Dental Blue Plus For Business - Bcbsal
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Table of ContentsOVERVIEW PLAN . 4Purpose of the Plan . 4Using myBlueCross to Get More Information Over the Internet . 4Definitions . 4Receipt of Dental Care . 4Beginning of Coverage . 4Limitations, Exclusions, and Waiting Periods . 4Dental Necessity . 5In-Network Benefits . 5Relationship Between Blue Cross and/or Blue Shield Plans and the Blue Cross and Blue ShieldAssociation . 5Claims and Appeals . 5Termination of Coverage . 5Respecting Your Privacy . 5ELIGIBILITY . 6Eligibility for the Plan . 6Waiting Period for Coverage under the Plan . 6Beginning of Coverage . 6Qualified Medical Child Support Orders . 8Termination of Coverage . 8Leaves of Absence . 9WAITING PERIODS . 9Exclusion Period for Adult Basic Dental Services . 9Exclusion Period for Adult Major Dental Services . 9Exclusion Period for Pediatric Orthodontic Services . 9COST SHARING . 10Calendar Year Deductible . 10Calendar Year Deductible for Pediatric Orthodontic Benefits . 10Calendar Year Out-of-Pocket Maximum for Pediatric Dental Services . 10Calendar Year Maximum Benefits for Adults . 11Other Cost Sharing Provisions . 11DENTAL BENEFITS AND LIMITATIONS . 11Adult Diagnostic and Preventive Dental Benefits . 12Adult Basic Dental Benefits . 12Adult Major Dental Benefits . 13Pediatric Diagnostic and Preventive Dental Benefits . 13Pediatric Basic Dental Benefits . 14Pediatric Major Dental Benefits . 14Pediatric Orthodontic Benefits . 15DENTAL BENEFIT EXCLUSIONS . 20CLAIMS AND APPEALS . 22Claims . 22Your Right to Information . 23Appeals . 232
Alabama Department of Insurance . 24COBRA . 24GENERAL INFORMATION . 29DEFINITIONS . 31STATEMENT OF ERISA RIGHTS . 323
OVERVIEW PLANThe following provisions of this booklet contain a summary in English of your rights and benefitsunder the plan. If you have questions about your benefits, please contact Customer Service at 1855-880-6348. If needed, simply request a Spanish translator and one will be provided to assistyou in understanding your benefits.Atención por favor - SpanishEste folleto contiene un resumen en inglés de sus beneficios y derechos del plan. Si tienealguna pregunta acerca de sus beneficios, por favor póngase en contacto con eldepartamento de Servicio al Cliente llamando al 1-855-880-6348. Solicite simplemente unintérprete de español y se proporcionará uno para que le ayude a entender sus beneficios.Purpose of the PlanThe plan is intended to help you and your covered dependents pay for the cost of dental care.The plan does not pay for all of your dental care. You may also be required to pay deductiblesand coinsurance.Using myBlueCross to Get More Information Over the InternetBlue Cross and Blue Shield of Alabama’s home page on the Internet is www.bcbsal.com. If yougo there, you will see a section of our home page called myBlueCross. Registering formyBlueCross is easy and secure; and once you have registered you will have access toinformation and forms that will help you take maximum advantage of your benefits under the plan.DefinitionsNear the end of this booklet you will find a section called Definitions, which identifies words andphrases that have specialized or particular meanings. In order to make this booklet morereadable, we generally do not use initial capitalized letters to denote defined terms. Please takethe time to familiarize yourself with these definitions so that you will understand your benefits.Receipt of Dental CareEven if the plan does not cover an expense or service, you and your provider are responsible fordeciding whether you should receive the care or treatment.Beginning of CoverageThe section of this booklet called Eligibility will tell you and your dependents what is required tobecome covered under the plan and when your coverage begins.Limitations, Exclusions, and Waiting PeriodsIn order to maintain the cost of the plan at an overall level that is reasonable for all plan members,the plan contains a number of provisions that limit benefits or in some cases subject them to awaiting period. These waiting periods are not reduced by your prior coverage under any plan.Please see the section of this booklet called Waiting Periods. There are also exclusions that youneed to pay particular attention to as well. These provisions are found throughout the remainderof this booklet. You need to be aware of the limits, waiting periods, and exclusions to determine ifthe plan will meet your dental care needs.4
Dental NecessityThe plan will only pay for care that is dentally necessary and not investigational, as determinedby us. The definitions of dental necessity and investigational are found in the Definitions sectionof this booklet.In-Network BenefitsOne way in which the plan tries to manage dental care costs and provide enhanced dentalbenefits is through negotiated discounts with in-network dentists. In-network dentists are dentiststhat contract with Blue Cross and Blue Shield of Alabama for furnishing dental care services at areduced price. Preferred Dentists are in-network dentists in the state of Alabama. National DentalNetwork (DenteMax) are in-network dentists located outside the state of Alabama. To locate innetwork dentists for the plan, go to www.bcbsal.com. Assuming the services are covered, you willnormally only be responsible for out-of-pocket costs such as deductibles and coinsurance whenusing in-network dentists.The plan does not cover any services or supplies you may receive from an out-of-network provider.You will be responsible for all charges billed to you by the out-of-network provider.Relationship Between Blue Cross and/or Blue Shield Plans and the Blue Crossand Blue Shield AssociationBlue Cross and Blue Shield of Alabama is an independent corporation operating under a licensefrom the Blue Cross and Blue Shield Association, an association of independent Blue Cross andBlue Shield plans. The Blue Cross and Blue Shield Association permits us to use the Blue Crossand Blue Shield service marks in the state of Alabama. Blue Cross and Blue Shield of Alabama isnot acting as an agent of the Blue Cross and Blue Shield Association. No representation is madethat any organization other than Blue Cross and Blue Shield of Alabama and your employer willbe responsible for honoring this contract. The purpose of this paragraph is for legal clarification; itdoes not add additional obligations on the part of Blue Cross and Blue Shield of Alabama notcreated under the original agreement.Claims and AppealsWhen you receive services from an in-network dentist, your dentist will in most cases file claims foryou. In other cases, you may be required to pay the dentist and then file a claim with us forreimbursement under the terms of the plan. If we deny a claim in whole or in part, you may file anappeal with us and we will give the claim a full and fair review. The provisions of the plan dealingwith claims and appeals are found later on in this booklet.Termination of CoverageThe section below called Eligibility tells you when coverage will terminate under the plan. Ifcoverage terminates, no benefits will be provided thereafter, even if for treatment that beganbefore your coverage termination. In some cases you will have the opportunity to buy COBRAcoverage after your group terminates. COBRA coverage is explained in detail later in thisbooklet.Respecting Your PrivacyTo administer this plan we need your personal health information from providers and others. Todecide if your claim should be paid or denied or whether other parties are legally responsible forsome or all of your expenses, we need records from healthcare providers, other insurancecompanies, and plan administrators. By applying for coverage and participating in this plan, youagree that we may obtain, use and release all records about you and your minor dependents that5
we need to administer this plan or to perform any function authorized or permitted by law. Youfurther direct all other persons to release all records to us about you and your minor dependentsthat we need to administer this plan. If you or any provider refuses to provide records, informationor evidence we request within reason, we may deny your benefit payments. Additionally, we mayuse or disclose your personal health information for treatment, payment, or healthcare operations,or as permitted or authorized by law, pursuant to the privacy regulations under the HealthInsurance Portability and Accountability Act of 1996 (HIPAA). We have prepared a privacy noticethat explains our obligations and your rights under the HIPAA privacy regulations. To request acopy of our notice or to receive more information about our privacy practices or your rights, pleasecontact us at the following:Blue Cross and Blue Shield of Alabama Privacy OfficeP. O. Box 2643Birmingham, Alabama 35202-2643Telephone: 1-800-292-8868You may also go to our website at www.bcbsal.com for a copy of our privacy notice.ELIGIBILITYEligibility for the PlanYou are eligible to enroll in this plan if all of the following requirements are satisfied: You are an employee and are treated as such by your employer. Examples of persons who arenot employees include independent contractors, board members, and consultants; and, Your employer has offered you coverage through the Small Business Health Options Program(SHOP) and the SHOP has determined you eligible for the plan.Eligible DependentsYour eligible dependents are: Your spouse (of the opposite sex); and A married or unmarried child up to age 26.The child may be the employee's natural child; stepchild; legally adopted child; child placed foradoption; or, eligible foster child. An eligible foster child is a child that is placed with you by anauthorized placement agency or by court order.You may not cover your grandchild unless your grandchild is your adopted child, a child placed foradoption, or your eligible foster child.Waiting Period for Coverage under the PlanThere may be a waiting period for coverage under the plan, as determined by your group. You shouldcontact your group to determine if this is the case. The length of any applicable waiting period will notbe any longer than 90 days. Coverage will begin on the date specified below under Beginning ofCoverage.Beginning of CoverageAnnual Open Enrollment PeriodIf you do not enroll during a regular enrollment period or a special enrollment period described below,you may enroll only during your group's annual open enrollment period (generally, 30 days before the6
beginning of each plan year). Your coverage will begin on the first day of the plan year following suchannual open enrollment period in which you enroll.Regular Enrollment PeriodIf you apply within 30 days after the date on which you first meet the plan's eligibility requirements, yourcoverage will begin as of the date thereafter specified by your group but no later than the ninety-firstst(91 ) day from the beginning of any applicable waiting period.Special Enrollment Period for Individuals Losing Other CoverageAn employee or dependent (1) who does not enroll during the first 30 days of eligibility because theemployee or dependent has other coverage, (2) whose other coverage was either COBRA coveragethat was exhausted or coverage by other dental plans which ended due to "loss of eligibility" (asdescribed below), and (3) who requests enrollment within 30 days of the exhaustion or termination ofcoverage, may enroll in the plan. Coverage will be effective no later than the first day of the firstcalendar month beginning after the date the request for special enrollment is received.Loss of eligibility with respect to a special enrollment period includes loss of coverage as a result oflegal separation, divorce, cessation of dependent status, death, termination of employment, reductionin the number of hours of employment, and any loss of eligibility that is measured by reference to anyof these events, but does not include loss of coverage due to failure to timely pay premiums ortermination of coverage for fraud or material misrepresentation of a material fact.Special Enrollment Period for Newly Acquired DependentsIf you have a new dependent as a result of marriage, birth, placement for adoption, or adoption, youmay enroll yourself and/or your spouse and your new dependent as special enrollees provided that yourequest enrollment within 30 days of the event. The effective date of coverage will be the date of birth,placement for adoption, or adoption. In the case of a dependent acquired through marriage, theeffective date will be no later than the first day of the first calendar month beginning after the date therequest for special enrollment is received.Other Special Enrollment PeriodsAn employee or dependent who is an Indian (as defined by section 4 of the Indian Health CareImprovement Act) may enroll in the plan at any time (but no more than once per calendar month). If therequest for special enrollment is received between the first and the fifteenth day of the month, coveragewill be effective no later than the first day of the following calendar month. If the request for specialenrollment is received between the sixteenth and the last day of the month, coverage will be effectiveno later than the first day of the second following month.An employee or dependent who becomes eligible for the plan because of a permanent move mayenroll in the plan provided that the employee or dependent requests special enrollment within 30 days.If the request for special enrollment is received between the first and the fifteenth day of the month,coverage will be effective no later than the first day of the following calendar month. If the request forspecial enrollment is received between the sixteenth and the last day of the month, coverage will beeffective no later than the first day of the second following month.An employee or dependent who the Health Insurance Marketplace determines is eligible for a specialenrollment period because of (1) unintentional, inadvertent or erroneous enrollment in another plan; (2)another plan under which the employee or dependent was enrolled substantially violated a materialprovision of that plan; or (3) other exception circumstances may also enroll in the plan provided that theemployee or dependent requests special enrollment within 30 days. If the request for specialenrollment is received between the first and the fifteenth day of the month, coverage will be effective nolater than the first day of the following calendar month. If the request for special enrollment is receivedbetween the sixteenth and the last day of the month, coverage will be effective no later than the firstday of the second following month.7
Qualified Medical Child Support OrdersIf the group (the plan administrator) receives an order from a court or administrative agency directingthe plan to cover a child, the group will determine whether the order is a Qualified Medical ChildSupport Order (QMCSO). A QMCSO is a qualified order from a court or administrative agencydirecting the plan to cover the employee's child regardless of whether the employee has enrolled thechild for coverage. The group has adopted procedures for determining whether such an order is aQMCSO. You have a right to obtain a copy of those procedures free of charge by contacting yourgroup.The plan will cover an employee's child if required to do so by a QMCSO. If the group determines thatan order is a QMCSO, the child will be enrolled for coverage effective as of a date specified by thegroup, but not earlier than the later of the following: If the plan receives a copy of the order within 30 days of the date on which it was entered, alongwith instructions from the group to enroll the child pursuant to the terms of the order, coveragewill begin as of the date on which the order was entered. If the plan receives a copy of the order later than 30 days after the date on which it was entered,along with instructions from the group to enroll the child pursuant to the terms of the order,coverage will begin as of the date on which the plan receives the order. The plan will notprovide retroactive coverage in this instance.Coverage may continue for the period specified in the order up to the time the child ceases to satisfythe definition of an eligible dependent. If the employee is required to pay extra to cover the child, thegroup may increase the employee's payroll deductions. During the period the child is covered underthe plan as a result of a QMCSO, all plan provisions and limits remain in effect with respect to thechild's coverage except as otherwise required by federal law.While the QMCSO is in effect we will make benefit payments – other than payments to providers – tothe parent or legal guardian who has been awarded custody of the child. We will also provide sufficientinformation and forms to the child's custodial parent or legal guardian to allow the child to enroll in theplan. We will also send claims reports directly to the child's custodial parent or legal guardian.Termination of CoveragePlan coverage ends as a result of the first to occur of the following (generally, coverage will continue tothe end of the month in which the event occurs): The date on which the employee fails to satisfy the conditions for eligibility to participate in theplan, such as termination of employment or reduction in hours (except during vacation or asotherwise provided in the Leaves of Absence rules below); For spouses, the date of divorce or other termination of marriage; For children, the date a child ceases to be a dependent; For the employee and his or her dependents, the date of the employee's death; Your group fails to pay us the amount due within 30 days after the day due; Upon discovery of fraud or intentional misrepresentation of a material fact by you or your group; Any time your group fails to comply with the contribution or participation rules in the plandocuments; When none of your group's members still live, reside or work in Alabama; or, On 30-days advance written notice from your group to us.8
All the dates of termination assume that payment for coverage for you and all other employees in theproper amount has been made to that date. If it has not, termination will occur back to the date forwhich coverage was last paid.Leaves of AbsenceIf your group is covered by the Family and Medical Leave Act of 1993 (FMLA), you may retain yourcoverage under the plan during an FMLA leave, provided that you continue to pay your premiums. Ingeneral, the FMLA applies to employers who employ 50 or more employees. You should contact yourgroup to determine whether a leave qualifies as FMLA leave.You may also continue your coverage under the plan for up to 30 days during an employer-approvedleave of absence, including sick leave. Contact your group to determine whether such leaves ofabsence are offered. If your leave of absence also qualifies as FMLA leave, your 30-day leave timeruns concurrently with your FMLA leave. This means that you will not be permitted to continuecoverage during your 30-day leave time in addition to your FMLA leave.If you are on military leave covered by the Uniformed Services Employment and Reemployment RightsAct of 1994, you should see your group for information about your rights to continue coverage underthe plan.WAITING PERIODSExclusion Period for Adult Basic Dental ServicesFor the first 180 days you are covered by this plan there are no plan benefits for Adult Basic DentalServices. The entire 180-day waiting period must be served before any benefits for Adult BasicDental Services are available under the plan. There is no exclusion period for Pediatric Basic DentalServices.Exclusion Period for Adult Major Dental ServicesFor the first 365 days you are covered under this plan there are no plan benefits for Adult MajorDental Services. The entire 365-day waiting period must be served before any benefits for AdultMajor Dental Services are available under the plan. There is no exclusion period for PediatricMajor Dental Services.Exclusion Period for Pediatric Orthodontic ServicesFor the first 730 days (24 months) you are covered under this plan there are no plan benefits forPediatric Orthodontic Services. The entire 730-day (24-month) waiting period must be servedbefore any benefits for Pediatric Orthodontic Services are available under the plan.9
COST SHARINGCalendar Year Deductible (does notapply to pediatric orthodonticbenefits) 40 per personCalendar Year Deductible forPediatric Orthodontic Benefits (up toage 19) 150 per personCalendar Year Out-of-PocketMaximum for Pediatric DentalBenefits(including pediatric dental benefitsthat apply to the calendar yeardeductible and the calendar yeardeductible for pediatric orthodonticbenefits)Calendar Year Maximum Benefits forAdults (ages 19 and over) 700 for one covered child up to age 19; 1,400 for two (2) or more covered children up to age 19 1,000 per person ages 19 and overCalendar Year DeductibleThe calendar year deductible is specified in the table above. The calendar year deductible underthe plan is the amount you must pay for dental expenses (other than pediatric orthodonticservices) covered by the plan before your dental care benefits begin. The calendar yeardeductible is applied on a per person per calendar year basis. The deductible will be applied toclaims in the order in which they are processed regardless of the order in which they arereceived.Calendar Year Deductible for Pediatric Orthodontic BenefitsThe calendar year deductible for pediatric orthodontic benefits is specified in the table above.The calendar year deductible for pediatric orthodontic benefits is the amount you must pay forpediatric orthodontic expenses covered by the plan before pediatric orthodontic benefits begin.This deductible is applied on a per person per calendar year basis. The deductible will be appliedto claims in the order in which they are processed regardless of the order in which they arereceived.Calendar Year Out-of-Pocket Maximum for Pediatric Dental ServicesThe calendar year out-of-pocket maximum for pediatric dental services (including pediatric orthodonticservices) is specified in the table above. Only cost-sharing amounts (calendar year deductible andcoinsurance) for covered pediatric dental services that you or your family are required to pay under theplan apply to the calendar year out-of-pocket maximum. Once the maximum has been reached, youwill no longer be subject to cost-sharing for covered pediatric dental services for the remainder of thecalendar year.There may be many expenses you are required to pay under the plan that do not count toward thecalendar year out-of-pocket maximum for pediatric dental services and that you must continue to payeven after you have met the calendar year out-of-pocket maximum for pediatric dental services. Thefollowing are some examples:10
All cost-sharing amounts (deductibles and coinsurance) paid for any in-network services orsupplies that may be covered under the plan (other than pediatric dental benefits); and, Amounts paid for non-covered services or supplies (including any out-of-network services orsupplies).Once the calendar year out-of-pocket maximum for covered pediatric dental services is met, affectedcovered benefits for all covered children up to age 19 will pay at 100% of the allowed amount for theremainder of the calendar year.Calendar Year Maximum Benefits for AdultsThe calendar year maximum benefits for adults ages 19 and over is specified in the table above. Thecalendar year maximum benefit for each adult age 19 and over under the plan is the maximum amountthe plan will pay for dental expenses covered by the plan. The calendar year maximum is applied on aper person per calendar year basis. The calendar year maximum will be applied to claims in the orderin which they are processed regardless of the order in which they are received. Once the calendar yearmaximum benefit is reached, adults will no longer receive any benefits under the plan for the remainderof that calendar year.Other Cost Sharing ProvisionsThe plan may also impose other types of cost sharing requirements such as the following: Coinsurance. Coinsurance is the amount that you must pay as a percent of the allowableamount. Actual full charges of out-of-network providers. If you see an out-of-network provider, theplan provides no coverage for such services. You will be responsible for payment of the fullamount of the dentist’s actual charges.DENTAL BENEFITS AND LIMITATIONSThe plan’s dental networks are Preferred Dentist in the state of Alabama and National Dental Network(DenteMax) outside the state of Alabama. We pay benefits toward the lesser of the allowable amountor the dentist's actual charge for services. All in-network dentists agree our payment is payment in full for covered services except for yourdeductible, coinsurance and amounts exceeding the calendar year maximum when applicable.If you are covered under another dental plan, an in-ne
Blue Cross and Blue Shield of Alabama is an independent corporation operating under a license from the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. The Blue Cross and Blue Shield Association permits us to use the Blue Cross and Blue Shield service marks in the state of Alabama.
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