Summary Plan Description Emory Traditional Dental Plan

Summary Plan Description Emory Traditional Dental Plan

SPD ? Traditional Dental Plan

Effective as of January 1, 2020

Page 1 of 38

Table of Contents

Important Notice ........................................................................................................................................... 5 Eligibility ...................................................................................................................................................... 6 Employees..................................................................................................................................................... 6

Dependents................................................................................................................................................ 6 Retiree and Covered Participants .............................................................................................................. 8 Enrolling Ineligible Individuals .................................................................................................................... 8 Enrollment Procedure.................................................................................................................................... 9 Annual Enrollment .................................................................................................................................... 9 Family Status Changes .............................................................................................................................. 9 Other Events Which May Entitle You to Mid-Year Changes.................................................................. 10 Transfers between Entities ...................................................................................................................... 10 Effective Date of Coverage......................................................................................................................... 10 Employees............................................................................................................................................... 10 Dependents.............................................................................................................................................. 11 Child Who Must Be Covered Due to a Qualified Medical Child Support Order (QMCSO).................. 11 Termination of Coverage ........................................................................................................................ 11 Dental Benefits Chart.................................................................................................................................. 12 Your Dental Benefits .................................................................................................................................. 12 Provider Networks ...................................................................................................................................... 13 Advance Claim Review .............................................................................................................................. 13 Covered Dental Expenses ........................................................................................................................... 14 Preventive Services ................................................................................................................................. 14 Basic Services ......................................................................................................................................... 14 Major Restorative.................................................................................................................................... 15 Orthodontic Treatment ............................................................................................................................ 16 Additional Eligible Dental Services............................................................................................................ 16 Eligible Dental Services (Additional) ..................................................................................................... 17 Payment of Benefits ................................................................................................................................ 17 Limitations .................................................................................................................................................. 17 Alternate Treatment Rule........................................................................................................................ 17 Replacement Rule ................................................................................................................................... 17 Tooth Missing But Not Replaced Rule ................................................................................................... 17

SPD ? Traditional Dental Plan

Page 2 of 38

Benefit Maximums...................................................................................................................................... 18 Periodontal Services.................................................................................................................................... 18 General Exclusions ..................................................................................................................................... 18

Applicable to Your Dental Benefits ........................................................................................................ 18 Effect of Benefits under Other Plans .......................................................................................................... 19

Coordination of Benefits - Other Plans Not Including Medicare............................................................ 19 Right to Receive and Release Needed Information ................................................................................ 19 Right of Recovery ................................................................................................................................... 20 Additional Provisions.................................................................................................................................. 21 Assignments ............................................................................................................................................ 21 Reimbursement Provision ....................................................................................................................... 22 Subrogation and Right of Recovery Provision........................................................................................ 22 Recovery of Overpayment ...................................................................................................................... 24 Reporting of Claims ................................................................................................................................ 24 Payment of Benefits ................................................................................................................................ 24 Records of Expenses ............................................................................................................................... 24 Legal Action................................................................................................................................................ 25 Filing an Appeal.......................................................................................................................................... 25 Eligibility for Coverage, Participation and Contributions ...................................................................... 25 How to File Your Appeal........................................................................................................................ 25 Health Plan Appeals for Claims Payment ............................................................................................... 26 Urgent Care ............................................................................................................................................. 26 Other Claims (Pre-Service and Post-Service) ......................................................................................... 26 Ongoing Course of Treatment................................................................................................................. 27 Exhaustion of Process Required ............................................................................................................. 28 Restriction of Venue ............................................................................................................................... 28 Discretionary Authority .......................................................................................................................... 28 Retrospective Record Review ................................................................................................................. 28 Summary of ERISA Information ................................................................................................................ 29 Continue Group Health Plan Coverage....................................................................................................... 30 USERRA Continuation Coverage............................................................................................................... 33 ERISA Rights.............................................................................................................................................. 34 Receive Information about Your Plan Benefits ...................................................................................... 34

SPD ? Traditional Dental Plan

Page 3 of 38

Continue Group Health Plan Coverage................................................................................................... 34 Prudent Actions by Plan Fiduciaries ........................................................................................................... 35

Enforce Your Rights ............................................................................................................................... 35 Assistance with Your Questions ............................................................................................................. 35 Definitions .................................................................................................................................................. 36

SPD ? Traditional Dental Plan

Page 4 of 38

The purpose of this Summary Plan Description ("SPD") is to provide you with a summary of your Benefits and other important information under the Traditional Dental Plan. Claims under this plan are administered by Aetna. This is one of the dental plan options available in the Emory University Dental Plan (The "Plan").

Important Notice

The Traditional Dental Plan is established by Emory voluntarily and may be amended or terminated at any time by Emory, in its sole discretion. Amendments may, among other things, affect eligibility, contribution rates, benefits coverage, reimbursement rates, procedures, participation, etc., at any time, regardless of whether the individual is participating in the benefit plans at the time of amendment, and even after an individual retires. The Plan Administrator has the discretionary authority to interpret the provisions of the Plan and SPD, and its decisions are final and binding. Nothing in the SPD or the Plan gives, or is intended to give any person the right to be retained in Emory's employment or to interfere with Emory's right to terminate the employment of any person.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires employer dental plans to maintain the privacy of your dental information and to provide you with a notice of the Plan's legal duties and privacy practices with respect to your dental information. The notice will describe how the Plan may use or disclose your dental information and under what circumstances it may share your dental information without your authorization (generally, to carry out treatment, payment or dental care operations). In addition, the notice will describe your rights with respect to your dental information. Refer to the Plan's privacy notice for more information. You can obtain a copy of the notice by contacting the Emory University Benefits Department at 404-727-7613.

It is Emory's policy and intent to comply with all applicable provisions of the HIPAA privacy rules and the related regulations. Emory will investigate fully any complaint that it or the Plan has not complied with such laws and regulations and will take steps to remedy any violations should they occur. If you believe that the Plan has violated a provision of HIPAA, you are encouraged to share your complaint with Emory by contacting the Emory University Benefits Department at 404-727-7613. Emory will not retaliate or otherwise discriminate against you if you assert a complaint or take any other action which is protected under HIPAA.

SPD ? Traditional Dental Plan

Page 5 of 38

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download