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When Coverage BeginsEligibility DateYou are eligible to request coverage on the date You firstbecome an Eligible Person.Your Eligible Dependents will be eligible for coverage onthe date they first become Eligible Dependents.If an Eligible Dependent is also an Eligible Member, he willbe eligible for coverage as a Member or as a Dependent, butnot as both.Medical Child Support Orders, typically issued in divorceproceedings, may create or recognize the right of a Child of aMember to be covered under The Dental Plan. Such an ordermust be qualified under federal law for The Dental Plan tobe bound by it. Please contact the Claims Department for afree copy of Our guidelines used to determine whether aMedical Child Support Order is qualified.Enrollment RequirementsYou must request coverage for yourself and/or Your EligibleDependent(s) after Your Eligibility Date by: Completing and signing an application for coverage orcompleting the online enrollment form; Remitting Your required Premium payment in full orcompleting a bank draft authorization form thatauthorizes Us to draft Your checking or savingsaccount for Your Premium; and Submitting Your application and Premium payment ordraft authorization to us.MemberYou may also enroll Your Eligible Dependent(s) any timeduring Your active enrollment in The Dental Plan bysubmitting a written request or completing the EnrollmentInformation Change form, which is available online atwww.geha.com/CDPlus. If You fail to submit a writtenrequest to add Your Eligible Dependent(s), they will not beenrolled in The Dental Plan. Your payroll office will notnotify The Dental Plan for You.Effective Date of CoverageIf all Enrollment Requirements are met, then You and/orYour Dependent(s)’ coverage will be effective on the firstday of the month next following the date We receive Yourapplication and required Premium payment.Coverage for any Eligible Dependents will become effectiveonly on or after the date You become a Member. All EligibleDependents enrolled more than 31 days after that date willhave a separate Effective Date of Coverage and WaitingPeriods as described under Covered Services.Your Effective Date of Coverage will be subject to therequired 12-month Waiting Period due to prior VoluntaryTermination. All Dental Plan Waiting Periods and BenefitPercentages will begin again upon re-enrollment.An Eligible Person or Dependent shall become a CoveredPerson on the date coverage for such person begins.When Coverage TerminatesYour coverage will terminate on the earliest of the followingdates: The date The Dental Plan is terminated; The last day of the month in which the final Premiumpayment is made; or The last day of the month in which We receive Yourrequest for voluntary termination. DependentsYour covered Dependent(s)’ coverage under The DentalPlan will end on the earliest of the following dates: The date The Dental Plan is terminated; The last day of the month in which an Eligible Person’scoverage is terminated, unless such Dependent isenrolled in Dependent Only coverage;5The date The Dental Plan is amended so as to terminatethe Dependent(s)’ coverage;The last day of the month in which the final Premiumpayment is made for the Dependent(s)’ coverage;The last day of the month in which the Dependentceases to be an Eligible Dependent; orThe last day of the month in which the Dependent getsmarried.

When Coverage Terminates continuedContinuation of Dependent Child CoverageAfter Age 26Subject to the other terms and conditions stated herein,coverage for any unmarried Dependent Child whose coverageis terminating because he has reached age 26 may becontinued if: The Child is incapable of self-support due to a mentalincapacity or physical disability; and The Child’s mental incapacity or physical disabilitystarted while covered and prior to age 26; and The Child is primarily dependent on You for supportand maintenance; and A request for continuation and satisfactory proof of theChild’s mental incapacity or physical disability ispresented to Us within 31 days after the Child’scoverage would otherwise end; and Any required Premium payment is made.We may require continued proof of the Child’s mentalincapacity or physical disability at reasonable intervalsthereafter. Any such proof will be at Your expense.Such continued coverage will end on the earliest of: The last day of the month in which the Child is nolonger incapable of self-support due to mental incapacityor physical disability; The last day of the month preceding any month in whichYou fail to provide any required proof or fail to makeany required Premium payments; or In the case of an Eligible Person’s Child, the last day ofthe month in which the Eligible Person’s coverageterminates, unless such Dependent is enrolled inDependent Only coverage.Termination Does Not Affect Existing ClaimsWhen a Covered Person’s coverage is terminated for anyreason other than Involuntary Termination for FraudulentClaims, such termination does not affect any claims forCovered Services that were incurred and completed while theCovered Person’s coverage was in force and Premium hasbeen paid.Voluntary TerminationsA Covered Person whose coverage is Voluntarily Terminatedmay not re-enroll until a minimum 12-month Waiting Periodis satisfied. Re-enrollment causes all Dental Plan WaitingPeriods and Benefit Percentages to begin again. VoluntaryTermination shall include termination of coverage becauseof non-payment of Premium.To request termination of Your Dental Plan coverage, callConnection Dental Plus at (800) 793-9335 or send a writtennotice of termination to:GEHA Connection Dental PlusPO Box 21542Eagan, MN 55121-9930Do not assume that making changes to Your FederalEmployees Health Benefits Program (FEHB) or FederalEmployees Dental and Vision Insurance Program(FEDVIP) coverage will automatically change Yourcoverage with this Dental Plan. You must initiate therequest for voluntary termination of Your Dental Plancoverage.The Dental Plan will not refund Premiums paid for themonth in which You request voluntary termination or anyprior months of coverage.Involuntary Termination forFraudulent ClaimsIf any Covered Person knowingly submits or participates inthe submission of information that contains false ormisleading facts, then We have the right to revoke thatCovered Person’s coverage back to the first day of themonth in which the fraud was perpetrated withoutprejudicing any other legal right or remedy that might beavailable to us, and terminate the coverage.If We terminate coverage under this provision, coverageshall be permanently terminated and the terminated personcannot re-enroll at any time in the future.Notice of IneligibilityYou must let Us know in writing within 30 days of YourDependent(s)’ loss of eligibility. Your payroll office willnot notify The Dental Plan for You. Your Dependent(s)’coverage will not be continued past the time it would haveended as described in this section even if You fail toprovide timely notice.6

Rights of a Covered PersonAs a Member in The Dental Plan, You are entitled to certainrights and protections under the Employee Retirement IncomeSecurity Act of 1974 (ERISA). ERISA provides that allMembers shall be entitled to: Examine, without charge, at Our office all PlanDocuments, including contracts, bargaining agreementsand copies of all documents filed by The Dental Planwith the U.S. Department of Labor, such as plandescriptions (filed before 1997) and annual reports; Obtain copies of all Dental Plan documents, includingcopies of the latest annual report and updated summaryplan description, and other information upon writtenrequest to us. We will make a reasonable charge forcopies; Receive a summary of The Dental Plan’s annualfinancial report (if applicable). We are required by lawto furnish each Member with a copy of this summaryfinancial report; and File suit in a federal court, if certain plan materialsrequested are not received within thirty (30) days ofYour request, unless the materials were not sent becauseof matters beyond Our control. The court may requireThe Dental Plan to pay up to 110 for each day’s delayuntil the materials are received.In addition to creating rights for Members, ERISA imposesobligations upon the persons who are responsible for theoperation of The Dental Plan. These persons are referred to as“Fiduciaries” in the law. Fiduciaries must act solely in theinterest of the Members and they must exercise prudence inthe performance of their duties. Fiduciaries who violateERISA may be removed and required to make good on anylosses they have caused The Dental Plan.No one may fire You or otherwise discriminate against You toprevent You from obtaining benefits under The Dental Plan orexercising Your rights under ERISA.In addition, if You disagree with The Dental Plan’sdecision about the qualified status of a medical childsupport order, You may file suit in federal court.If Plan Fiduciaries are misusing The Dental Plan’s money,or if You are discriminated against for asserting Yourrights, You have the right to file suit in federal court orrequest assistance from the U.S. Department of Labor. IfYou are successful in the lawsuit, the court may, if it sodecides, require the other party to pay legal costs,including any attorney fees. If You are unsuccessful in thelawsuit, the court may, if it so decides, require You to paythe other party’s legal costs and fees if, for example, thecourt decides the lawsuit is frivolous.If You have any questions about this statement of Yourrights under ERISA, contact The Dental Plan or thenearest office of the Employee Benefits SecurityAdministration, U.S. Department of Labor, listed in thephone book, or the Division of Technical Assistance andInquiries, Employee Benefits Security Administration,U.S. Department of Labor, 200 Constitution AvenueN.W., Washington, D.C. 20210. You may also getpublications about Your rights and responsibilities underERISA by calling the publications hotline of the EmployeeBenefits Security Administration.Your spouse or dependent may continue coverage if he orshe loses coverage under The Dental Plan as a result of aQualifying Event. Your dependents will have to pay forsuch coverage. Review this plan brochure and thedocuments covering The Dental Plan on the rulesgoverning Your COBRA Continuation of Coverage rights.Esta Descripción Sumaria Del Plan contiene un resumenen Inglés de sus derechos y ventajas del Plan Dental. Siusted tiene dificultad entendiendo cualquier parte de estadescripción Sumaria Del Plan, comuniquese con elAdministrador Del Plan al(800) 793-9335 para ayuda.If Your claim for benefits is denied or ignored in full or inpart, You have the right to know why this was done, to obtainfree copies of documents relating to the decision and to appealthe denial. You also have the right to file suit in a federal orstate court, if You have exhausted the claims proceduresavailable to You under the Plan.7

Effective July 1, 2021Government Employees Health Association, IncNotice of Privacy PracticesTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSEDAND HOW YOU CAN GET ACCESS TO THIS INFORMATION.PLEASE REVIEW IT CAREFULLYPurpose of this noticeGEHA understands that medical information about you andyour health is personal. We are committed to protecting yourhealth information. This notice applies to the benefits offeredunder GEHA’s Voluntary Welfare Benefit Plan, which areGEHA’s Connection Dental Plus Plan, Connection DentalDiscount, and GEHA’s Connection Vision Plan Powered byEyeMed (the “Vision Plan”). The notice explains your rightsunder HIPAA and how you can get access to your protectedhealth information (“PHI”). It also describes how we may useand disclose your PHI, and our legal obligations concerningthat information. PHI is information about you, includingdemographic information, that may identify you and thatrelates to your past, present or future physical or mentalhealth or condition and related health care services, orpayment for health care services.State lawWhere state law that GEHA follows is stricter and providesgreater privacy protections than HIPAA, GEHA will followthe stricter applicable state law.GEHA’s designation as a HIPAA hybrid entityGEHA as an employee organization conducts activities that areboth covered and non-covered functions under HIPAA. GEHAhas designated itself a hybrid entity under HIPAA, and onlythose sections of GEHA that perform covered functions mustcomply with HIPAA. The list of the designated “Health CareComponents” are available here: geha.com/hcc.GEHA’s dutiesWe are required by law to: Ensure PHI that identifies you is kept private; Give you this notice of our legal duties and privacypractices regarding your PHI; Follow the terms of the notice that is currently in effect; and Notify you following a breach of your unsecured PHI asprovided under law.How we may use or disclose your PHIWe typically use or share your health information in thefollowing ways.To help manage the treatment you receive: We can useyour health information and share it with professionals whoare treating you. For example, a dentist and GEHA canshare your health information so we can coordinate andmanage your care.For payment: We may use and disclose your PHI as wepay for your health services, and manage your account. Forexample, we may use health information in the form ofyour dental history from your provider to determinewhether a particular treatment is medically necessary, or todetermine whether a treatment is covered. We may discloseinformation to assist with the subrogation of claims or tocoordinate benefit payments. We may share explanation ofbenefits (EOBs) with the subscriber of your plan forpayment purposes.For health care operations: We may use or disclose yourPHI for other GEHA operations as needed. These uses anddisclosures are necessary to GEHA’s business operations,and can include quality assessment, customer service, legaland auditing functions, fraud and abuse detection programs,business planning and development, and generaladministrative activities. For example, we may use or shareyour PHI to develop better services for you.To business associates: We may share your PHI with ourbusiness associates that assist us in providing certain typesof services and perform various activities on our behalf. Forexample, we may share your health information with abusiness associate to help detect potential fraud or abuse.Whenever an arrangement between GEHA and a businessassociate involves the use or sharing of your PHI, we willhave a written contract that contains terms to ensure thebusiness associate protects the privacy of your healthinformation to the same extent as is set forth in this Noticeof Privacy Practices.To the plan sponsor: We may disclose your PHI to the plansponsor, GEHA, to permit it to perform plan administrationfunctions. Please refer to your brochure for a fullexplanation of the limited uses and disclosures that the plansponsor may make of your PHI in performing planadministration functions. Additionally, summary healthinformation may be shared for the purpose of makingdecisions regarding modifying, amending, or terminatingthe group health plan. Information may also be disclosed tothe plan sponsor on whether you are participating in thegroup health plan.8

Notice of Privacy Practices continuedOrganized Health Care Arrangement: Connection DentalPlus and the Vision Plan are both maintained by GEHA as thehealth plan sponsor. If you are covered by GEHA throughConnection Dental Plus and the Vision Plan, the plans mayshare PHI with each other as necessary to carry out treatment,payment, or health care operations relating to the organizedhealth care arrangement. For example, enrollment informationregarding address changes and payment information in orderto coordinate benefits are some of the ways in whichinformation may be shared.As required by law and for public health activities: We mayuse or disclose your PHI to the extent that federal, state, orlocal law requires the use or dis

WITH A NATIONAL NETWORK OF PARTICIPATING DENTISTS. Open to . all . current and former federal employees, year long. WHO MAY ENROLL IN THIS PLAN: All current and former federal employees and . it can readyli be undersotod and used by You and by GEHA in administering C onnection Dental . Plus. Connection Dental . Plus has exclusions .