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GROUP DENTAL PLANLane Community CollegeDelta Dental Premier PlanEffective Date: July 1, 2013Group No. 10008142ODSPPO-BENE-IH 11-1-2009www.modahealth.comMember handbooks and more are available at www.modahealth.comInsurance products provided by Oregon Dental Service
TABLE OF CONTENTSSECTION 1.WELCOME . 1SECTION 2.USING THE PLAN . 22.1MEMBER RESOURCES . 2SECTION 3.DEFINITIONS . 3SECTION 4.BENEFITS AND LIMITATIONS . 74.1CLASS I:. 74.1.14.1.24.2CLASS II:. 84.2.14.2.24.2.34.2.44.2.54.3Restorative . 10Prosthodontic . 10Other 11GENERAL LIMITATION – OPTIONAL SERVICES . 11NON‐PARTICIPATING DENTISTS . 12SECTION 5.5.1Restorative . 8Oral Surgery . 9Endodontic . 9Periodontic . 9Anesthesia . 10CLASS III: . 104.3.14.3.24.3.34.44.5Diagnostic . 7Preventive. 8ORAL HEALTH, TOTAL HEALTH PROGRAM . 13ORAL HEALTH, TOTAL HEALTH BENEFITS . 135.1.15.1.25.1.3Diabetes . 13Pregnancy . 13How 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. 19RETIREMENT . 197.6.17.6.27.6.3Employee Eligibility . 19Dependent Eligibility . 19When Retiree Eligibility Ends. 19SECTION 8.ENROLLMENT . 208.18.28.38.4ENROLLING ELIGIBLE EMPLOYEES . 20ENROLLING NEW DEPENDENTS . 20OPEN ENROLLMENT . 20SPECIAL ENROLLMENT RIGHTS . 208.4.1Loss of Other Coverage . 20ODSDent 7‐1‐2012 (10008142)
8.4.28.4.38.58.6Eligibility for Premium Subsidy . 21New Dependents . 22WHEN COVERAGE BEGINS . 22WHEN COVERAGE ENDS . 228.6.18.6.28.6.38.6.48.6.58.6.68.6.7Termination of the Group Plan. 22Termination by Subscriber . 22Death . 22Loss of Eligibility, Layoff or Leave of Absence . 23Loss of Eligibility by Dependent. 23Rescission by Insurer . 23Continuing Coverage . 23SECTION 9.CLAIMS ADMINISTRATION & PAYMENT . 249.1SUBMISSION AND PAYMENT OF CLAIMS . 249.1.19.1.29.1.39.2Claim Submission . 24Explanation of Benefits (EOB) . 24Claim Inquiries . 24APPEALS . 249.2.19.2.29.2.39.2.49.2.59.3Definitions . 24Time Limit for Submitting Appeals . 25The Review Process . 25First Level Appeals . 25Second Level Appeal . 25BENEFITS AVAILABLE FROM OTHER SOURCES . 269.3.19.3.2Coordination of Benefits (COB) . 26Third Party Liability . 26SECTION 10.COORDINATION OF BENEFITS. 3010.110.210.310.410.510.610.7DEFINITIONS . 30HOW COB WORKS . 31ORDER OF BENEFIT DETERMINATION (WHICH PLAN PAYS FIRST?) . 32EFFECT ON THE BENEFITS OF THIS PLAN . 33ODS’ RIGHT TO COLLECT AND RELEASE NEEDED INFORMATION . 33CORRECTION OF PAYMENTS . 34RIGHT OF RECOVERY . 34SECTION 1.1211.1311.14MISCELLANEOUS PROVISIONS . 35REQUEST FOR INFORMATION . 35CONFIDENTIALITY OF MEMBER INFORMATION . 35TRANSFER OF BENEFITS . 35RECOVERY OF BENEFITS PAID BY MISTAKE. 35CONTRACT PROVISIONS . 35WARRANTIES . 36LIMITATION OF LIABILITY . 36PROVIDER REIMBURSEMENTS . 36INDEPENDENT CONTRACTOR DISCLAIMER . 36NO WAIVER . 36GROUP IS THE AGENT. 37GOVERNING LAW . 37WHERE ANY LEGAL ACTION MUST BE FILED . 37TIME LIMITS FOR FILING A LAWSUIT . 37WELCOMEODSDent 7‐1‐2012 (10008142)4
SECTION 12.12.112.2CONTINUATION OF DENTAL COVERAGE . 38INDIVIDUAL DENTAL EXCHANGE PROGRAM . 38OREGON CONTINUATION COVERAGE FOR SPOUSES & DOMESTIC PARTNERS AGE 55 ANDOVER . 3812.2.112.2.212.2.312.2.412.2.512.3Introduction . 38Eligibility Requirements for 55 Oregon Continuation Coverage . 38Notice and Election Requirements for 55 Oregon Continuation Coverage . 39Premiums for 55 Oregon Continuation Coverage . 39When 55 Oregon Continuation Coverage Ends . 39COBRA CONTINUATION COVERAGE . 12.3.912.3.1012.412.512.612.7UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA) . 44FAMILY AND MEDICAL LEAVE. 45LEAVE OF ABSENCE . 45STRIKE OR LOCKOUT . 46SECTION 13.13.113.2Introduction . 39Qualifying Events . 40Other Coverage . 41Notice and Election Requirements . 41COBRA Premiums . 42Length of Continuation Coverage. 42Extending the Length of COBRA Coverage . 42Newborn or Adopted Child. 44Special Enrollment and Open Enrollment . 44When Continuation Coverage Ends. 44EXHIBITS . 47TOOTH CHART – THE PERMANENT ARCH . 47EXAMPLE OF HOW THE PLAN PAYS . 48WELCOMEODSDent 7‐1‐2012 (10008142)5
SECTION 1.WELCOMEOregon Dental Service (ODS) was created in 1955 and was the first company in America to provideprepaid dental coverage. Today ODS is Oregon’s largest, covering over 650,000 people from morethan 1,400 groups.ODS is pleased to have been chosen by the Group as its dental plan. This handbook is designed toprovide members with important information about the Plan’s benefits, limitations and procedures.Members may direct questions to one of the numbers listed below or access tools and resources onODS’ personalized member website, myModa, at www.modahealth.com. myModa is available 24hours a day, 7 days a week allowing members to access plan information whenever it’s convenient.ODSP.O. Box 40384Portland, Oregon 97240Dental Customer Service DepartmentPortland503‐265‐2965Toll Free888‐217‐2365En EspañolLlamado Gratis503‐265‐2963877‐299‐9063Relay Service for the Hearing and Speech Impaired711ODS reserves the right to monitor telephone conversations and e‐mail communications between itsemployees and its members for legitimate business purposes as determined by ODS. Themonitoring is to ensure the quality and accuracy of the service provided by employees of ODS to allmembers.This handbook may be changed or replaced at any time, by the Group or ODS, without the consentof any member. All plan provisions are governed by the Group’s policy with ODS. This handbookmay not contain every plan provision.WELCOMEODSDent 7‐1‐2012 (10008142)1
SECTION 2.USING THE PLANODS’ dental plans are easy to use and cost effective. If members choose a participating Delta DentalPremier dentist from the ODS Delta Dental Premier Dental Directory (which is available on ODS’website at www.modahealth.com under “Find Care”), all of the paperwork takes place betweenODS and the dentist's office. More than 90% of all licensed dentists in Oregon are ODS participatingDelta Dental Premier dentists. For travelers and employees outside Oregon, ODS’ national affiliationwith Delta Dental Plans Association provides offices and/or contacts in every state. Also, dentalclaims incurred 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. An example is provided in section 13.2. While a member maychoose the services of any dentist, ODS does not guarantee the availability of any particular dentist.At an initial appointment, members should tell the dentist that they have dental benefits throughODS. Members will need to provide their subscriber identification number and ODS group numberto the dentist. These numbers are located on the I.D. card.For expensive treatment plans, ODS provides a predetermination service. The dentist may submit apredetermination request to get an estimate of what the Plan would pay. The predetermination willbe processed according to the Plan’s current contract and returned to the dentist. The member andhis or her dentist should review the information before beginning treatment.For questions about the Plan, members should contact ODS Customer Service.This handbook describes the benefits of the Plan. It is the member’s responsibility to review thishandbook carefully and to be aware of the Plan’s limitations and exclusions.2.1 MEMBER RESOURCESModa Health Website (log in to myModa)www.modahealth.comDental Customer Service DepartmentPortland 503‐265‐2965; Toll‐free 888‐217‐2365; En Español 503‐265‐2963; Llamado gratis 877‐299‐9063Telecommunications Relay Service for the hearing impaired711USING THE PLANODSDent 7‐1‐2012 (10008142)2
SECTION 3.DEFINITIONSThe following are definitions of some important terms used in this handbook.Accepted Fee means the filed fee approved by ODS for a specific dental procedure performed by aparticipating dentist submitting that fee and performing that dental service. If the database doesnot contain a fee for a particular procedure in a particular area, the claim is referred to ODS’ DentalConsultant who determines a comparable code to the one billed. ODS will use the maximum planallowance for the comparable code to price the claim.Affidavit of Domestic Partnership means a signed document that attests the subscriber and oneother 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 performed mostcommonly in conjunction with the removal of a tooth or multiple teeth to have the gums healsmoothly 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 13.1).Benefits means those covered services that are available under the terms of the Plan.Bicuspid is a premolar tooth, between the front and back teeth (tooth chart in section 13.1).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. Retai
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. A
