procedures and services performed on an Employee or Dependent, according to the Employee's dental benefit plan.
Employer The term Employer means the plan sponsor self-insuring the benefits described in this booklet, on whose behalf Cigna is providing claim administration services.
HC-DFS123
04-10
V1
Dentist The term Dentist means a person practicing dentistry or oral surgery within the scope of his license. It will also include a provider operating within the scope of his license when he performs any of the Dental Services described in the policy.
HC-DFS8
04-10
V1
Maximum Reimbursable Charge - Dental The Maximum Reimbursable Charge for covered services is determined based on the lesser of: the provider’s normal charge for a similar service or supply; or the policyholder-selected percentile of charges made by providers of such service or supply in the geographic area where it is received as compiled in a database selected by Cigna. The percentile used to determine the Maximum Reimbursable Charge is listed in The Schedule. The Maximum Reimbursable Charge is subject to all other benefit limitations and applicable coding and payment methodologies determined by Cigna. Additional information about how Cigna determines the Maximum Reimbursable Charge is available upon request.
HC-DFS125
04-10
V3
Dependent Dependents are:
your lawful spouse; and any child of yours who is less than 26 years old.
26 or more years old, unmarried, and primarily supported by you and incapable of self-sustaining employment by reason of mental or physical disability. Proof of the child's condition and dependence may be required to be submitted to the plan within 31 days after the date the child ceases to qualify above. From time to time, but not more frequently than once a year, the plan may require proof of the continuation of such condition and dependence. The term child means a child born to you or a child legally adopted by you. It also includes a stepchild, a foster child, or a child for whom you are the legal guardian. Benefits for a Dependent child will continue until the last day of the calendar month in which the limiting age is reached. No one may be considered as a Dependent of more than one Employee.
HC-DFS752
07-14
V5
Medicaid 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.
HC-DFS16
04-10
V1
HC-DFS875 M
01-17
Medicare The term Medicare means the program of medical care benefits provided under Title XVIII of the Social Security Act of 1965 as amended.
Employee The term Employee means a full-time employee of the Employer who is currently in Active Service. 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.
HC-DFS17
04-10
V1
HC-DFS1094 M
12-17
28
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