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OregonGroup Dental PlanLane Community CollegeDelta Dental Premier PlanEffective Date: July 1, 2015Group Number: 10008142ODSDent‐LGOR 1‐1‐2015 [insert plan name here]ODSDent‐LGOR 1‐1‐2015Dental Plans in Oregon provided by Oregon Dental Service
TABLE OF CONTENTSSECTION 1.1.1WELCOME . 1MEMBER RESOURCES . 1SECTION 2.USING THE PLAN . 2SECTION 3.DEFINITIONS . 3SECTION 4.BENEFITS AND LIMITATIONS . 74.14.24.34.44.5CLASS I:. 74.1.1Diagnostic . 74.1.2Preventive . 8CLASS II:. 84.2.1Restorative . 84.2.2Oral Surgery . 94.2.3Endodontic . 94.2.4Periodontic . 94.2.5Anesthesia. 10CLASS III: . 104.3.1Restorative . 104.3.2Prosthodontic . 104.3.3Other . 11GENERAL LIMITATION – OPTIONAL SERVICES . 11NON‐PARTICIPATING DENTISTS . 12SECTION 5.ORAL HEALTH, TOTAL HEALTH PROGRAM . 135.1ORAL HEALTH, TOTAL HEALTH BENEFITS . 135.1.1Diabetes . 135.1.2Pregnancy . 135.2HOW TO ENROLL. 13SECTION 6.EXCLUSIONS . 14SECTION 7.ELIGIBILITY . 177.17.27.37.47.57.6SUBSCRIBER . 17DEPENDENTS . 17QUALIFIED MEDICAL CHILD SUPPORT ORDER (QMCSO) . 18NEW DEPENDENTS . 18ELIGIBILITY AUDIT. 18RETIREMENT . 197.6.1Employee Eligibility . 197.6.2Dependent Eligibility . 197.6.3When Retiree Eligibility Ends . 19SECTION 8.ENROLLMENT . 20ODSDent‐LGOR 1‐1‐2015 (10008142)Delta Dental Premier Plan
8.18.28.38.4ENROLLING ELIGIBLE EMPLOYEES . 20ENROLLING NEW DEPENDENTS . 20OPEN ENROLLMENT . 20SPECIAL ENROLLMENT RIGHTS . 208.4.1Loss of Other Coverage . 208.4.2Eligibility for Premium Subsidy . 218.4.3New Dependents . 218.5WHEN COVERAGE BEGINS . 218.6WHEN COVERAGE ENDS . 228.6.1Termination of the Group Plan . 228.6.2Termination by Subscriber. 228.6.3Death. 228.6.4Loss of Eligibility, Layoff or Leave of Absence . 228.6.5Loss of Eligibility by Dependent . 238.6.6Rescission . 238.6.7Continuing Coverage. 23SECTION 9.CLAIMS ADMINISTRATION & PAYMENT . 249.1SUBMISSION AND PAYMENT OF CLAIMS . 249.1.1Claim Submission . 249.1.2Explanation of Benefits (EOB) . 249.1.3Claim Inquiries . 249.2APPEALS . 249.2.1Definitions . 249.2.2Time Limit for Submitting Appeals . 259.2.3The Review Process . 259.2.4First Level Appeals . 259.2.5Second Level Appeal . 259.3BENEFITS AVAILABLE FROM OTHER SOURCES . 269.3.1Coordination of Benefits (COB) . 269.3.2Third Party Liability . 26SECTION 10.10.110.210.310.4DEFINITIONS . 29HOW COB WORKS . 30ORDER OF BENEFIT DETERMINATION (WHICH PLAN PAYS FIRST?) . 31EFFECT ON THE BENEFITS OF THIS PLAN . 32SECTION 11.11.111.211.311.411.5COORDINATION OF BENEFITS. 29MISCELLANEOUS PROVISIONS . 33RIGHT TO COLLECT AND RELEASE NEEDED INFORMATION . 33CONFIDENTIALITY OF MEMBER INFORMATION . 33TRANSFER OF BENEFITS . 33RECOVERY OF BENEFITS PAID BY MISTAKE. 33CORRECTION OF PAYMENTS . 33ODSDent‐LGOR 1‐1‐2015 (10008142)Delta Dental Premier Plan
RACT PROVISIONS . 33WARRANTIES . 34LIMITATION OF LIABILITY . 34PROVIDER REIMBURSEMENTS . 34INDEPENDENT CONTRACTOR DISCLAIMER . 34NO WAIVER . 34GROUP IS THE AGENT. 35GOVERNING LAW . 35WHERE ANY LEGAL ACTION MUST BE FILED . 35TIME LIMITS FOR FILING A LAWSUIT . 35SECTION 12.12.112.212.312.412.512.6OREGON CONTINUATION FOR SPOUSES & DOMESTIC PARTNERS AGE 55 AND OVER. 3612.1.1 Introduction . 3612.1.2 Eligibility . 3612.1.3 Notice and Election Requirements . 3612.1.4 Premiums . 3712.1.5 When Coverage Ends . 37COBRA CONTINUATION COVERAGE . 3712.2.1 Introduction . 3712.2.2 Qualifying Events . 3812.2.3 Other Coverage . 3912.2.4 Notice and Election Requirements . 3912.2.5 COBRA Premiums. 3912.2.6 Length of Continuation Coverage . 4012.2.7 Extending the Length of COBRA Coverage . 4012.2.8 Newborn or Adopted Child . 4112.2.9 Special Enrollment and Open Enrollment . 4112.2.10 When Continuation Coverage Ends . 41UNIFORMED SERVICES EMPLOYMENT & REEMPLOYMENT RIGHTS ACT (USERRA) . 42FAMILY AND MEDICAL LEAVE. 43LEAVE OF ABSENCE . 43STRIKE OR LOCKOUT . 43SECTION 13.13.113.213.313.413.513.6CONTINUATION OF DENTAL COVERAGE . 36ERISA DUTIES . 44PLAN ADMINISTRATOR AS DEFINED UNDER ERISA . 44INFORMATION ABOUT THE PLAN AND BENEFITS . 44CONTINUATION OF GROUP DENTAL PLAN COVERAGE . 44PRUDENT ACTIONS BY PLAN FIDUCIARIES . 44ENFORCEMENT OF RIGHTS . 45ASSISTANCE WITH QUESTIONS . 45SECTION 14.TOOTH CHART . 46THE PERMANENT ARCH. 46ODSDent‐LGOR 1‐1‐2015 (10008142)Delta Dental Premier Plan
SECTION 1.WELCOMEOregon Dental Service (ODS) was created in 1955 and was the first company in America toprovide prepaid dental coverage. Today ODS, part of the Moda Health organization, is Oregon’slargest, covering over 650,000 people from more than 1,400 groups.ODS is pleased to have been chosen by the Group as its dental plan. This handbook is designedto provide members with important information about the Plan’s benefits, limitations andprocedures.Members may direct questions to one of the numbers listed below or access tools andresources on ODS’ personalized member website, myModa, at www.modahealth.com.myModa is available 24 hours a day, 7 days a week allowing members to access planinformation whenever it’s convenient.ODS reserves the right to monitor telephone conversations and e‐mail communicationsbetween its employees and its members for legitimate business purposes as determined byODS. The monitoring is to ensure the quality and accuracy of the service provided by employeesof ODS.This handbook may be changed or replaced at any time, by the Group or ODS, without theconsent of any member. The most current handbook is available on myModa, accessed throughthe Moda Health website. All plan provisions are governed by the Group’s policy with ODS. Thishandbook may not contain every plan provision.1.1 MEMBER RESOURCESModa Health Website (log in to myModa)www.modahealth.comDental Customer Service DepartmentPortland 503‐265‐2965; Toll‐free 888‐217‐2365En Español 503‐265‐2963; Llamado gratis 877‐299‐9063Telecommunications Relay Service for the hearing impaired711ODSP.O. Box 40384Portland, Oregon 97240WELCOMEODSDent‐LGOR 1‐1‐2015 (10008142)1Delta Dental Premier Plan
SECTION 2.USING THE PLANODS’ dental plans are easy to use and cost effective. If members choose a participating DeltaDental Premier dentist from the Delta Dental Premier Dental Directory (available on myModaby using “Find Care”), all of the paperwork takes place between ODS and the dentist's office.More than 90% of all licensed dentists in Oregon are participating Delta Dental Premierdentists. For travelers and employees outside Oregon, ODS’ national affiliation with DeltaDental Plans Association provides offices and/or contacts in every state. Also, dental claimsincurred any place in the world may be processed in Oregon.Members needing dental care may go to any dental office. However, there are differences inreimbursement by ODS for participating Delta Dental Premier dentists and non‐participatingdentists or dental care providers. While a member may choose the services of any dentist, ODSdoes not guarantee the availability of any particular dentist.At an initial appointment, members should tell the dentist that they have dental benefitsthrough ODS. Members will need to provide their subscriber identification number and ODSgroup number to the dentist. These numbers are located on the I.D. card.For expensive treatment plans, ODS provides a predetermination service. The dentist maysubmit a predetermination request to get an estimate of what the Plan would pay. Thepredetermination will be processed according to the Plan’s current contract and returned tothe dentist. The member and his or her dentist should review the information before beginningtreatment.For questions about the Plan, members should contact Customer Service.This handbook describes the benefits of the Plan. It is the member’s responsibility to reviewthis handbook carefully and to be aware of the Plan’s limitations and exclusions.USING THE PLANODSDent‐LGOR 1‐1‐2015 (10008142)2Delta Dental Premier Plan
SECTION 3.DEFINITIONSAffidavit of Domestic Partnership means a signed document that attests the subscriber andone other eligible person meet the criteria in the definition of unregistered domestic partner.Alveoloplasty is the surgical shaping of the bone of the upper or the lower jaw. It is performedmost commonly in conjunction with the removal of a tooth or multiple teeth to have the gumsheal smoothly for the placement of partial denture or denture.Amalgam is a silver‐colored material used in restoring teeth.Anterior refers to teeth located at the front of the mouth (tooth chart in Section 14).Bicuspid is a premolar tooth, between the front and back teeth (tooth chart in Section 14).Bridge is also called a fixed partial denture. A bridge replaces one or more missing teeth using apontic (false tooth or teeth) permanently attached to the adjacent teeth. Retainer crowns(crowns placed on adjacent teeth) are considered part of the bridge.Broken A tooth is considered broken when a piece or pieces of the tooth have been completelyseparated from the rest of the tooth. A tooth with cracks is not considered broken.Cast Restoration includes crowns, inlays, onlays, and any other restoration to fit a specificmember’s tooth that is made at a laboratory or dental office and cemented into the tooth.Coinsurance means the percentages of covered expenses to be paid by a member.Composite is a tooth‐colored material used in restoring teeth.Cost Sharing is the share of costs a member must pay when receiving a covered service,including deductible, copayments or coinsurance. Cost sharing does not
Members needing dental care may go to any dental office. However, there are differences in reimbursement by ODS for participating Delta Dental Premier dentists and non‐participating dentists or dental care providers. While a member may
