers, the amount that Cigna has agreed to pay that entity is the allowable amount used to determine your coinsurance or deductible payments. If the 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: 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.
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Coordination of Benefits This section applies if you or any 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.
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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. 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. If your benefits are reduced under the Primary Plan (through the imposition of a higher copayment 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 Allowable 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. 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: The Plan that covers you as an enrollee or an employee shall be the Primary Plan and the Plan that covers you as a Dependent shall be the Secondary Plan; If you are a Dependent child whose parents are not divorced or legally separated, the Primary Plan shall be the Plan which covers the parent whose birthday falls first in the calendar year as an enrollee or employee; If you are the Dependent of divorced or separated parents, benefits for the Dependent shall be determined in the following order: first, if a court decree states that one parent is responsible for the child's healthcare expenses or health coverage and the Plan for that parent has actual knowledge of the terms of the order, but only from the time of actual knowledge; then, the Plan of the parent with custody of the child;
then, the Plan of the spouse of the parent with custody of the child; then, the Plan of the parent not having custody of the child; and finally, the Plan of the spouse of the parent not having custody of the child. The Plan that covers you as an active employee (or as that employee's Dependent) shall be the Primary Plan and the Plan 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. The Plan that covers you under a right of continuation which is provided by federal or state law shall be the Secondary Plan and the Plan that covers you as an active employee or retiree (or as that employee's Dependent) 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. 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. If none of the above rules determines the order of benefits, the 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% 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 the Secondary Plan, will be recorded as a benefit reserve for you. Cigna will use this benefit reserve to pay any Allowable Expense not otherwise paid during the Claim Determination Period. As each claim is submitted, Cigna will determine the following: Cigna’s obligation to provide services and supplies under this policy; whether a benefit reserve has been recorded for you; and whether there are any unpaid Allowable Expenses during the Claims Determination Period.
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If there is a benefit reserve, Cigna will use the benefit reserve recorded for you to pay up to 100% of the total of all 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 each new Claim Determination Period. Recovery of Excess Benefits If Cigna pays charges for benefits that should have been paid by the Primary Plan, or if Cigna pays charges in excess of those for which we are obligated to provide under the Policy, Cigna will have the right to recover the actual payment made or the Reasonable Cash Value of any services. Cigna 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 we request, you must execute and deliver to us such instruments and documents as we determine are necessary to secure the right of recovery. Right to Receive and Release Information Cigna, 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, you 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 claim will be processed.
underinsured motorist, homeowners, workers' compensation, government insurance (other than Medicaid), or similar type of insurance or coverage. The coverage under this plan is secondary to any automobile no-fault or similar coverage. Right Of Reimbursement If a Participant incurs a Covered Expense for which, in the opinion of the plan or its claim administrator, another party may be responsible or for which the Participant may receive payment as described above, the plan is granted a right of reimbursement, to the extent of the benefits provided by the plan, from the proceeds of any recovery whether by settlement, judgment, or otherwise. Lien Of The Plan By accepting benefits under this plan, a Participant: grants a lien and assigns to the plan an amount equal to the benefits paid under the plan against any recovery made by or on behalf of the Participant which is binding on any attorney or other party who represents the Participant whether or not an agent of the Participant or of any insurance company or other financially responsible party against whom a Participant may have a claim provided said attorney, insurance carrier or other party has been notified by the plan or its agents; agrees that this lien shall constitute a charge against the proceeds of any recovery and the plan shall be entitled to assert a security interest thereon; agrees to hold the proceeds of any recovery in trust for the benefit of the plan to the extent of any payment made by the plan. Additional Terms No adult Participant hereunder may assign any rights that it may have to recover medical expenses from any third party or other person or entity to any minor Dependent of said adult Participant without the prior express written consent of the plan. The plan’s right to recover shall apply to decedents’, minors’, and incompetent or disabled persons’ settlements or recoveries. No Participant shall make any settlement, which specifically reduces or excludes, or attempts to reduce or exclude, the benefits provided by the plan. The plan’s right of recovery shall be a prior lien against any proceeds recovered by the Participant. This right of recovery shall not be defeated nor reduced by the application of any so-called “Made-Whole Doctrine”, “Rimes Doctrine”, or any other such doctrine purporting to defeat the plan’s recovery rights by allocating the proceeds exclusively to non-medical expense damages. No Participant hereunder shall incur any expenses on behalf of the plan in pursuit of the plan’s rights hereunder,
HC-COB137
01-17
Expenses For Which A Third Party May Be Responsible This plan does not cover: Expenses incurred by you or your Dependent; (hereinafter individually and collectively referred to as a "Participant,") for which another party may be responsible as a result of having caused or contributed to an injury or Sickness. Expenses incurred by a Participant to the extent any payment is received for them either directly or indirectly from a third party tortfeasor or as a result of a settlement, judgment or arbitration award in connection with any automobile medical, automobile no-fault, uninsured or
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specifically; no court costs, attorneys' fees or other representatives' fees may be deducted from the plan’s recovery without the prior express written consent of the plan. This right shall not be defeated by any so-called “Fund Doctrine”, “Common Fund Doctrine”, or “Attorney’s Fund Doctrine”. The plan shall recover the full amount of benefits provided hereunder without regard to any claim of fault on the part of any Participant, whether under comparative negligence or otherwise. The plan hereby disavows all equitable defenses in the pursuit of its right of recovery. The plan’s recovery rights are neither affected nor diminished by equitable defenses. In the event that a Participant shall fail or refuse to honor its obligations hereunder, then the plan shall be entitled to recover any costs incurred in enforcing the terms hereof including, but not limited to, attorney’s fees, litigation, court costs, and other expenses. The plan shall also be entitled to offset the reimbursement obligation against any entitlement to future medical benefits hereunder until the Participant has fully complied with his reimbursement obligations hereunder, regardless of how those future medical benefits are incurred. Any reference to state law in any other provision of this plan shall not be applicable to this provision, if the plan is governed by ERISA. By acceptance of benefits under the plan, the Participant agrees that a breach hereof would cause irreparable and substantial harm and that no adequate remedy at law would exist. Further, the plan shall be entitled to invoke such equitable remedies as may be necessary to enforce the terms of the plan, including, but not limited to, specific performance, restitution, the imposition of an equitable lien and/or constructive trust, as well as injunctive relief. Participants must assist the plan in pursuing any recovery rights by providing requested information.
Cigna may, at its option, make payment to you for the cost of any Covered Expenses from a Non-Participating Provider even if benefits have been assigned. When benefits are paid to you or your Dependents, you or your Dependents are responsible for reimbursing the provider. If any person to whom benefits are payable is a minor or, in the opinion of Cigna 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, Cigna may, at its option, make payment to the person or institution appearing to have assumed his custody and support. When one of our participants passes away, Cigna may receive notice that an executor of the estate has been established. The executor has the same rights as our insured and benefit payments for unassigned claims should be made payable to the executor. Payment as described above will release Cigna from all liability to the extent of any payment made. Recovery of Overpayment When an overpayment has been made by Cigna, Cigna will have the right at any time to: recover that overpayment from the person to whom or on whose behalf it was made; or offset the amount of that overpayment from a future claim payment. In addition, your acceptance of benefits under this plan and/or assignment of Dental Benefits separately creates an equitable lien by agreement pursuant to which Cigna may seek recovery of any overpayment. You agree that Cigna, in seeking recovery of any overpayment as a contractual right or as an equitable lien by agreement, may pursue the general assets of the person or entity to whom or on whose behalf the overpayment was made.
HC-POB4
09-13
V8
Miscellaneous As a Cigna Dental plan member, you may be eligible for various discounts, benefits, or other consideration for the purpose of promoting your general health and well being. Please visit our website at www.cigna.com for details. If you are a Cigna Dental plan member you may be eligible for additional dental benefits during 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.
HC-SUB78
01-17
Payment of Benefits To Whom Payable
Dental Benefits are assignable to the provider. When you assign benefits to a provider, you have assigned the entire amount of the benefits due on that claim. If the provider is overpaid because of accepting a patient’s payment on the charge, it is the provider’s responsibility to reimburse the patient. Because of Cigna’s contracts with providers, all claims from contracted providers should be assigned.
HC-POB5
04-10
V1
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