Silver medical benefits

Transcription

Plan 185
Summary Plan Description
Your Health and Welfare Benefits
UNITE HERE HEALTH
Summary Plan Description
Hospitality Plan (185)
Effective January 2016
This Summary Plan Description supersedes and
replaces all materials previously issued.
Table of Contents
Using this book................................................................. A-1
How can I get help?........................................................... A-5
How do I get the most from my benefits?........................ A-7
Prior authorization program........................................... B-1
Gold medical benefits....................................................... C-1
Silver medical benefits...................................................... C-15
Prescription drug benefits ............................................... C-29
Dental benefits.................................................................. C-37
Vision benefits.................................................................. C-47
Short-term disability benefits.......................................... C-51
Life and AD&D insurance benefits................................. C-55
General exclusions and limitations................................. C-61
Coordination of benefits.................................................. D-1
Subrogation....................................................................... D-5
Eligibility for coverage...................................................... E-1
Termination of coverage................................................... E-11
Re-establishing eligibility................................................. E-15
COBRA continuation coverage........................................ E-19
Claim filing and appeal provisions................................. F-1
Definitions........................................................................ G-1
Other important information.......................................... G-9
Your rights under ERISA................................................. G-14
Important contact information....................................... G-16
UNITE HERE HEALTH Board of Trustees................... G-17
Using this book
Learn:
ӹӹ What UNITE HERE HEALTH is.
ӹӹ What this book is and how to use it.
ӹӹ How your benefit options affect you.
Using this book
A
Using this book
Please take some time to review this book.
“Medical Benefits.” If you want to know more about your life and AD&D insurance benefit, read
the section titled “Life and AD&D Insurance Benefits.”
If you have dependents, share this information with them, and let them know
where you put this book so you and your family can use it for future reference.
Remember, this SPD may describe benefits that do not apply to you. Your CBA determines which
benefit options you have (see below).
What is UNITE HERE HEALTH?
UNITE HERE HEALTH (the Fund) was created to provide benefits for you and your covered
dependents. UNITE HERE HEALTH serves participants working for employers in the hospitality
industry and is governed by a Board of Trustees made up of an equal number of union and employer trustees. Each employer contributes to the Fund based on the terms of specific Collective
Bargaining Agreements (CBAs) between the employer and the union.
This book is your Summary Plan Description (SPD). Your SPD helps you understand what your
benefits are and how to use your benefits. It is a summary of the Plan’s rules and regulations and
describes:
The benefits you elect apply to both you and your enrolled dependents. You cannot elect coverage
for your dependents only. You must elect coverage for yourself in order to elect coverage for your
dependents.
• What your benefits are
• Limitations and exclusions
• How you become eligible for coverage
• How to file claims
• When your dependents are covered
• How to appeal denied claims
No contributing employer, employer association, labor organization, or
any person employed by one of these organizations has the authority to answer questions or
interpret any provisions of this Summary Plan Description on behalf of the Fund.
How do I use my SPD?
This SPD is broken into sections. You can get more information about different topics by carefully
reading each section. A summary of the topics is shown at the start of each section. When you
have questions, you should always contact the Fund at (855) 405-FUND (3863). The Fund can
help you understand your benefits.
Plan 185
What are my benefit options?
What is this book and why is it important?
If information contained in this SPD is inconsistent with the Plan Document,
the Plan Document will govern.
A-2
Some terms are defined for you in the section titled “Definitions” starting on page G-2. The SPD
will also explain what some commonly used terms mean. When you have questions about what
certain words or terms mean, contact the Fund (see page A-5).
The benefits described in this SPD describe the terms of all of the benefit options available under
the Hospitality Plan. However, your CBA and your enrollment elections determine which benefit
options you have. For example, if dental benefits are available to you, but you don’t want dental
benefits, the part of the SPD that explains dental benefits does not apply to you. If your CBA does
not include short-term disability benefits, the part of the SPD that explains short-term disability
benefits does not apply to you.
Your Plan, the Hospitality Plan, is part of UNITE HERE HEALTH. The Hospitality Plan has been
adopted by the Trustees to pay for medical and other health and welfare benefits through the
Fund.
Read your SPD for important information about how your benefits are paid and what rules you
may need to follow. You can find more information about a specific benefit in the applicable section. For example, you can get more information about your medical benefits in the section titled
A
You can change your coverage choices at certain times during the year, called “enrollment periods.” See page E-8 for more information about enrollment periods.
When you have questions about your benefit options, contact the Fund at (855) 405-FUND
(3863).
Medical benefits
The Hospitality Plan has a Silver Plan and a Gold Plan. You enrolled in one of these plans during
your enrollment period. You can check your ID card or call the Fund at (855) 405-FUND (3863)
to see in which plan you are enrolled. The amount of money you pay for your benefits depends on
your CBA, which medical plan you choose, and whether or not you enroll your dependents. The
benefits you elect apply to both you and your enrolled dependents.
Dental/Vision benefits
Based on the terms of your CBA, you have the choice to add dental and vision benefits to your
medical benefits. If you want dental, you have to take vision, and vice versa. For example, you
can’t choose dental but waive vision. The amount of money you pay for your dental and vision
benefits depends on your CBA and whether or not you enroll your dependents.
Your CBA may also let you choose whether or not to cover your dependents under the dental and
vision benefit option. If it is allowed under your CBA, you can choose different benefit options for
A-3
Plan 185
How can
I can
getI get
help?
How
help?
Using this book
A
dental and vision coverage than you choose for medical. For example, you can choose the medical
benefit option for just yourself, but elect the dental and vision benefit option for yourself and all
of your dependents.
However, if your CBA doesn’t let you choose different options for your dependents than you
choose for medical, the options you choose for your dependents for your medical benefits also
applies to your dental/vision benefits. For example, if your CBA says your medical, dental, and
vision options all have to be the same, if you choose family medical coverage, your dependents
will also get dental and vision coverage.
Other benefits
Depending on the terms of your CBA, you may also get life and AD&D insurance benefits and/
or short-term disability benefits. If your CBA requires your employer to make contributions for
life and AD&D insurance benefits and/or short-term disability benefits, you will get the benefit
option even if you don’t enroll in the medical benefits.
A
UNITE HERE HEALTH
(855) 405-FUND (3863)
Call the Fund:
• When you have questions about your
benefits.
eligibility.
• To update your address.
• To request new ID cards.
• To get forms or a new SPD.
claim—including whether the claim has
been received or paid.
You can also visit UNITE HERE HEALTH’s website to get forms, get another copy of your SPD,
or ask for other information: www.uhh.org.
This booklet contains a summary in English of your plan rights and benefits under the Hospitality
Plan of UNITE HERE HEALTH. If you have difficulty understanding any part of this booklet, you
can visit or contact any of the regional offices shown below. Office hours are from 9:00 A.M. to 4:30
P.M. Monday through Friday. You may also call UNITE HERE HEALTH at (855) 405-FUND for
assistance. Phones are answered from 9:00 A.M. to 5:00 P.M. local time.
Este folleto contiene un resumen en inglés de sus derechos y beneficios bajo el Plan Hospitality de
UNITE HERE HEALTH. Si tiene dificultad para entender cualquier parte de este folleto, puede
ponerse en contacto o visitar cualquiera de las oficinas regionales que se muestran a continuación.
Los horarios de oficina son de 9:00 a.m. a 4:30 p.m. de lunes a viernes. También puede ponerse en
contacto con UNITE HERE HEALTH al (855) 405-FUND para asistencia Las llamadas son contestadas de 9:00 a.m. a 5:00 p.m. hora local.
Regional offices (Llame para consulta médica)
• 218 S. Wabash Ave., Suite 800, Chicago, IL 60605.
• 1801 Atlantic Ave, Suite 200 Atlantic City, NJ 08401.
• 33 Harrison Ave, Suite 500, Boston, MA 02111.
• 13252 Garden Grove Boulevard Suite 200, Garden Grove, CA 92843.
• 130 S. Alvarado St, 2nd Floor, Los Angeles, CA 90057.
A-4
Plan 185
• 702 Forest Ave, Suite B, Pacific Grove, CA 93950.
• 275 Seventh Avenue, Suite 1504, New York, NY 10001.
A-5
Plan 185
How do I get the most
from my benefits?
Learn:
ӹӹ Why you should get a primary care provider.
ӹӹ Why you should get preventive care.
ӹӹ How to reduce your costs for urgent care.
ӹӹ Why you should call the Fund.
ӹӹ How to use network providers to save time and money.
A-6
Plan 185
How do I get the most from my benefits?
A
Get a primary care provider
Call the Fund
You and each of your dependents should have a primary care provider (also called a “PCP”). You
should get to know your PCP so he or she can help you get, and stay, healthier. Your PCP can help
you find potential problems as early as possible, answer questions for you, and help coordinate
your care with specialists. Your PCP also helps you keep track of when you need preventive care.
The Fund is here to help you. Fund staff can help you find a provider, answer your questions
about your benefits, get you in touch with Nevada Health Solutions to get prior authorization for
your care, and answer other questions for you. See page B-2 for more information.
You are encouraged to have a PCP, but the Fund doesn’t track your PCP. You don’t need to tell the
Fund who your PCP is, and you don’t need to tell the Fund if you change PCPs.
✓✓ Call the Fund at (855) 405-FUND (3863).
✓✓ Call Blue Cross Blue Shield at (800) 810-BLUE (2583) to find a network PCP. Your
network is the Participating Provider Organization (PPO) network.
Use your smart phone or the internet to talk to a doctor
✓✓ You can also call the Fund (855) 405-FUND to get help finding a PCP.
If you need to see a healthcare provider but can’t get into the office, you can video chat with one
through Doctor on Demand. You can access Doctor on Demand by internet or through your
smart phone.
Get preventive care
Your Plan pays 100% for most types of preventive care. Getting preventive care helps you stay
healthy by looking for signs of serious medical conditions. If preventive care or tests show there is
a problem, the sooner you get diagnosed, the sooner you can start treatment.
(800) 997-6196
www.doctorondemand.com
You pay only $15 per telehealth visit. See page C-6 for more information.
Call for medical advice / Llame para consulta médica
(855) 785-7885
www.consejosano.com
¡Llama GRATIS hoy mismo!
Get prior authorization for your care
You or your provider must call before you get certain types of care. See page B-2 for information
about the list of services and supplies that require prior authorization. If you don’t call first, you
may pay more for your healthcare—you may even have to pay all of the cost. Be sure you get prior
authorization for your care!
✓✓ Call Nevada Health Solutions at (855) 487-0353 to get prior approval for your care.
A
• Asesoría Médica General
• Dieta, Obesidad & Nutrición
• Apoyo Emocional & Psicológico
• Asesoría Para Padres de Familia
Re-think emergency room care
Is it really an emergency? If not, you pay less when you go to an urgent care center. You pay much
less when you go to a network urgent care center than when you go to the emergency room.
A-8
Plan 185
If you use a network hospital emergency room for routine care your PCP could provide, you pay
your deductible (if applicable) plus 50% of the allowable charges. If you use a non-network hospital emergency room for routine care your PCP could provide, you pay the entire cost of the visit.
(See page G-4 for a definition of “emergency.”)
✓✓ If you need emergency care, call 911 or go to the emergency room.
A-9
Plan 185
A
• ConsejoSano: Consulta médica que no es de emergencia en español
ConsejoSano es un servicio de consejería médica en Español por teléfono diseñado. Puedes
llamar a cualquier hora y hablar de inmediato con un asesor médico en Español acerca de cualquier pregunta de salud. ¡Toma el control de tu salud y la de tu familia y mantén un estilo de
vida saludable!
¡Ahora es más fácil cuidar de tu salud!
• Todos nuestros asesores médicos son Hispanos y hablan Español.
• Nos tomamos el tiempo para escucharte, entenderte y brindarte la mejor asesoría médica
posible.
• Nuestros asesores médicos se adaptan a tu horario y están disponibles las 24 horas, 7 días de
la semana, todo el año.
• Llama todas las veces que necesites pro el tiempo que tu desees, ¡no hay limite de llamadas!
Habla hoy con un asesor médico en Español
• PASO 1: Baja nuestra aplicación móvil ConsejoSano llama y habla con un asesor médico en
segundos.
• PASO 2: No tienes un smarthphone? Sólo llámanos desde cualquier teléfono al (855) 7857885.
• PASO 3: Brinda tu nombre y número de cliente al asesor médico con el que hables. ¡Así de
fácil!
Use network providers
Reduce your costs with a network provider
The Plan generally pays higher benefits if you choose a network provider than if you choose
non-network care. You only have to pay the difference between the network provider’s discounted
rate (the Plan’s allowable charge) and what the Plan pays for covered services. The network provider cannot charge you for the difference between the allowable charge and his or her actual
charges (sometimes called balance billing). This means that you will usually pay less out-ofpocket if you choose a network provider.
Look in the medical benefits section for an example of how using a network provider can save
you money.
A-10
Plan 185
The Plan will apply network benefits to treatment provided by non-network healthcare providers who specialize in emergency medicine, radiology, anesthesiology, or pathology, as well as for
in-hospital consultations with non-network providers. However, the allowable charge will be
A
determined based on whether or not the provider is in the network. You must still pay the difference between the Plan’s allowable charge and what the non-network provider charges.
This rule also applies if there is no network provider in that specialty.
Easier claims filing with a network provider
The other advantage to using a network provider is that the network provider will usually file a
claim for you. You generally don’t have to fill out a claim form or submit your receipts.
If you choose a non-network provider, you may have to pay the entire cost of your care. The nonnetwork provider may or may not file a claim for you. If you choose a non-network provider, you
can file a claim to get paid back for the Plan’s share of your covered care. See page F-2 for more
information about filing claims.
How do I stay in the network?
• Blue Cross Blue Shield of Illinois provides access to a national network of doctors, hospitals,
and other healthcare providers. Your network is the Participating Provider Organization
(PPO) network.
To find a network provider:
BCBSIL
(800) 810-BLUE (2583)
• True Choice provides access to a select national network of participating pharmacies that
you must use in order to get benefits for prescription drugs. Not all pharmacies are in the
network. For example, Walgreens is in your network while CVS and Wal-Mart are not.
To find a network pharmacy:
UNITE HERE HEALTH
(855) 405-FUND (3863)
• If you are enrolled in the vision benefit option, Vision Service Plan (VSP) provides access
to a national network of vision care providers. You can stay in the network by using any
participating VSP Choice provider.
To find a network vision provider:
VSP
(800) 877-7195
• If you are enrolled in the dental benefit option, Cigna provides access to a national health
maintenance organization (HMO) network of dental care providers. Your network is the
Cigna Dental Care HMO network.
To find a network dental provider:
Cigna
(800) 244-6224
If you have questions about your benefits, or if you need help finding a network provider, call the
Fund at (855) 405-FUND (3863).
A-11
Plan 185
Prior authorization program
Learn when and why you should call Nevada Health Solutions:
ӹӹ To get prior authorization for your care.
ӹӹ To sign up for the case management program.
A-12
Plan 185
The prior authorization program is designed to help make sure you and your dependents get the
right care in the right setting. It helps make sure you don’t get unnecessary medical care and
helps you manage complex or long-term medical conditions. The prior authorization program
includes mandatory prior authorization of certain types of care to help you make decisions about
your healthcare and a voluntary case management program.
B
Nevada Health Solutions works with you to help you find a provider, understand your treatment
plan, and coordinate your healthcare and the information flow between your providers.
To get prior authorization, call toll free:
Nevada Health Solutions
(855) 487-0353
The prior authorization program is not intended as and is not medical advice. You are still responsible for making any decisions about medical matters, including whether or not to follow
your healthcare provider’s suggestions or treatment plan. UNITE HERE HEALTH is not responsible for any consequences resulting from decisions you or your provider make based on the prior
authorization program or the Plan’s determination of the benefits it will pay.
• The following radiology services:
B
ӹӹ CT or CTA scans (computed tomography or computed tomography angiography).
ӹӹ Discography.
ӹӹ MRA or MRI (magnetic resonance imaging or magnetic resonance angiography).
ӹӹ PET-Scan (positron emission tomography scintiscan).
• Dialysis.
• Durable medical equipment rentals or purchases over $500. (This includes breast pumps
costing over $500.)
• Genetic testing.
• Skilled services provided in a home setting, including home healthcare and home infusion
• Hyperbaric treatment.
• Inpatient admissions, including mental health/substance abuse inpatient and residential
Get prior authorization for medical and surgical treatment
You and your healthcare provider must get prior authorization before you get any of the types of
care listed below. If your healthcare provider does not get prior authorization before you receive
these types of care, your claim may be denied. Nevada Health Solutions will ask for more information to decide whether the claim should be re-processed and paid. Making sure Nevada
Health Solutions is called first helps you avoid surprise medical bills. If you get treatment,
services, or supplies that are not covered or are not medically necessary, you pay 100% of your
care.
toll free: (855) 487-0353
✓✓ Prior authorization or referrals provided under the prior authorization program does not
guarantee eligibility for benefits. The payment of Plan benefits are subject to all Plan rules,
including but not limited to eligibility, cost sharing, and exclusions.
When to call for prior authorization
You or your healthcare provider should contact Nevada Health Solutions before any of the following:
B-2
Plan 185
• Air ambulance transportation.
• Clinical trials.
care, admissions following observation or an emergency room visit, and admissions for
skilled nursing facility care, acute rehabilitation care, and long-term acute facility care.
• Medical foods for inborn errors of metabolism.
• Oncology and hematology services.
• Orthotic and prosthetic appliance rentals or purchases of over $500.
• Orthognathic surgery.
• Outpatient surgery or procedures performed in an ambulatory surgical center, and surgery
or invasive diagnostic procedures performed in the outpatient hospital surgery area.
However, colonoscopies or sigmoidoscopies do not require prior authorization.
• Physical, speech, or occupational therapy.
• Sleep studies.
• TMJ procedures.
• Transplant services, including consultations.
• Travel and lodging.
• Varicose vein procedures.
You should contact Nevada Health Solutions before receiving any of the above types of services
and supplies. If you need emergency care, you should contact Nevada Health Solutions as soon as
possible after you get the service or supply. If you are hospitalized because you are having a baby,
B-3
Plan 185
you must call Nevada Health Solutions if your stay will be longer than 48 hours for normal childbirth, or 96 hours for a Cesarean section.
B
Group health plans and health insurance issuers generally may not, under federal law, restrict
benefits for any hospital length of stay in connection with childbirth for the mother or a newborn
child to less than 48 hours following a vaginal delivery, or less than 96 hours following a Cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending
provider, after consulting with the mother, from discharging the mother or her newborn earlier
than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal
law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
You may be required to use the case management program in order to get benefits for transplants
or travel and lodging costs. Otherwise, it is your choice whether or not to join the case management program, and whether or not to follow the program’s recommendations.
B
You do not need prior authorization in order to access obstetrical or gynecological care from a
network healthcare provider who specializes in obstetrics or gynecology. The healthcare provider,
however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making
referrals. For help finding participating healthcare providers who specialize in obstetrics or gynecology, contact the Fund at (855) 405-FUND (3863).
See page F-2 for information about when Nevada Health Solutions must respond to your request
for prior authorization and for information about how to appeal a prior authorization denial.
Case management program
You and your dependents may be eligible for the case management program if you have a catastrophic or chronic medical condition, or if your condition has a high expected cost. For example,
case management may apply to cancer, chronic obstructive pulmonary disease (COPD), spinal
injury, multiple trauma, stroke, head injury, AIDs, multiple sclerosis (MS), severe burns, severe
psychiatric disorders, high-risk pregnancy, or premature birth.
If you are selected for the case management program, a case manager will work with you and
your healthcare providers to create a treatment plan and help you manage your care. The goal
of case management is to make sure that your healthcare needs are met while helping you work
toward the best possible health outcome, and managing the cost of your care.
You or your healthcare provider can ask to join the case management program. In most cases,
Nevada Health Solutions will look for patients who may benefit from case management services.
Nevada Health Solutions may ask you to join the case management program.
B-4
Plan 185
The case manager may recommend treatments, services, or supplies that are medically appropriate but are more cost-effective than the treatment proposed by your healthcare provider. UNITE
HERE HEALTH, at its discretion and in its sole authority, may approve coverage for those alternatives, even if the treatment, service, or supply would not normally be covered.
However, in all cases, you and your healthcare provider make all treatment decisions.
B-5
Plan 185
Gold medical benefits
Learn:
ӹӹ What you pay for healthcare.
ӹӹ How the network out-of-pocket limits protect you from large out-ofpocket expenses.
ӹӹ What types of medical healthcare the plan covers.
ӹӹ What types of medical healthcare are not covered.
B-6
Plan 185
Gold Plan Medical Plan Payments
Gold Plan Medical Benefits
In general, what you pay for medical care is based on what kind of care you get, where you get your care,
and whether you go to a network or a non-network provider. For example, you pay less using an urgent
care center instead of going to the emergency room.
Unless shown otherwise, this table shows what you pay for your care (called your “cost-sharing”). You
pay any copays, your coinsurance share, any amounts over a maximum benefit, and any expenses that
are not covered, including any charges that are more than the allowable charge.
C
Annual Deductibles
None
BCBS PPO Network
Office Visits
Preventive Healthcare (See page G-7 )
Non-Network
$0
Not covered
Primary Care Provider (PCP) Office Visits
$20 copay/visit
50%
Doctor on Demand Telehealth Visits
$15 copay/visit
n/a
ConsejoSano Medical Advice Calls
$0 copay/visit
n/a
Specialist Office Visits
$40 copay/visit
50%
Mental Health/Substance Abuse Office Visits
$20 copay/visit
50%
Chiropractic Services —
up to 12 total visits per person each year
$20 copay/visit
Not covered
BCBS PPO Network
Non-Network
Ambulatory Surgical Center
$150 copay/visit
50%
Hospital Outpatient Department
$250 copay/visit
50%
Outpatient Surgery
Physical, Speech, Occupational Therapy — up to 60 total visits per person each year for physical and
occupational therapies combined, and up to 30 total visits per person each year for speech therapy
Provider’s Office or Non-Hospital Facility
$20 copay/visit
50%
$40 copay/visit
50%
20%
50%
$0
50%
20%, maximum of
$200/visit
50%
$0
50%
$20 copay/visit
50%
20%, maximum of
$200/visit
50%
Radiation Therapy
Dialysis
Provider’s Office or Non-Hospital Dialysis
Center
Chemotherapy or Infusion Medication
Home
Provider’s Office or Non-Hospital Infusion
Center
Emergency and Urgent Care
Urgent Care Center
$40 copay/visit
50%
$150 copay/visit
waived if admitted
$150 copay/visit
waived if admitted
50%
Not covered
$150 copay/trip
limited to 2 trips/year
$150 copay/trip
$150 copay/trip
$150 copay/trip
Hospital Emergency Room
Emergency Care Provided in an ER
Routine Care Provided in an ER
Professional Ground Ambulance Services
Professional Air Ambulance Services
Outpatient Services
Laboratory Services
C-2
Plan 185
Inpatient Treatment
Inpatient Hospitalization, including for Mental
Health/Substance Abuse Treatment
Skilled Nursing Facility —
up to 30 total days per person each year
$250 copay/day, up to
$750 per admission
50%
$250 copay/day, up to
$750 per admission
less any copay for
inpatient hospitalization
50%
Other Services and Supplies
Diabetes Education
$0
Not covered
Nutrition Education —
$0
Not covered
$40 copay/day, up to $750
per episode of treatment
50%
$10 copay/visit
50%
Partial Hospitalization, Intensive Outpatient,
or Ambulatory Detoxification Treatment
$20 copay/visit
50%
$80 copay/visit
50%
$20 copay/visit
50%
$80 copay/visit
50%
Hospice Care
$0
50%
Podiatric Orthotics —
up to $500 total per person every 24 months
$0
Not covered
Durable Medical Equipment
25%
Not covered
Radiology (X-ray, Ultrasound, Fetal Monitoring)
Diagnostic Imaging (CT, MRI, PET) and Cardiac Imaging Testing
$150 copay/visit
50%
$250 copay/visit
50%
C
Home Healthcare Services —
C-3
Plan 185
Medical Foods for Inborn Metabolic Errors
Transportation and Lodging for Certain
Serious Medical Conditions
C
All Other Types of Medical Care
Medical Out-of-Pocket Limits – The most you
pay out-of-pocket for copays and coinsurance
for certain covered medical expenses in a
calendar year
BCBS PPO Network
Non-Network
The Plan will reimburse you 100%,
up to $2,500 per person each year
The Plan pays 100% up to $250 per day,
and up to $10,000 per episode of care
20%
50%
$5,000 per person/$10,000 per family
Neither you, your beneficiary, nor any other claimant may commence a lawsuit against the Plan (or its Trustees,
providers or staff) for benefits denied until the Plan’s internal appeal procedures have been exhausted. The internal
appeal procedures do not include your right to an external review by an independent review organization (”IRO”)
under the Affordable Care Act.
If you finish all internal appeals and decide to file a lawsuit against the Plan, that lawsuit must be commenced no
more than 12 months after the date of the appeal denial letter. If you fail to commence your lawsuit within this
12-month time frame, you will permanently and irrevocably lose your right to challenge the denial in court or in
any other manner or forum. This 12-month rule applies to you and to your beneficiaries and any other person or
entity making a claim on your behalf.
Network providers
The Plan pays benefits based on whether treatment is rendered by a network provider or a nonnetwork provider. To find network providers, contact:
Blue Cross and Blue Shield of Illinois (BCBSIL)—PPO Network
toll free: (800) 810-BLUE (2583)
www.bcbsil.com
(Go to the Provider finder and select the “Participating Provider Organization (PPO)” network)
The next graphic is a sample medical claim to show how using a network provider usually saves
you money. You can see how staying in the network means less money out of your pocket.
See page A-10 for more information about how staying in the network can help you save time and
money.
Plan 185
Network Provider
Non-Network Provider
A. Total charge
$10,000
$20,000
B. Network discount
- $5,000
n/a
$5,000
$5,000
C. Plan’s allowable charge (See page G-2)
C
What you pay
Commencement of legal action
C-4
Sample claim—outpatient surgery in an ambulatory surgical facility
D. Amount over allowable charge
$0
(A minus B minus C)
$15,000
(A minus C)
$0
$0
$150
$2,500
(50% of C)
E. Deductible
F. Your copay share of the cost
Your total payment
$150
(D plus E plus F)
$17,500
(D plus E plus F)
What you pay
You must pay your cost share (such as copays, and coinsurance for your share of covered expenses. You must also pay any expenses that are not considered covered expenses (see page G-3
for information about excluded expenses), including any amounts over the allowable charge, or
charges once a maximum benefit or limitation has been met.
See page C-2 for a summary of your cost sharing.
Copays
The copay covers all healthcare you receive at the time of the service. For example, you only pay
one office visit copay for all healthcare you receive during the office visit. You only pay one emergency room copay for all emergency care received during the emergency room visit.
If you have multiple types of care during one visit, you only have to pay the highest cost sharing
amount. You do not have to pay a separate copay for each procedure. For example, if you get an
x-ray, a CT scan, and lab services all at the same time at the same network non-hospital facility,
you pay only the $150 CT scan copay.
See page G-2 for more information about what a copay is.
Out-of-Pocket limit for network services and supplies
Your out-of-pocket cost sharing for most network medical covered expenses is limited to $5,000
per person ($10,000 per family) each year. Once your out-of-pocket costs for covered expenses
C-5
Plan 185
meet these limits, the Plan will usually pay 100% for your (or your family’s) network medical
covered expenses during the rest of that year.
Only your out-of-pocket cost sharing for medical healthcare applies to your $5,000 out-of-pocket
limit ($10,000 limit for your family). Amounts you pay out of pocket for prescription drugs,
vision care, or dental care will not apply to the $5,000 or $10,000 out-of-pocket limits. The only
exception is that amounts you pay out-of-pocket for pediatric vision exams will count towards
your out-of-pocket limit. A separate out-of-pocket limit applies to prescription drug benefits (see
page C-31).
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See page G-7 for more information about what an out-of-pocket limit is.
Telehealth
Doctor on Demand
(800) 997-6196
through Doctor on Demand. You pay a $15 copay for each telehealth visit with Doctor on Demand.
You can access Doctor on Demand by internet or through your smart phone.
Call for:
• Medical advice on common ailments: colds, allergies, pain, and more.
• Support for first time mothers: from nursing to answers about your baby’s health.
• Emotional and mental support: stress, relationships, self-image and more.
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• Diabetes and obesity: help you understand lab results and provide advice.
• Nutrition and weight loss: personalized diets and meal plans.
ConsejoSano le da acceso a consultas médicas que no son de emergencia las 24 horas al día, 7
días de la semana. Usted puede llamar o chatear con un asesor de salud en cualquier momento.
¡Este es un servicio gratis para usted! Consulte la página A-9 para obtener más información.
Llame para:
• Consulta médica sobre enfermedades comunes: resfriados, alergias, dolor y más.
• El apoyo a madres primerizas: desde la lactancia hasta respuestas sobre la salud de su bebé.
• Apoyo emocional y mental: estrés, relaciones, imagen de sí mismo y más.
• Diabetes y obesidad: para ayudarle a entender los resultados de exámenes de laboratorio y
proporcionarle consejos.
• Nutrición y pérdida de peso: dietas personalizadas y planes de alimentación.
• Internet: visit www.doctorondemand.com using Google Chrome (you must use Google
Chrome to access Doctor on Demand). Select “Get started” and follow the on-screen
instructions.
• Smart phone: download the Doctor on Demand app to your smartphone through an app
store or through www.doctorondemand.com.
You can then video chat with a Board-certified healthcare provider. A Doctor on Demand healthcare provider can even prescribe prescription drugs for you in many cases.
Doctor on Demand can treat many common sicknesses, like colds and flu, skin issues, diarrhea
and vomiting, and eye conditions. However, if you want to discuss a complex condition like cancer, or a serious injury, you should not use Doctor on Demand.
ConsejoSano (for non-emergency medical advice in Spanish)
(855) 785-7885
www.consejosano.com
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Plan 185
ConsejoSano provides access to non-emergency medical advice in Spanish 24/7. You can call or
chat with a health advisor any time. This is a free service for you! See page A-9 for more information.
Covered Benefits
What’s covered
The Plan will only pay benefits for injuries or sicknesses that are not related to your job. Benefits
are determined based on allowable charges for covered services resulting from medically necessary care and treatment prescribed or furnished by a healthcare provider.
• Preventive healthcare services (see page G-7) when a network provider is used. The
following limits apply to specific types of preventive care (other limits may apply to other
types of preventive care based on your gender, age, and health status):
ӹӹ Cervical cancer screening (pap smears) once every 36 months for just the pap smear,
or once every 60 months if both a pap smear and human papillomavirus screening are
done together.
ӹӹ Routine mammograms for women are covered every 1-2 years if you are age 40
through age 74. Routine mammograms for women under 40, or older than 75, may be
covered if you are at high-risk for breast cancer.
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Plan 185
ӹӹ PSA tests for men are covered every year if you are between ages 40 and 69.
• Professional medical and surgical services of a healthcare provider. The following rules
apply:
ӹӹ If more than one surgery or procedure is done through the same incision or natural
body cavity during the same operation, covered expenses are limited to the allowable
charge for the major surgery or procedure.
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ӹӹ Covered expenses do not include incidental procedures performed through the same
incision during one surgery.
• Telehealth services when provided by Doctor on Demand.
• Non-routine surgical podiatric services. If more than one surgery is done during the same
operation, covered expenses are limited to the allowable charge for the major procedure.
ӹӹ Non-routine podiatric care, excluding x-rays. Podiatric orthotics provided by a network
provider, limited to a total of $500 per person every 24 months. Non-network podiatric
orthotics are not covered.
ӹӹ Non-routine podiatric office visits are considered a specialist visit.
• Treatment of mental health conditions and substance abuse, including inpatient and
residential care, outpatient care, partial hospitalization, intensive outpatient care, and
ambulatory detoxification.
• Chiropractic care provided by a network provider, excluding x-rays, up to a total of 12 visits
per person each year. Non-network chiropractic care is not covered.
• Outpatient services in a clinic or urgent care center.
• Transportation by a professional ambulance service to an area medical facility that is
able to provide the required treatment. If you have no control over the ambulance getting
called, for example when the ambulance is called by a healthcare professional, employer, law
enforcement, school, etc., the ambulance will be considered medically necessary. Contact
the Fund (see page A-5) if you had no control over an ambulance being called.
• X-rays and laboratory work, including x-rays and laboratory work for chiropractic and
non-routine podiatric care.
• Ambulatory surgical facility services, including general supplies, anesthesia, drugs, and
operating and recovery rooms. If you have multiple surgeries, covered expenses are limited
to charges for the primary surgery. However, professional services for surgical procedures
that would normally be performed in a provider’s office are not covered.
C-8
Plan 185
• Outpatient rehabilitation services for physical and occupational therapy, limited to a
total of 60 combined visits per person each year for network and non-network treatment
combined.
• Outpatient speech therapy services, limited to a total of 30 visits per person each year for
network and non-network treatment combined.
ӹӹ For adults, only speech therapy to restore speech lost as the result of injury or sickness
is covered.
ӹӹ For dependent children, speech therapy is only covered to:
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ȣȣ Screen, detect, and treat pervasive developmental disorders, such as autism and
Asperger’s.
ȣȣ Restore or improve speech for speech-language and developmental delay disorders
caused by a non-chronic sickness, intra-uterine trauma, hearing loss, difficulty
swallowing or acute sickness or injury.
ȣȣ Treat a speech delay associated with a specific disease, injury, or congenital defect,
such as cleft lip and palate.
• Radiation therapy.
• Kidney dialysis services.
• Chemotherapy and infusion services.
• For employees and spouses only, pregnancy and pregnancy-related conditions, including
childbirth, miscarriage, or abortion. However, routine preventive healthcare for a dependent
child’s pregnancy will also be considered a covered expense. Non-preventive care for a
dependent child’s pregnancy, including but not limited to ultrasounds, charges associated
with a high-risk pregnancy, abortions, and maternity and delivery charges will not be
covered.
• Hospital charges for room and board, and other inpatient or outpatient services.
ӹӹ Professional services provided during your inpatient stay, including professional
consultations, will generally be paid at 100% of allowable charges (you pay only
amounts over the allowable charge).
• Mastectomies, including reconstruction of the breast upon which the mastectomy is
performed, surgical treatment of the other breast to produce a symmetrical appearance,
breast implants, and treatment of physical complications resulting from a mastectomy,
including swollen lymph glands.
• Medical services for organ transplants if the following rules are all met:
ӹӹ The transplant must be covered by Medicare, including meeting Medicare’s clinical,
facility, and provider requirements.
ӹӹ You must use any case management program recommended by the Fund or its
C-9
representative.
Plan 185
ӹӹ The Fund or its representative must get prior authorization for the transplant.
ӹӹ Donor expenses for your transplant are only covered if the donor has no other
coverage.
ӹӹ Transplant coverage does not include your expenses if you are giving an organ instead
of getting an organ.
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• Jaw reduction, open or closed, for a fractured or dislocated jaw.
• Skilled nursing facility care, limited to a total of 30 days per person each year for network
and non-network care combined. All of the following rules must be met:
ӹӹ The person must be under the care of a healthcare provider during the confinement.
ӹӹ The person must be confined as a regular bed patient.
• Network professional services for diabetes education and training for the care, monitoring,
or treatment of diabetes. Non-network expenses are not covered.
• Network professional services for nutrition counseling, limited to a total of 4 visits per
person each year. Non-network expenses are not covered.
• Home healthcare services, limited to a total of 30 visits per person each year for network
and non-network services combined. General housekeeping services or custodial care is not
covered.
• Hospice services and supplies for a person who is terminally ill. The services must be
authorized by a healthcare provider.
• Durable medical equipment and supplies for all non-disposable devices or items prescribed
by a healthcare provider, such as wheelchairs, hospital-type beds, respirators and associated
support systems, infusion pumps, home dialysis equipment, monitoring devices, home
traction units, and other similar medical equipment or devices, including supplies for the
DME. Non-network DME is not covered.
• Reimbursement for travel, lodging, and meal costs for transportation to get certain
treatment more than 50 miles away from your home (as long as you travel within the United
States). You must get prior authorization for these expenses before the Plan will reimburse
you. Covered expenses only include travel, lodging and meal costs related to: (1) transplants,
(2) cancer-related treatments, and (3) congenital heart defect care. The following rules apply:
people will be covered if the patient is a child.)
ӹӹ Reimbursement is limited to $10,000 per episode of care for you and your traveling
companion(s) combined. Up to $250 each day will be reimbursed for lodging and meal
costs.
ӹӹ You must provide the Plan with your original receipts.
ӹӹ You must participate in any case management programs required by the Fund.
ӹӹ You cannot get reimbursed for expenses related to your participation in a clinical trial,
or for an organ transplant if you are donating an organ instead of getting an organ.
• Anesthesia and its administration.
• Blood and blood plasma and their administration.
• Oxygen and rental equipment for its administration.
• Repair of sound natural teeth and their supporting structures, if the covered expenses are
the result of an injury. Treatment must be received while you are covered under the Plan
and within six months of the injury. You may have additional dental coverage under your
dental benefits, if applicable—see the dental benefits sections.
• Sterilization procedures for employees and spouses, and female dependent children.
ӹӹ However, if DME can be either rented or bought, and if the rental fees for the course of
• Surgical supplies and dressings, including casts, splints, prostheses, braces, canes,
ӹӹ If DME is bought, costs for repair or maintenance are also covered.
• Medical foods if you have an inborn error of metabolism (IEM). You must get prior
authorization for your medical food costs before the Plan will reimburse you. The Plan will
reimburse 100% of your costs for medical foods, up to a total of $2,500 per person each year.
To be reimbursed, the medical food must be: (1) ordered by and used under the supervision
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ӹӹ The travel, lodging, and meal costs of one other person will also be covered. (Two other
• Services of a surgical nurse (a nurse who works under a surgeon to provide specialized
treatment are likely to be more than the equipment’s purchase price, benefits may be
limited to the equipment’s purchase price.
Plan 185
of a healthcare provider; (2) the primary source of your nutrition; and (3) labeled and used
for dietary management of your IEM.
ӹӹ Rental fees are covered if the DME can only be rented, and the purchase price is
covered if the DME can only be bought.
C-10
nursing services before, during, and after surgery).
crutches, and trusses.
• Treatment of tumors, cysts and lesions not considered a dental procedure.
What’s not covered
See page C-62 for a list of the Plan’s general exclusions and limitations. In addition to that list,
the Plan will not pay benefits for, or in connection with, the following treatments, services, and
supplies:
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Plan 185
• Ambulatory surgical facility fees for procedures normally performed in a provider’s office.
• Prescription drugs and medications, other than those used where they are dispensed.
• Services or supplies provided by a non-network provider if benefits are only payable for such
services or supplies when a network provider is used.
Prescription drugs may be covered under the prescription drug benefit shown on page C-30.
• Any elective procedure, except sterilization or abortion, that is not to treat a bodily injury or
sickness. The Trustees have the sole right and discretion to decide if a procedure is elective.
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• Acupuncture.
• Routine foot care (routine podiatry).
• Any services or supplies for or in connection with the treatment of teeth, natural or
otherwise, and supporting structures. However, charges made by a hospital or other facility
for dental procedures covered under the dental benefit provisions, if applicable (see the
dental benefits sections), will be covered if the procedure requires the patient to be treated
in an institutional setting to safely receive the care. For example, if you suffer from a
medical or behavioral condition, such as autism or Alzheimer’s, that severely limits your
ability to cooperate with the dentist providing the care, charges made by a hospital or other
facility will be considered a covered expense. Benefits for other types of dental care may be
covered under the dental benefit as described in the dental section, if applicable.
• Treatment of temporomandibular joint (TMJ) disorders, craniofacial disorders or
orthognathic disorders, unless UNITE HERE HEALTH or its representative provides
written prior approval.
• Surgery to modify jaw relationships including, but not limited to, osteoplasty and
genioplasty procedures. However, Le Fort-type operations are covered when primarily to
repair birth defects of the mouth, conditions of the mid-face (over or under development of
facial features), or damage caused by accidental injury.
• Hospital charges for personal comfort items, including but not limited to telephones,
televisions, cosmetics, guest trays, magazines, and bed or cots for family members or other
guests.
• Private duty nursing care.
• Routine care that could be provided in an office or urgent care center if that care is provided
in the emergency room of a non-network hospital.
• Eye or hearing exams, except as specifically stated as covered, or unless the exam is for the
diagnosis or treatment of an accidental bodily injury or an illness. However, eye exams may
be covered under the vision benefits, if applicable.
• Any dental treatment of teeth or their supporting structures, other than those services
C-12
Plan 185
covered under the dental benefit, unless otherwise specifically listed as a covered expense.
• Eye refractions, eyeglasses, or contact lenses. However, these expenses may be covered
under the vision benefits, if applicable.
C-13
Plan 185
Learn:
ӹӹ What you pay for healthcare.
ӹӹ How the network out-of-pocket limits protect you from large out-ofpocket expenses.
ӹӹ About Doctor on Demand and Consejo Sano.
ӹӹ What types of medical healthcare the plan covers.
ӹӹ What types of medical healthcare are not covered.
C-14
Plan 185
Silver Plan Medical Plan Payments
Silver Plan Medical Benefits
In general, what you pay for medical care is based on what kind of care you get, where you get your care,
and whether you go to a network or a non-network provider. For example, you pay less using an urgent
care center instead of going to the emergency room.
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Diagnostic Imaging (CT, MRI, PET) and Cardiac Imaging Testing
$175 copay/visit
50% (after deductible)
$300 copay/visit
Ambulatory Surgical Center
20% after deductible
30% after deductible
Outpatient Surgery
Annual Deductibles —
applies to both network and non-network services combined.
Physical, Speech, Occupational Therapy — up to 60 total visits per person each year for physical and
occupational therapies combined, and up to 30 total visits per person each year for speech therapy
$1,500/person & $3,000/family
BCBS PPO Network
Office Visits
Preventive Healthcare – See page G-7
Non-Network
$0
Not covered
Primary Care Provider (PCP) Office Visits
$25 copay/visit
Doctor on Demand Telehealth Visits
$15 copay/visit
n/a
ConsejoSano Medical Advice Calls
$0 copay/visit
n/a
Specialist Office Visits
$50 copay/visit
Mental Health/Substance Abuse Office Visits
$25 copay/visit
Chiropractic Services —
$25 copay/visit
Not covered
Emergency and Urgent Care
Urgent Care Facility
$50 copay/visit
$200 copay/visit
waived if admitted
$200 copay/visit
waived if admitted
Not covered
Professional Ground Ambulance Services
Professional Air Ambulance Services
Hospital Emergency Room
Emergency Care Provided in an ER
Routine Care Provided in an ER
Outpatient Services
Laboratory Services
$30 copay/visit
$60 copay/visit
$0
30% (no deductible),
maximum of $250/visit
$0
$25 copay/visit
30% (no deductible),
maximum of $250/visit
Radiation Therapy
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Dialysis
Provider’s Office or Non-Hospital Dialysis
Center
Chemotherapy or Infusion Medication
Home
Provider’s Office or Non-Hospital Infusion
Center
Inpatient Treatment
Inpatient Hospitalization, including for Mental
Health/Substance Abuse Treatment
Skilled Nursing Facility —
up to 30 total days per person each year
Other Services and Supplies
Diabetes Education
$0
Not covered
Nutrition Education —
$0
Not covered
$0
$15 copay/visit
$25 copay/visit
$100 copay/visit
Partial Hospitalization, Intensive Outpatient,
or Ambulatory Detoxification Treatment
$25 copay/visit
Home Healthcare Services —
$100 copay/visit
Hospice Care
$0
Podiatric Orthotics —
up to $500 total per person every 24 months
$0
Not covered
Radiology (X-ray, Ultrasound, Fetal Monitoring)
Plan 185
Non-Network
Unless shown otherwise, this section shows what you pay for your care (called your “cost-sharing”). You
pay any copays, deductibles, your coinsurance share, any amounts over a maximum benefit, and any
expenses that are not covered, including any charges that are more than the allowable charge.
C-16
BCBS PPO Network
C-17
Plan 185
BCBS PPO Network
Non-Network
Durable Medical Equipment
Not covered
Medical Foods for Inborn Metabolic Errors
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Transportation and Lodging for Certain
Serious Medical Conditions
All Other Types of Medical Care
Medical Out-of-Pocket Limits – The most you
pay out-of-pocket for copays, coinsurance, and
deductibles for certain covered medical expenses
in a calendar year
The Plan will reimburse you 100%,
up to $2,500 per person each year
(no deductible applies)
The Plan pays 100% up to $250 per day,
and up to $10,000 per episode of care
(no deductible applies)
$5,000 per person/$10,000 per family
Sample claim—outpatient surgery in an ambulatory surgical facility
Network Provider
A. Total charge
$10,000
$20,000
B. Network discount
- $5,000
n/a
$5,000
$5,000
C. Plan’s allowable charge (See page G-2)
C
What you pay
D. Amount over allowable charge
$0
(A minus B minus C)
$15,000
(A minus C)
$1,500
$1,500
$700
(20% of C minus E)
$1,750
(50% of C minus E)
E. Deductible
F. Your coinsurance share of the cost
Your total payment
$2,200
(D plus E plus F)
$18,250
(D plus E plus F)
What you pay
You must pay your cost share (such as copays, and coinsurance for your share of covered expenses. You must also pay any expenses that are not considered covered expenses (see page G-3
for information about excluded expenses), including any amounts over the allowable charge, or
charges once a maximum benefit or limitation has been met.
See page C-2 for a summary of your cost sharing.
Network providers
The Plan pays benefits based on whether treatment is rendered by a network provider or a
non-network provider. To find network providers, contact:
Blue Cross and Blue Shield of Illinois (BCBSIL)—PPO Network
toll free: (800) 810-BLUE (2583)
www.bcbsil.com
(Go to the Provider finder and select the “Participating Provider Organization (PPO)” network)
The next graphic is a sample medical claim to show how using a network provider usually saves
you money. You can see how staying in the network means less money out of your pocket.
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Plan 185
See page A-10 for more information about how staying in the network can help you save time and
money.
Copays
The copay covers all healthcare you receive at the time of the service. For example, you only pay
one office visit copay for all healthcare you receive during the office visit. You only pay one emergency room copay for all emergency care received during the emergency room visit.
If you have multiple types of care during one visit, you only have to pay the highest cost sharing
amount. You do not have to pay a separate copay for each procedure. For example, if you get an
x-ray, a CT scan, and lab services all at the same time at the same network non-hospital facility,
you pay only the $150 CT scan copay.
See page G-2 for more information about what a copay is.
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Plan 185
Deductibles
Your deductible applies to both network and non-network expenses. You only have to pay the
deductible once each year. Once you have paid your deductible (sometimes called “satisfying your
deductible”), you do not have to make any more payments toward your deductible for the rest of
that year. The same rule applies if two or more members of your family satisfy the $3,000 family
deductible. Once your family deductible has been satisfied, no one else in your family has to pay
deductibles for the rest of that year.
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Your $1,500 individual and $3,000 family deductibles only apply to the medical benefits.
Amounts you pay for prescription drugs, vision care, or dental care will not apply to the $1,500
and $3,000 deductibles. A separate deductible applies to dental benefits (see the dental benefits
sections).
Any allowable charges that apply to your (or your family’s) deductible during October, November,
or December of a year will apply to your (or your family’s) deductible during the next calendar
year. For example, if you pay $500 toward your deductible in November, your deductible for the
next year will be $1,000 ($1,500 minus the $500 you paid in November).
See page G-3 for more information about what a deductible is.
Out-of-Pocket limit for network services and supplies
Your out-of-pocket cost sharing for most network medical covered expenses is limited to $5,000
per person ($10,000 per family) each year. Once your out-of-pocket costs for covered expenses
meet these limits, the Plan will usually pay 100% for your (or your family’s) network medical covered expenses during the rest of that year.
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Plan 185
through Doctor on Demand. You pay a $15 copay for each telehealth visit with Doctor on Demand.
You can access Doctor on Demand by internet or through your smart phone.
• Internet: visit www.doctorondemand.com using Google Chrome (you must use Google
• Smart phone: download the Doctor on Demand app to your smartphone through an app
store or through www.doctorondemand.com.
You can then video chat with a Board-certified healthcare provider. A Doctor on Demand healthcare provider can even prescribe prescription drugs for you in many cases.
Doctor on Demand can treat many common sicknesses, like colds and flu, skin issues, diarrhea
and vomiting, and eye conditions. However, if you want to discuss a complex condition like cancer, or a serious injury, you should not use Doctor on Demand.
ConsejoSano (for non-emergency medical advice in Spanish)
(855) 785-7885
www.consejosano.com
ConsejoSano provides access to non-emergency medical advice in Spanish 24/7. You can call or
chat with a health advisor any time. This is a free service for you! See page A-9 for more information.
Call for:
Only your out-of-pocket cost sharing for medical healthcare applies to your $5,000 out-of-pocket limit ($10,000 limit for your family). Amounts you pay out of pocket for prescription drugs,
vision care, or dental care will not apply to the $5,000 or $10,000 out-of-pocket limits. The only
exception is that amounts you pay out-of-pocket for pediatric vision exams will count towards
your out-of-pocket limit. A separate out-of-pocket limit applies to prescription drug benefits (see
page C-31).
• Medical advice on common ailments: colds, allergies, pain, and more.
See page G-7 for more information about what an out-of-pocket limit is.
• Nutrition and weight loss: personalized diets and meal plans.
• Support for first time mothers: from nursing to answers about your baby’s health.
• Emotional and mental support: stress, relationships, self-image and more.
• Diabetes and obesity: help you understand lab results and provide advice.
Telehealth
ConsejoSano le da acceso a consultas médicas que no son de emergencia las 24 horas al día, 7
días de la semana. Usted puede llamar o chatear con un asesor de salud en cualquier momento.
¡Este es un servicio gratis para usted! Consulte la página A-9 para obtener más información.
Doctor on Demand
Llame para:
(800) 997-6196
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Chrome to access Doctor on Demand). Select “Get started” and follow the on-screen
instructions.
• Consulta médica sobre enfermedades comunes: resfriados, alergias, dolor y más.
C-21
• El apoyo a madres primerizas: desde la lactancia hasta respuestas sobre la salud de su bebé.
Plan 185
• Apoyo emocional y mental: estrés, relaciones, imagen de sí mismo y más.
• Diabetes y obesidad: para ayudarle a entender los resultados de exámenes de laboratorio y
proporcionarle consejos.
• Nutrición y pérdida de peso: dietas personalizadas y planes de alimentación.
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• Treatment of mental health conditions and substance abuse, including inpatient and
residential care, outpatient care, partial hospitalization, intensive outpatient care, and
ambulatory detoxification.
• Chiropractic care provided by a network provider, excluding x-rays, up to a total of 12 visits
What’s covered
• Transportation by a professional ambulance service to an area medical facility that is
following limits apply to specific types of preventive care (other limits may apply to other
types of preventive care based on your gender, age, and health status):
ӹӹ Cervical cancer screening (pap smears) once every 36 months for just the pap smear,
or once every 60 months if both a pap smear and human papillomavirus screening are
done together.
ӹӹ Routine mammograms for women are covered every 1-2 years if you are age 40
through age 74. Routine mammograms for women under 40, or older than 75, may be
covered if you are at high-risk for breast cancer.
ӹӹ PSA tests for men are covered every year if you are between ages 40 and 69.
• Professional medical and surgical services of a healthcare provider. The following rules
apply:
ӹӹ If more than one surgery or procedure is done through the same incision or natural
body cavity during the same operation, covered expenses are limited to the allowable
charge for the major surgery or procedure.
ӹӹ Covered expenses do not include incidental procedures performed through the same
incision during one surgery.
• Telehealth services when provided by Doctor on Demand.
• Non-routine surgical podiatric services. If more than one surgery is done during the same
operation, covered expenses are limited to the allowable charge for the major procedure.
ӹӹ Non-routine podiatric care, excluding x-rays. Podiatric orthotics provided by a network
provider, limited to a total of $500 per person every 24 months. Non-network podiatric
orthotics are not covered.
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per person each year. Non-network chiropractic care is not covered.
• Outpatient services in a clinic or urgent care center.
• Preventive healthcare services (see page G-7) when a network provider is used. The
Plan 185
ӹӹ Non-routine podiatric office visits are considered a specialist visit.
Covered Benefits
The Plan will only pay benefits for injuries or sicknesses that are not related to your job. Benefits
are determined based on allowable charges for covered services resulting from medically necessary care and treatment prescribed or furnished by a healthcare provider.
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able to provide the required treatment. If you have no control over the ambulance getting
called, for example when the ambulance is called by a healthcare professional, employer, law
enforcement, school, etc., the ambulance will be considered medically necessary. Contact
the Fund (see page A-5) if you had no control over an ambulance being called.
• X-rays and laboratory work, including x-rays and laboratory work for chiropractic and
non-routine podiatric care.
• Ambulatory surgical facility services, including general supplies, anesthesia, drugs, and
operating and recovery rooms. If you have multiple surgeries, covered expenses are limited
to charges for the primary surgery. However, professional services for surgical procedures
that would normally be performed in a provider’s office are not covered.
• Outpatient rehabilitation services for physical and occupational therapy, limited to a
total of 60 combined visits per person each year for network and non-network treatment
combined.
• Outpatient speech therapy services, limited to a total of 30 visits per person each year for
network and non-network treatment combined.
ӹӹ For adults, only speech therapy to restore speech lost as the result of injury or sickness
is covered.
ӹӹ For dependent children, speech therapy is only covered to:
ȣȣ Screen, detect, and treat pervasive developmental disorders, such as autism and
Asperger’s.
ȣȣ Restore or improve speech for speech-language and developmental delay disorders
caused by a non-chronic sickness, intra-uterine trauma, hearing loss, difficulty
swallowing or acute sickness or injury.
ȣȣ Treat a speech delay associated with a specific disease, injury, or congenital defect,
such as cleft lip and palate.
• Radiation therapy.
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Plan 185
• Kidney dialysis services.
• Chemotherapy and infusion services.
• For employees and spouses only, pregnancy and pregnancy-related conditions, including
childbirth, miscarriage, or abortion. However, routine preventive healthcare for a dependent
child’s pregnancy will also be considered a covered expense. Non-preventive care for a
dependent child’s pregnancy, including but not limited to ultrasounds, charges associated
with a high-risk pregnancy, abortions, and maternity and delivery charges will not be
covered.
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• Hospital charges for room and board, and other inpatient or outpatient services.
ӹӹ Professional services provided during your inpatient stay, including professional
consultations, will generally be paid at 100% of allowable charges (you pay only
amounts over the allowable charge).
• Mastectomies, including reconstruction of the breast upon which the mastectomy is
performed, surgical treatment of the other breast to produce a symmetrical appearance,
breast implants, and treatment of physical complications resulting from a mastectomy,
including swollen lymph glands.
• Medical services for organ transplants if the following rules are all met:
ӹӹ The transplant must be covered by Medicare, including meeting Medicare’s clinical,
facility, and provider requirements.
ӹӹ You must use any case management program recommended by the Fund or its
representative.
ӹӹ The Fund or its representative must get prior authorization for the transplant.
ӹӹ Donor expenses for your transplant are only covered if the donor has no other
coverage.
ӹӹ Transplant coverage does not include your expenses if you are giving an organ instead
of getting an organ.
• Jaw reduction, open or closed, for a fractured or dislocated jaw.
• Skilled nursing facility care, limited to a total of 30 days per person each year for network
and non-network care combined. All of the following rules must be met:
ӹӹ The person must be under the care of a healthcare provider during the confinement.
ӹӹ The person must be confined as a regular bed patient.
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Plan 185
• Network professional services for diabetes education and training for the care, monitoring,
or treatment of diabetes. Non-network expenses are not covered.
• Network professional services for nutrition counseling, limited to a total of 4 visits per
person each year. Non-network expenses are not covered.
• Home healthcare services, limited to a total of 30 visits per person each year for network
and non-network services combined. General housekeeping services or custodial care is not
covered.
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• Hospice services and supplies for a person who is terminally ill. The services must be
authorized by a healthcare provider.
• Durable medical equipment and supplies for all non-disposable devices or items prescribed
by a healthcare provider, such as wheelchairs, hospital-type beds, respirators and associated
support systems, infusion pumps, home dialysis equipment, monitoring devices, home
traction units, and other similar medical equipment or devices, including supplies for the
DME. Non-network DME is not covered.
ӹӹ Rental fees are covered if the DME can only be rented, and the purchase price is
covered if the DME can only be bought.
ӹӹ However, if DME can be either rented or bought, and if the rental fees for the course of
treatment are likely to be more than the equipment’s purchase price, benefits may be
limited to the equipment’s purchase price.
ӹӹ If DME is bought, costs for repair or maintenance are also covered.
• Medical foods if you have an inborn error of metabolism (IEM). You must get prior
authorization for your medical food costs before the Plan will reimburse you. The Plan will
reimburse 100% of your costs for medical foods, up to a total of $2,500 per person each year.
To be reimbursed, the medical food must be: (1) ordered by and used under the supervision
of a healthcare provider; (2) the primary source of your nutrition; and (3) labeled and used
for dietary management of your IEM.
• Reimbursement for travel, lodging, and meal costs for transportation to get certain
treatment more than 50 miles away from your home (as long as you travel within the United
States). You must get prior authorization for these expenses before the Plan will reimburse
you. Covered expenses only include travel, lodging and meal costs related to: (1) transplants,
(2) cancer-related treatments, and (3) congenital heart defect care. The following rules apply:
ӹӹ The travel, lodging, and meal costs of one other person will also be covered. (Two other
people will be covered if the patient is a child.)
ӹӹ Reimbursement is limited to $10,000 per episode of care for you and your traveling
companion(s) combined. Up to $250 each day will be reimbursed for lodging and meal
costs.
ӹӹ You must provide the Plan with your original receipts.
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ӹӹ You must participate in any case management programs required by the Fund.
Plan 185
ӹӹ You cannot get reimbursed for expenses related to your participation in a clinical trial,
or for an organ transplant if you are donating an organ instead of getting an organ.
• Anesthesia and its administration.
• Blood and blood plasma and their administration.
• Oxygen and rental equipment for its administration.
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• Repair of sound natural teeth and their supporting structures, if the covered expenses are
the result of an injury. Treatment must be received while you are covered under the Plan
and within six months of the injury. You may have additional dental coverage under your
dental benefits, if applicable—see the dental benefits sections.
• Sterilization procedures for employees and spouses, and female dependent children.
• Services of a surgical nurse (a nurse who works under a surgeon to provide specialized
nursing services before, during, and after surgery).
facility will be considered a covered expense. Benefits for other types of dental care may be
covered under the dental benefit as described in the dental section, if applicable.
• Treatment of temporomandibular joint (TMJ) disorders, craniofacial disorders or
orthognathic disorders, unless UNITE HERE HEALTH or its representative provides
written prior approval.
genioplasty procedures. However, Le Fort-type operations are covered when primarily to
repair birth defects of the mouth, conditions of the mid-face (over or under development of
facial features), or damage caused by accidental injury.
• Hospital charges for personal comfort items, including but not limited to telephones,
televisions, cosmetics, guest trays, magazines, and bed or cots for family members or other
guests.
• Private duty nursing care.
• Surgical supplies and dressings, including casts, splints, prostheses, braces, canes,
• Routine care that could be provided in an office or urgent care center if that care is provided
• Treatment of tumors, cysts and lesions not considered a dental procedure.
• Eye or hearing exams, except as specifically stated as covered, or unless the exam is for the
crutches, and trusses.
See page C-62 for a list of the Plan’s general exclusions and limitations. In addition to that list,
the Plan will not pay benefits for, or in connection with, the following treatments, services, and
supplies:
• Ambulatory surgical facility fees for procedures normally performed in a provider’s office.
• Prescription drugs and medications, other than those used where they are dispensed.
Prescription drugs may be covered under the prescription drug benefit shown on page C-30.
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• Surgery to modify jaw relationships including, but not limited to, osteoplasty and
in the emergency room of a non-network hospital.
diagnosis or treatment of an accidental bodily injury or an illness. However, eye exams may
be covered under the vision benefits, if applicable.
• Any dental treatment of teeth or their supporting structures, other than those services
covered under the dental benefit, unless otherwise specifically listed as a covered expense.
• Eye refractions, eyeglasses, or contact lenses. However, these expenses may be covered
under the vision benefits, if applicable.
• Services or supplies provided by a non-network provider if benefits are only payable for such
services or supplies when a network provider is used.
• Any elective procedure, except sterilization or abortion, that is not to treat a bodily injury or
sickness. The Trustees have the sole right and discretion to decide if a procedure is elective.
• Acupuncture.
• Routine foot care (routine podiatry).
• Any services or supplies for or in connection with the treatment of teeth, natural or
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Plan 185
otherwise, and supporting structures. However, charges made by a hospital or other facility
for dental procedures covered under the dental benefit provisions, if applicable (see the
dental benefits sections), will be covered if the procedure requires the patient to be treated
in an institutional setting to safely receive the care. For example, if you suffer from a
medical or behavioral condition, such as autism or Alzheimer’s, that severely limits your
ability to cooperate with the dentist providing the care, charges made by a hospital or other
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Plan 185
Prescription drug benefits
Learn:
ӹӹ What you pay for your covered prescription drugs.
ӹӹ How the out-of-pocket limit protects you from high-cost prescription
drugs.
ӹӹ How you can save money by using generic prescription drugs.
ӹӹ What types of prescription drugs the Plan covers.
ӹӹ How the safety and cost containment programs help save you money
and help protect your health.
ӹӹ The limits on the quantity of a prescription drug you can get at one
time.
ӹӹ What the mail order pharmacy is and how to use it.
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Plan 185
ӹӹ What the specialty order pharmacy is and when you must use it.
ӹӹ What types of prescription drugs are not covered.
The Plan has contracted with HospitalityRx to administer your prescription drug benefits.
The Plan will only pay benefits if you buy your prescription drugs at a pharmacy that participates
in the True Choice network. Not all retail pharmacies are in your pharmacy network. Retail
pharmacies like Walgreens are in your network.
If you use a pharmacy not in your network, you will have to pay 100% of the cost of the prescription drug. For example, CVS and Wal-Mart are not in your network. The Plan will not
reimburse you for the cost of any prescription drugs you buy at a non-network pharmacy.
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What you pay
You must pay the applicable copay shown below for each fill of a prescription drug. You must also
pay any expenses that are not considered covered expenses (see page C-35) for information about
excluded expenses), including any amounts over the allowable charge.
Gold Plan and Silver Plan Prescription Drug Benefits
Your Copay for
Each Fill or Refill
Preventive prescriptions or supplies (see page G-7 ), including
immunizations
$0
Generic prescription drugs
$10
Preferred brand name prescription drugs on the formulary, including
insulin and formulary diabetic supplies (such as OneTouch or TrueTest)
$30
Specialty and biosimilar prescription drugs
25% of the cost,
maximum of $50
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Plan 185
Brand name drugs and supplies on the formulary are safe, effective, high-quality drugs and supplies that do not have generic equivalents. No benefits are paid for brand name drugs not on the
formulary unless the Fund approves the drug. Ask your healthcare provider to prescribe a drug
that is on the formulary. Prescription drugs and supplies may be added to or removed from the
formulary from time to time. Contact the Fund at (855) 405-FUND (3863) if you or your healthcare provider have questions about which prescription drugs and supplies are on the formulary.
If your healthcare provider wants you to take a brand name drug that is not on the formulary,
he or she should call the Fund (877) 266-9991 to get prior authorization. If the Fund makes an
exception and allows the non-preferred brand name drug, you will have to pay the $30 copay for
preferred brand name drugs.
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You must use the specialty pharmacy to get specialty and biosimilar prescription drugs. See page
C-35 for more information about the specialty pharmacy.
Prescription drug out-of-pocket limit
Your copays for prescription drugs purchased through the prescription drug benefit are limited to
$1,600 per person each year ($3,200 per family). Once your prescription drug copays total $1,600
($3,200 for your family’s prescription drugs copays), the Plan will pay 100% for your (or your
family’s) covered prescription drugs and supplies during the rest of that year.
Amounts you pay for prescription drugs or supplies that are not covered do not count toward
your out-of-pocket limit. Only your copays for prescription drugs or supplies apply to your $1,600
out-of-pocket limit ($3,200 limit for your family). Out-of-pocket payments you pay for medical
healthcare, vision, or dental care will not apply to the $1,600 or $3,200 out-of-pocket limits for
prescription drugs. A separate out-of-pocket limit applies to medical healthcare (see page C-5).
Generic prescription drug policy
If you or your provider chooses a brand name prescription drug when you could get a generic
equivalent instead, you pay the difference in cost between the brand name prescription drug
and the generic equivalent. For example, if the brand name prescription drug costs $80, and the
Fund’s cost for the generic equivalent is $30, you must pay the $50 difference. You will also have
to pay the $10 generic prescription drug copay.
The generic prescription drug policy does not apply to certain prescription drugs that need to be
closely monitored, or if very small changes in the dose could be extremely harmful. The policy
will also not apply if the prior authorization program makes an exception. The prescription drugs
that are not subject to the generic prescription drug policy change from time to time. You can
get up-to-date information by calling the Fund. Your healthcare provider will need to get prior
approval in order to ask for an exception.
If you have an exception to the generic prescription drug policy, you will still have to pay the $30
copay for preferred brand name drugs.
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Plan 185
What’s covered
The Plan pays benefits only for the types of expenses listed below:
• FDA-approved prescription drugs which can legally be purchased only with a written
prescription from a healthcare provider. This includes oral and injectable contraceptives,
vitamins, and drugs mixed to order by a pharmacist, if it contains at least one medicinal
substance and one prescription drug.
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See page F-6 for information about appealing a request for prior authorization and for appealing
a denial of prescription drug benefits.
• Disposable syringes and needles, and lancets.
If you have a prescription for certain drugs, your healthcare provider must be asked for your
medical records to find out if the prescription drug is clinically appropriate for your medical situation. The list of prescription drugs that require prior authorization changes from time to time.
Call (877) 266-9991 for a list of drugs on the prior authorization list.
• Non-prescription (over-the-counter) preventive healthcare services and supplies, including
immunizations (see page G-7).
Free glucometers
You can get a free glucometer every 12 months by calling either of the following phone numbers:
(800) 227-8862 for OneTouch (LifeScan) products
(866) 788-9618 for TrueTest (Nipro) products
Prior authorization is also required for any prescription drug for which the U.S. Food and Drug
Administration (FDA) is reviewing certain new or existing products based on a known or potential serious risks under a risk evaluation and mitigation strategy.
Step therapy
In many cases, effective lower-cost alternatives are available for certain prescription drugs. A step
therapy program will ask you to try over-the-counter, generic, or preferred formulary versions
of prescription drugs first. If the first level of prescription drugs does not work for you, or causes
serious side effects, you are “stepped up” to another level of prescription drugs.
You can only get a free glucometer through the Fund. If you don’t want one of the Fund’s free
glucometers, you have to pay the full cost of the glucometer and then submit a claim to the Fund.
The claim will be paid based on the rules for durable medical equipment under the medical benefits.
For example, if you need an ARB (angiotensin receptor blocker)—used to treat high blood pressure—you may first be asked to try a generic version, such as candesartan. If the generic version
does not work or causes serious side effects, you may be asked to try a preferred formulary version, such as Benicar.
Safety and cost containment programs for prescription
drugs
The list of prescription drugs that require step therapy changes from time to time. Contact the
Fund (see page A-5) with questions about which prescription drugs require prior authorization.
The Fund provides extra protection through several safety and cost containment programs. These
programs may change from time to time, and the prescription drugs or types of prescription
drugs that are part of these programs may also change from time to time. You and your healthcare provider can always get the most current information by contacting the Fund at (855) 405FUND (3863) or visiting www.uhh.org.
Safety and cost containment programs help make sure you and your family get the most effective
and appropriate care. These programs look at whether a prescription drug is safe for you to take.
For example, some prescription drugs cannot be taken together. Safety programs help make sure
you are not taking prescription drugs in a combination that could harm you. The programs also
can help make sure your money is not wasted on prescription drugs that will not work for you.
For example, some prescription drugs cause serious side effects in some patients. By limiting your
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Prior authorization
Call HospitalityRx at (877) 266-9991 for prior authorization.
• Prescription drugs and supplies that are preventive healthcare (see page G-7).
Plan 185
prescription to a limited number of pills, you can make sure the prescription drug is safe for you
to take before you pay for a large supply of pills you will have to throw away if you get serious side
effects.
• Insulin and diabetic test strips.
• Thyrogen (a prescription drug used to help identify the existence of thyroid cancer).
C-32
Case management
The pharmacy case managers may contact you if you take high-cost or specialty drugs or have a
chronic long-term condition. This program will help you make sure you are taking your prescription drugs the way you are supposed to take them. The case managers can also help you manage
and monitor your condition, and answer questions about your prescription drugs. If you are
taking certain prescription drugs, including high-cost prescription drugs or prescription drugs
for conditions that will not respond well to treatment if you don’t take the prescription drugs as
prescribed, you may be required to use the case management program. If you don’t use the case
management program when it’s required, the Fund may stop paying benefits for your prescription
drugs.
Be sure you talk with the case managers if they reach out to you!
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Plan 185
Fill and refill limits
Specialty pharmacy
Quantity limits
You must use the specialty pharmacy to purchase all specialty prescription drugs. (The only
exception is for drugs prescribed to treat HIV/AIDs. You should use the specialty pharmacy for
these drugs, but you can get these drugs from any network pharmacy.)
Each prescription fill or refill is limited to the amount prescribed by your healthcare provider.
However, a prescription filled at a retail pharmacy will not be filled for more than a 34-day supply
at one time (you can get refills up to the total amount your doctor prescribes). However:
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• Birth control drugs that are only available in 90-day quantities (such as Seasonale®) or that
use a steady hormone release over time (such as NuvaRing®) will be filled based on one
application or one unit, whichever applies.
• If you use the mail order pharmacy, you can get up to a 60-day supply at a time.
You generally cannot refill a prescription until you have used at least 75% of the supply. You may
be able to refill a prescription sooner. For example, if you plan to be out of the country when you
would run out of a prescription drug, the Plan may approve an early refill. However, if your eligibility will terminate, you will only be able to get enough days’ supply to match the number of days
of eligibility you have left. For example, if your eligibility terminates in 15 days, you can only get a
15-day supply of the prescription drug, even if UNITE HERE HEALTH allows for an early refill.
Exceptions to the standard quantity limits
There are certain prescription drugs that many providers prescribe at higher dosages (for example, more pills taken at one time or more often during the day) than approved by the FDA.
Coverage for these prescription drugs will be limited to a 30-day supply. To help protect you and
your family, in these situations you may get a smaller supply of a prescription drug than usually
allowed.
You or your healthcare provider can call for information about these quantity limits. Your healthcare provider may also call to get an exception to these rules.
You can save money by using the WellDyneRx mail order pharmacy. If you need a prescription
drug to treat a chronic, long-term condition, you can order these prescription drugs through the
mail order pharmacy. You can get up to a 60-day supply of your prescription drug (sometimes
called a “maintenance” prescription drug) for the same copay you would pay for a 34-day supply
at a retail pharmacy.
You can order from the mail order pharmacy by mail, by phone, or on the internet.
Plan 185
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Walgreens Specialty Pharmacy
(877) 647-5807
See page C-62 for a list of the Plan’s general exclusions and limitations. In addition to that list, the
following types of treatments, services, and supplies are not covered under the prescription drug
benefit:
• Prescription drugs that have not been approved by the FDA. However, you or your
healthcare provider may ask for an exception through the Fund’s prior authorization
program.
• Any drugs to treat Hepatitis C, other than interferon, ribavirin, Harvoni, or Solvadi.
• Specialty prescription drugs, other than those used to treat HIV/AIDS, if you do not use the
specialty pharmacy.
• Experimental or investigational drugs.
Mail order pharmacy
C-34
The specialty pharmacy provides prescription drugs for certain chronic or difficult health conditions, such as multiple sclerosis (MS) or Hepatitis C. Specialty prescription drugs often need to
be handled differently than other prescription drugs, or they may need special administration or
monitoring. Using the specialty pharmacy gives you access to pharmacists and other healthcare
providers who specialize in helping people with your condition. The specialty pharmacy staff can
help make sure your specialty prescription gets refilled on time, and can answer your questions
about your prescription drugs and your condition.
WellDyneRx
P.O. Box 90369
Lakeland, FL 33804
(844) 813-3860
www.mywdrx.com
• Fertility drugs.
• Prescriptions or refills in amounts over the quantity limits (see page C-34).
• Non-sedating antihistamines.
• Prescription drugs that have an over-the-counter equivalent or are otherwise available
over-the-counter (unless the drugs or supplies are preventive healthcare—see page G-7).
However, prescription drugs that have a higher dosage than their over-the-counter
equivalents will be covered.
• Any prescription drugs that are considered a lifestyle prescription drug. Lifestyle
prescription drugs are not primarily intended to prevent, treat, or cure a disease or manage
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Plan 185
pain. Examples of lifestyle drugs include but are not limited to prescription drugs used
to treat erectile dysfunction, acne, or wrinkles. The Fund or its representative determines
whether a prescription drug is considered a lifestyle prescription drug.
• Any prescription drugs that are not self-administered, meaning a prescription drug that you
cannot give to yourself. However, this type of prescription drug may be covered under the
medical benefits.
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• New-to-market prescription drugs until the Fund or its representative has reviewed and
approved the drugs.
• High-cost “me too” prescription drugs, unless the Fund or its representative approves the
prescription drugs for purchase. “Me-too” drugs usually have only very small differences
in how they work, but are considered “new” prescription drugs with no generic equivalent.
Often, the manufacturer charges high prices for these prescription drugs even though there
are other prescription drugs available that work just as well for a lower cost. You can find
out if a “me too” prescription drug is covered by contacting the Fund (see page A-5).
Dental benefits
• Glucometers, other than those available to you at no charge through the Fund. You may
be able to get a glucometer through the medical benefits if you do not want one of the free
ones, but you will usually have cost sharing. (See page C-10 for information about durable
medical equipment under the medical benefit.)
• Rogaine and other drugs to prevent hair loss.
Learn:
• Drugs used, consumed or administered at the place where it is dispensed, other than
immunizations. (These drugs may be covered under your medical benefits.)
• Drugs for which you are required to use the case management program if you do not
participate in the program. The Fund or its designated representative has the sole authority
to determine whether or not an individual is participating in the case management
program.
• Diagnostics or biologicals, other than thyrogen.
• Drugs used for cosmetic reasons.
• Human growth hormone, except to treat emaciation due to AIDS.
• Drugs not purchased from a network pharmacy.
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Plan 185
ӹӹ What you pay for your covered dental care.
ӹӹ What the maximum benefits are.
ӹӹ What types of dental care the Plan covers.
ӹӹ How to find out what your dental care will cost you before you get
treatment.
ӹӹ What types of dental care are not covered.
This section applies only if you have elected dental benefits. If you are not sure if you
have elected dental benefits, please call UNITE HERE HEALTH to find out.
Dental benefits
Dental benefits
UNITE HERE HEALTH has contracted with Cigna to provide dental benefits to you and your
dependents. This contract determines what your benefits are and how Cigna pays for your dental
benefits. This part of the SPD summarizes your dental benefits; however, if there is any conflict
between this SPD and the contract, the terms of the Cigna contract governs.
The contract with Cigna is governed by applicable state law. Depending on the state governing
your dental benefits, there may be small differences between this summary of your benefits and
how your dental benefits actually work. For example, who your dependent is for dental benefits,
how Cigna must pay claims, and the types of benefits that are covered may be slightly different
from state to state. (Cigna’s rules would only apply to your Cigna dental benefits - not to other
benefits provided under the Plan.) If you have any questions about how your dental benefits
work, please contact Cigna. The rules about who your dependent is under the Cigna dental benefits only apply to dental benefits, and do not apply to any other benefits offered under the Plan.
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Cigna Dental Care HMO
toll free: (800) 244-6224
www.mycigna.com
Benefits are only payable if you use a network provider. Your copay depends on the type of dental care you
get. This table shows the copays for some of the more common dental procedures. However, the contract
with Cigna governs your dental benefits, and the contract will govern if there is a conflict.
Periodic Oral Exam
$0 copay
Most X-rays
$0 copay
Regular Periodic Cleaning (adult or child
prophylaxis) —

up to 2 total per person each year
$0 copay
Topical Application of Fluoride —

$0 copay
Periodontal Maintenance—
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Plan 185
$17 copay/tooth
$60 - $110 copay per quadrant
$77 copay
Amalgam Fillings
$6 - $18 copay, depending on number of surfaces
Onlays (metallic)
$370 - $440 copay, depending on type of onlay
Crowns —
one replacement per person every 5 years
$370 - $460 copay, depending on type of crown
Gingevectomy or Gingivoplasty (other than for
restorative procedure)
$14 copay
Root Canal
$275 - $440 copay, depending on type of root canal
Full Denture (Upper or Lower) —
one set per person every 5 years
$535 copay each
Denture Reline or Rebase —
one reline or rebase per person every 36 months
$120 - $210 copay, depending on type of repair
Removal of Impacted Tooth
$71 - $200 copay, depending on type of removal
Orthodontia for Child under 19
(24 months of treatment)
$2,280 copay total ($95 copay per month)
Orthodontia for Adult
(24 months of treatment)
$3,000 copay total ($125 copay per month)
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Dental Benefits—Dental Health Maintenance Organization
Periodontal Scaling and Root Planing—
up to 4 quadrants total per person every 12
months
Pulp Cap
There is no limit on the benefits paid for your dental care each year
(you have to register for an account)
Sealants
Dental Benefits—Dental Health Maintenance Organization
$105 - $240 copay, depending on teeth per quadrant
Using your benefits
Your dental benefits are provided through a dental health maintenance organization (DHMO).
Under a DHMO, you must follow certain rules in order to get dental benefits. If you don’t follow
these rules, you may have to pay the entire cost of the dental care yourself. If you have any questions about how to use your dental benefits, please contact Cigna at (800) 244-6224.
• You must pick a primary dentist (see page C-40) who is in the Cigna Dental Care HMO
network. Your primary dentist provides your dental care and refers you to specialists, if
necessary. You don’t need a referral to see a network orthodontist.
• Except in emergencies, you must use a network dentist. If you don’t use a network dentist,
you will have to pay the full cost of your dental care.
If you have an emergency, such as excessive bleeding, acute infection or severe pain, try to
reach your primary dentist. Your primary dentist should handle any emergency within 24
hours. If you are outside the Cigna service area, or you cannot reach your primary dentist,
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Plan 185
Dental benefits
you can go to any dentist to get treatment. You can then file a claim with Cigna (see page
F-9). Cigna will pay you back for up to $50 for your treatment for immediate relief of the
emergency. You will still be responsible for: any copays for your care; charges in excess of
the $50 maximum reimbursement, or any charges that Cigna does not cover. Once you have
immediate relief for the emergency, you should see your primary dentist for any follow-up
treatment.
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• You can always get a second opinion regarding proposed dental care. Just contact Cigna to
get a referral to another dentist.
• If you live and work outside the Cigna Dental Care HMO service area, you will not have any
dental benefits. This rule applies to any dependents (such as adult children attending college
or who no longer live with you). This rule applies until you, or your dependent, live or work
in the service area again.
• Certain state laws will govern how Cigna pays your benefits. Your dental benefits and who
is considered your dependent for dental benefits may be slightly different than described in
this SPD.
• Cigna will not usually coordinate dental benefits if you have coverage under another dental
plan, or if you and your spouse are both covered under Cigna as employees.
Your primary dentist
You must pick a primary dentist, and use your primary dentist, for your dental care. If you need
specialist care, your primary dentist will refer you for specialist care. You must have this referral
in order to get benefits for specialist care.
You can pick any dentist in the Cigna DHMO network who is taking new patients. You do not
have to pick the same primary dentist as your dependents. You and your spouse can use one primary dentist while your children use another dentist.
Children under age 7 can use a pediatric dentist as the primary dentist. After a child turns 7, he
or she can only see a pediatric dentist with a referral from a primary dentist who is not a pediatric
dentist.
You can change your primary dentist any time you want, and as often as you want. However, you
must wait to see your new primary dentist until Cigna has processed your request to change primary dentists. Cigna can tell you whether your change in primary dentists has been made.
You can log on to www.mycigna.com, or contact Cigna at (800) 244-6224 to choose a primary
dentist or to change a primary dentist.
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Plan 185
Dental benefits
What you pay
You will pay any required copay for your dental care. The booklet titled “Patient Charge Schedule” lists your copays. If you need a copy of this booklet, contact UNITE HERE HEALTH or
Cigna. Many types of routine dental care, such as standard exams and x-rays, have no copays.
You will have to pay a copay for other types of covered expenses for your dental care.
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You will also have to pay for any dental care that is not considered a covered expense, including
any dental care you get more frequently than allowed.
What’s covered
Covered expenses mean all allowable charges made by a dentist for the types of services and
supplies listed below. In order to be considered a covered expense, Cigna must determine that the
service or supply was based on a valid dental need and performed according to accepted standards of dental practice.
There are limits on how often certain services and supplies are covered. If the amount of time
shown below has not passed since the service or supply was last provided, you may have to pay
100% of the cost. You can always contact Cigna to find out the last time you got benefits for a
certain service or supply. A time limit starts on the date you last got the service or supply. Time
limits are measured in consecutive months or years.
The types of services and supplies that are covered are listed below. Cigna’s patient charge schedule and certificates of coverage contain more specific information about what is covered.
• Diagnostic and preventive services and procedures to evaluate existing conditions and/or
to prevent dental abnormalities or disease, including exams and cleanings.
ӹӹ Oral exams, limited to 4 every 12 months.
ӹӹ Prophylaxis (regular cleaning), limited to 2 every year. Additional, medically necessary
visits may be permitted under certain circumstances. A copay will usually apply to any
additional visits.
ӹӹ Panoramic x-rays, limited to 1 set every 3 years.
ӹӹ Intraoral x-rays (complete series), limited to 1 set every 3 years.
ӹӹ Cone beam CT capture, limited to 1 every year, and only covered in connection with
temporomandibular joint (TMJ) evaluation.
ӹӹ Topical application of fluoride, limited to 2 times every year.
ӹӹ Sealants.
ӹӹ Space maintainers.
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Plan 185
Dental benefits
• Emergency palliative care, including treatment to temporarily relieve pain and discomfort.
• Diagnostic x-rays to diagnose a specific condition.
• Restorative services, including amalgam and resin-based fillings and polishing.
• Crowns and bridges, including inlays, onlays, crowns, core buildups, pin retention, pontics,
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and recementation. Replacement of crowns and bridges are limited to 1 every 5 years.
• Endodontic services and procedures to treat teeth with diseased or damaged nerves,
including pulp caps, pulpotomies, root canals, apicoectomy or periadicular surgery and
retrograde filling.
• Periodontic services to treat diseases of the gums and supporting structures of the teeth,
including gingivectomy or gingivoplasty, clinical crown lengthening, osseous surgery, bone
replacement graft, and soft tissue graft.
ӹӹ Periodontal scaling and root planing is limited to 4 quadrants every 12 months.
ӹӹ Periodontal maintenance is limited to 4 per year, and only after active periodontal
therapy.
ӹӹ Full mouth debridement is limited to 1 time per lifetime.
ӹӹ Periodontal regenerative procedures are limited to once per site (or tooth).
ӹӹ Localized delivery of antimicrobial agents is limited to 8 teeth (or sites) every 12
months.
• Prosthetics (removable tooth replacements, including implants and abutments) and repairs
(relining and rebasing).
ӹӹ Adjustments to prosthetics will be covered up to 4 times during the first 6 months after
insertion.
ӹӹ Replacement prosthetics are limited to 1 every 5 years.
ӹӹ Denture relining is limited to 1 every 36 months.
ӹӹ Replacement of crowns, bridges, and implant-supported dentures is limited to 1 every 5
years.
• Oral surgery, extractions and other surgical procedures, including pre-operative and postoperative care, and general anesthesia. No coverage is provided if you are under age 15.
ӹӹ Occlusal orthotic devices or guards are limited to 1 set every 24 months, and are only
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Plan 185
covered in connection with TMJ treatment.
ӹӹ General anesthesia is covered when done by an oral surgeon for a medically necessary
covered expense, and limited to 1 hour per appointment.
Dental benefits
ӹӹ I.V. sedation is covered when done by an oral surgeon or periodontist for a medically
necessary covered expense, and limited to 1 hour per appointment.
• Orthodontic treatment, limited to 24 months of treatment. Each month of active treatment
is a separate service and has a separate copay.
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Unless required by state law, the following types of treatments, services, and supplies are not
covered.
• Services or supplies provided by a non-network dentist without Cigna’s prior approval,
except in the case of emergency care received in accordance with Cigna’s rules governing
emergency care.
• Services or supplies provided by a specialist when such specialist care has not been referred
by your primary dentist and approved by Cigna.
• Services or supplies provided by a network dentist who has not been approved by Cigna
as your primary dentist, except in the case of emergency care received in accordance with
Cigna’s rules governing emergency care.
• Services not specifically listed as covered under Cigna’s patient charge schedule or the terms
of Cigna’s contract.
• Services or supplies provided more frequently than allowed under Cigna’s patient charge
schedule or the terms of Cigna’s contract.
• For or in connection with an injury arising out of, or in the course of, any employment for
wage or profit.
• For charges that would not have been made in any facility, other than a hospital or a
correctional institution, owned or operated by the United States government or by a state or
municipal government if you had no insurance.
• To the extent that payment is unlawful where you are living when the expenses are incurred
or the services are received.
• For charges that you (or your dependents) are not legally required to pay.
• For charges that would not have been made if you had no insurance.
• For or in connection with self-inflicted injury.
• Services related to any injury or illness paid under worker’ compensation, occupational
disease or similar law.
• Services provided or paid by or through a Federal or state governmental agency or
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Plan 185
Dental benefits
Dental benefits
authority, political subdivision or a public program, other than Medicaid.
• Services required while serving in the armed forces of any country or international
• Intentional root canal treatment in the absence of injury or disease solely to facilitate a
• Cosmetic dentistry or cosmetic dental surgery (as defined by Cigna), unless specifically
• authority or relating to a declared or undeclared war or acts of war.
listed as covered under Cigna’s patient charge schedule.
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apicoectomy or periadicular surgery.
• General anesthesia, sedation and nitrous oxide, unless medically necessary and in
connection with covered services performed by an oral surgeon or periodontist. Cigna does
not cover general anesthesia or I.V. sedation for anxiety control or patient management.
• Prescription drugs.
• Procedures, appliances, or restorations, if the main purpose is to change a vertical
dimension (degree of separation of the jaw when teeth are in contact), or restore teeth that
have been damaged by attrition, abrasion, erosion, and/or abfraction.
• Replacement of fixed and/or removable appliances (including fixed and removable
orthodontic appliances) that have been lost, stolen, or damaged due to patient abuse,
misuse, or neglect.
• Surgical placement of a dental implant; repair, maintenance, or removal of a dental implant;
implant abutment(s) or any services related to the surgical placement of a dental implant,
unless specifically listed on the patient charge schedule.
• Services considered to be unnecessary or experimental in nature, or that do not meet
commonly accepted dental standards.
• Procedures or appliances for minor tooth guidance or to control harmful habits.
restorative procedure.
Services performed by a prosthodontist.
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• Localized delivery of antimicrobial agents when performed alone or in the absence of
traditional periodontal therapy.
• Any localized delivery of antimicrobial agent procedures when more than 8 of these
procedures are reported on the same date of service.
• Infection control and/or sterilization.
• The recementation of any inlay, onlay, crown, post and core, or fixed bridge within 180 days
of initial placement.
• Services to correct congenital malformations, including the replacement of congenitally
missing teeth.
• Crowns, bridges, and/or implant-supported prosthesis used solely for splinting.
• Resin-bonded retainers and associated pontics.
• Services or supplies for anyone not considered a dependent under the terms of the Cigna
contract.
• Treatment already in progress when you become covered under the dental benefits.
• Any other service or supply not covered under the terms of Cigna’s contract.
• Hospitalization, including any associated incremental charges for dental services performed
in a hospital, except that benefits are payable for network general dentist charges for covered
services performed at a hospital (other associated charges are not covered).
• Services to the extent that you are covered under any group medical plan, unless required
under state law.
• The completion of crowns, bridges, dentures, or root canal treatment already in progress
when you become eligible for dental benefits.
• The completion of implant-supported prosthesis, including crowns, bridges, and dentures,
already in progress when you become eligible for dental benefits, unless specifically listed as
covered under the patient charge schedule.
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Plan 185
• Bone grafting and/or guided tissue regeneration when performed at the site of a tooth
extraction, unless specifically listed as covered under the patient charge schedule.
• Bone grafting and/or guided tissue regeneration when performed in conjunction with an
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Plan 185
Vision benefits
Learn:
ӹӹ What you pay for your covered vision care.
ӹӹ Why network providers can save you time and money.
ӹӹ What types of vision care are covered.
ӹӹ What types of vision care are not covered.
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Plan 185
This section applies only if you have elected vision benefits. If you are not sure if you
have elected vision benefits, please call UNITE HERE HEALTH to find out.
Vision benefits
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Vision benefits
UNITE HERE HEALTH has contracted with Vision Service Plan (VSP) to administer the vision
benefits provided to you and your dependents. The terms of this contract governs your vision
benefits. If there are any conflicts between this SPD and the contract, the terms of the contract
will govern.
Network and non-network vision providers
Certain state laws will govern how VSP pays your benefits. Your vision benefits and who is considered your dependent for vision benefits may be slightly different than described in this SPD.
(VSP’s rules would only apply to your VSP vision benefits - not to other benefits provided under
the Plan.)
To locate a network provider near you, contact:
Vision Care Benefits
Benefits payable every 12 months
Exam
Frames
Lenses
Elective Contacts (instead of glasses)
VSP Provider
$10 copay
$0 copay
The Plan only pays up to $45
$25 copay
allowance for frames; you get
an extra $20 off certain name
brands, and a 20% discount
on other frames over the
allowance
100% for exam
Your cost for the exam is
limited to $60
$0 for contacts
for contacts
$0 copay
$0 copay
single vision, $50 for lined
bifocal, $65 for lined trifocal,
and $100 for lenticular lenses
$0 copay
Benefits will be paid once per person every 12 months. This means that you can get one eye exam
and one set of eye wear (glasses or contacts) each year.
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Plan 185
The Plan pays benefits based on whether you get treatment from a network provider or a non-network provider.
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VSP
toll free: (800) 877-7195
www.vsp.com
See page A-10 for more information about how using network providers can save you time and
money.
What you pay
You pay any copays shown in the chart at the beginning of this section. You also pay for any expenses the Plan does not cover, including costs that are more than a particular maximum benefit.
Upgrade options and other discounts through network providers
Although the Plan will not pay for any upgrades or options, if you use a network provider, you
can get certain upgrades or options for a set fee. Common lens options include but are not limited
to anti-reflective coatings, polycarbonate lenses for adults, and photochromic lenses. Standard
scratch resistant coatings and polycarbonate lenses for children are available with no copay to
you.
You can also get discounts on laser eye surgery. (Benefits are not payable for laser eye surgery.)
Get your questions about options answered by contacting VSP, or by asking your network provider. Your cost or discount depends on which option or upgrade(s) you pick.
What the Plan pays
The Plan pays 100% of covered expenses after you make any applicable copay. If you use a nonnetwork provider, the Plan only pays up to the maximum shown in the table for your vision care.
What’s covered
• Exams, consultations, or treatment by a licensed vision care professional.
• Lenses, including single vision, bifocal lenses, trifocal lenses, or lenticular lenses.
• Frames.
• Contact lenses.
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Plan 185
Vision benefits
You can also get low vision services if a network provider believes you need additional treatment.
VSP must pre-approve any low vision services. Generally, the Plan pays 100% of low vision tests,
up to 2 tests per year, and 75% for supplemental aids, up to $1,000 every 2 years, regardless of
whether you use a network or a non-network provider. Your VSP provider must prescribe the low
vision services, and you must meet VSP’s criteria for eligibility for low level vision services. Contact VSP for more information about low vision services.
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The following treatments, services, and supplies are not covered under the vision benefit:
• Non-prescription lenses.
• Two pairs of glasses instead of bifocals.
• Any type of lenses, frames, services, supplies, or options that are not covered under the VSP
contract.
Short-term disability benefits
• Orthoptics or vision training or any associated supplemental testing.
• Medical or surgical treatment of the eyes.
• Contact lens modification, polishing or cleaning.
• Low vision services or supplies that are not pre-approved, or that are more than the
maximum benefits or frequency limits specified in the contract with VSP.
• Replacement of lost or broken contacts, lenses, or frames before the beginning of a
12-month benefit period.
• Frames/lenses in addition to contact lenses during the same benefit period.
• Any other service or supply excluded under the VSP contract.
Learn:
ӹӹ What your short-term disability benefits are.
ӹӹ What happens if you have more than one disability, or if your
disability recurs.
ӹӹ What types of accidents or sicknesses are ineligible for short-term
benefits.
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Plan 185
This section applies only if you have elected short-term disability benefits.
If you are not sure if you have elected short-term disability benefits,
please call UNITE HERE HEALTH to find out.
Short-term disability benefits are for employees only. Dependents are not eligible for shortterm disability benefits.
$200, payable for up to 26 weeks
When Benefits Start
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• The 1st day of disability caused by injury; or
• The 8th day of disability caused by sickness, including for pregnancy.
What the Plan Pays
Weekly Amount
Benefits begin:
Disabled because of an Accident
1st day
Disabled because of a Sickness (including Pregnancy)
8th day
You are considered disabled if you are prevented from engaging in the normal activities of your
job because of a non-occupational (non-work-related) injury or sickness. If you are disabled, the
Plan pays short-term disability benefits directly to you. You must be eligible when your disability
starts in order to get short-term disability benefits. No benefits are paid if your disability begins:
Social Security taxes (FICA) will be withheld from any benefits paid.
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Multiple periods of disability
Benefits are paid per period of disability. If you receive the maximum amount of benefits, you will
not be eligible for more short-term disability benefits until you begin a new period of disability.
Multiple periods of disability due to the same cause are considered one period of disability. A new
period of disability begins when you return to work for at least 2 weeks, or when you have a new
injury or sickness.
If you are disabled for unrelated causes, you must return to work for at least one day before a new
period of disability will begin.
See page C-62 for a list of the Plan’s general exclusions and limitations. No short-term disability
benefits will be paid for any disability related to any of the exclusions or limitations on this list.
• Before you become initially eligible (see page E-5); or
• After your employment terminates.
You must submit a completed form and a doctor’s statement showing you are totally disabled
before benefits will be paid. You can get the form by contacting the Fund (see page A-5).
What the Plan pays
If a non-work-related injury or sickness keeps you from doing your job, the Plan pays $200 per
week, up to 26 weeks for any one period of disability.
If you are disabled for less than a full week (7 days) the Plan pays $28.57 per day of disability.
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Plan 185
Plan 185
Life and AD&D
insurance benefits
Learn:
ӹӹ What your life insurance benefit is.
ӹӹ How you can continue your coverage if you are disabled.
ӹӹ How to convert your life insurance to an individual policy if you lose
coverage.
ӹӹ What your AD&D insurance benefit is.
ӹӹ How to tell the Fund who should get the benefit if you die.
ӹӹ How to file a claim for life or AD&D insurance benefits.
ӹӹ Additional benefits under the life and AD&D insurance benefit.
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Plan 185
This section applies only if you are eligible for life and AD&D insurance benefits.
If you are not sure if you are eligible for these benefits,
please call UNITE HERE HEALTH to find out.
Life and AD&D insurance benefits
Life and Accidental Death and Dismemberment (AD&D) insurance benefits are for employees
only. Dependents are not eligible for life and AD&D insurance benefits.
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AD&D insurance benefits will continue if you provide proof of your total disability. Your benefits
will continue until the earlier of the following dates:
Event
Benefit
Who Receives
• Your total disability ends.
Life Insurance
$10,000
Your beneficiary
Accidental Death & Dismemberment
Insurance (full amount)
• You fail to provide satisfactory proof of continued disability.
$5,000
Your beneficiary (if you die)
Life and AD&D insurance benefits are provided under a group insurance policy issued to UNITE
HERE HEALTH by Dearborn National. The terms and conditions of your (the employee’s) life
and AD&D insurance coverage are contained in a certificate of insurance. The certificate describes, among other things:
• How much life and AD&D insurance coverage is available.
• When benefits are payable.
• How benefits are paid if you do not name a beneficiary or if a beneficiary dies before you do.
• How to file a claim.
The terms of the certificate are summarized below. If there is a conflict between this summary
and the certificate of insurance, the certificate governs. You may request a copy of the certificate
of insurance by contacting the Fund or Dearborn National.
• You become age 70.
For purposes of continuing your life insurance benefit, you are totally disabled if an injury or a
sickness is expected to prevent you from engaging in any occupation for which you are reasonably
qualified by education, training, or experience for at least 12 months.
You must provide a completed application for benefits plus a doctor’s statement establishing your
total disability. The form and the doctor’s statement must be provided to UNITE HERE HEALTH
within 12 months of the start of your total disability. (Forms are available from the Fund.) UNITE
HERE HEALTH must approve this statement and your disability form. You must also provide a
written doctor’s statement every 12 months, or as often as may be reasonably required based on the
nature of the total disability. During the first two years of your disability, UNITE HERE HEALTH
has the right to have you examined by a doctor of its choice as often as reasonably required. After
two years, examinations may not be more frequent than once a year.
Converting to individual life insurance coverage
If your insurance coverage ends and you don’t qualify for the disability continuation just described, you may be able to convert your group life coverage to an individual policy of whole life
insurance by submitting a completed application and the required premium to Dearborn National
within 31 days after the date your coverage under the Plan ends.
Premiums for converted coverage are based on your age and the amount of insurance you select.
Conversion coverage becomes effective on the day following the 31-day period during which you
could apply for conversion if you pay the required premium before then. For more information
about conversion coverage, contact Dearborn National.
Dearborn National
1020 31st Street
Downers Grove, IL 60515
(800) 348-4512
Life insurance benefit
Your life insurance benefit is $10,000 and will be paid to your beneficiary(ies) if you die while
you are eligible for coverage or within the 31-day period immediately following the date coverage
ends.
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Continuation if you become totally disabled
If you become totally disabled before age 62 and while you are eligible for coverage, your life and
Plan 185
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• You refuse to be examined by the doctor chosen by UNITE HERE HEALTH.
Terminal illness benefit
If you have a terminal illness (an illness so severe that you have a life expectancy of 24 months or
less), your Life Insurance pays a cash lump sum equal to 75% of the death benefit in force on the
day proof of terminal illness is accepted. The remaining 25% of your death benefit will be paid to
your named beneficiaries after your death.
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Plan 185
Accidental death & dismemberment insurance benefit
If you die or suffer a covered loss within 365 days of an accident that happens while you are eligible for coverage, AD&D insurance benefits will be paid as shown below.
Event
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Benefit
Who Receives
Death
$5,000
Your beneficiary
Loss of both hands or feet
$5,000
You
Loss of sight in both eyes
$5,000
You
Loss of one hand and one foot
$5,000
You
Loss of one hand and sight in one eye
$5,000
You
Loss of one hand or one foot
$2,500
You
Loss of the sight in one eye
$2,500
You
Loss of index finger and thumb on same hand
$1,250
You
AD&D exclusions
AD&D insurance benefits do not cover losses caused by:
• Any disease, or infirmity of mind or body, and any medical or surgical treatment thereof.
• Any infection, except an infection of an accidental injury.
• Any intentionally self-inflicted injury.
• Suicide or attempted while sane or insane.
• Losses caused while you are under the influence of narcotics or other controlled substances,
gas or fumes.
• Losses caused while intoxicated.
• Losses caused by active participation in a riot.
• Losses caused by war or an act of war while serving in the military.
See your certificate for complete details.
benefit, with a maximum of $3,000 each year. Benefits will be paid for up to four years per
child. If you have children in elementary or high school at the time of your death, your
additional AD&D coverage pays a one-time benefit of $1,000. You will have to provide proof
of dependent status. See the certificate of coverage for more information about how to file a
claim.
• Seat Belt Benefit—If you are wearing a seat belt at the time of an accident resulting in
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your death, your additional AD&D coverage pays a benefit equal to 10% of the amount of
your life insurance benefit, with a minimum benefit of $1,000 and a maximum benefit of
$25,000. If it is not clear that you were wearing a seat belt at the time of the accident, your
additional AD&D coverage will only pay a benefit of $1,000.
• Air Bag Benefit—If you are wearing a seat belt at the time of an accident resulting in your
death and an air bag deployed, your additional AD&D coverage pays a benefit equal to
5% of the amount of your life insurance benefit, with a minimum benefit of $1,000 and
a maximum benefit of $5,000. If it is not clear that the air bag deployed, your additional
AD&D coverage will only pay a benefit of $1,000.
• Transportation Benefit—If you die more than 75 miles from your home, your additional
AD&D coverage pays up to $5,000 to transport your remains to a mortuary.
Naming a beneficiary
Your beneficiary is the person or persons you want Dearborn National to pay if you die. Beneficiary designation forms are available from the Fund. You can name anyone you want and you can
change beneficiaries at any time. However, beneficiary designations will only become effective
when a completed form is received.
If you don’t name a beneficiary, death benefits will be paid to your surviving relatives in the
following order: your spouse; your children in equal shares; your parents in equal shares; your
brothers and sisters in equal shares; or your estate. However, Dearborn National may pay up to
$2,000 to anyone who pays expenses for your burial. The remainder will be paid in the order
described above.
If a beneficiary is not legally competent to receive payment, Dearborn National may make payments to that person’s legal guardian.
Additional accidental death & dismemberment insurance benefits
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The additional insurance benefits described below have been added to your AD&D benefits. The
full terms and conditions of these additional insurance benefits are contained in a certificate
made available by Dearborn National. If there is a conflict between these highlights and the certificate, the certificate governs.
• Education Benefit—If you have children in college at the time of your death, your
additional AD&D coverage pays a benefit equal to 3% of the amount of your life insurance
Plan 185
Additional services
In addition to the benefits described above, Dearborn National has also made the following
services available. These services are not part of the insured benefits provided to UNITE HERE
HEALTH by Dearborn National but are made available through outside organizations that have
contracted with Dearborn National. They have no relationship to UNITE HERE HEALTH or the
benefits it provides.
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Plan 185
• Online Will Preparation—Online will preparation gives you the ability to easily and
quickly create a will, free of charge. Online will preparation services are administered by
ComPsych®, a major provider of global employee assistance programs.
• Beneficiary Resource Services—Beneficiary Resource Services is available to beneficiaries
of an insured person who dies and to an insured person who qualifies for the Terminal
Illness Benefit. The program combines grief, legal, and financial counseling provided by
Bensinger, DuPont & Associates, a nationwide organization utilizing masters degreed grief
counselors, licensed attorneys, and Certified Consumer Credit Counselors. Services are
provided via telephone, face-to-face contact, and referrals to local support resources.
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• Travel Resource Services—Europ Assistance USA, Inc. provides 24-hour emergency
medical and related services for short-term travel more than 100 miles from home.
Services include: assistance with finding a doctor, medically necessary transportation,
and replacement of drugs or eyeglasses. Other non-medical related travel services are also
available. Europ Assistance USA, Inc. arranges and pays for covered services up to the
program maximum.
Contact the Fund when you have questions about these benefits.
General exclusions
and limitations
Learn:
ӹӹ About the types of care that are not covered by the Plan.
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Plan 185
General exclusions and limitations
This section does not apply to dental or vision benefits. Exclusions and limitations under the
dental benefits or the vision benefits will be based on the contract with Cigna or with VSP, as
applicable.
Each benefit section has a list of the types of treatment, services, and supplies that are not covered. In addition to those lists, the following types of treatment, services and supplies are also
excluded for all medical care, prescription drugs, and short-term disability benefits. No benefits
will be paid under the Plan for charges incurred for or resulting from any of the following:
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• Any bodily injury or sickness for which the person for whom a claim is made is not under
the care of a healthcare provider.
• Any injury or sickness which arises out of or in the course of any occupation or
employment, or for which you have gotten or are entitled to get benefits under a workers’
compensation or occupational disease law, whether or not you have applied or been
approved for such benefits.
• Any treatment, services, or supplies:
ӹӹ For which no charge is made.
ӹӹ For which you, your spouse or your child is not required to pay.
ӹӹ Which are furnished by or payable under any plan or law of a federal or state
government entity, or provided by a county, parish, or municipal hospital when there is
no legal requirement to pay for such treatment, services, or supplies.
• Any charge which is more than the Plan’s allowable charge (see page G-2).
• Treatment, services, or supplies not recommended or approved by the attending healthcare
provider, or not medically necessary in treating the injury or sickness as defined by UNITE
HERE HEALTH (see page G-6).
• Experimental treatment (see page G-4), or treatment that is not in accordance with
generally accepted professional medical standards as defined by UNITE HERE HEALTH .
• Any service or supply not covered or denied because prior authorization was required when
such prior authorization was not received.
• Any expense or charge for failure to appear for an appointment as scheduled, or charge for
completion of claim forms, or finance charges.
• Any treatment that is denied or not covered because you did not get prior authorization for
the care as required.
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Plan 185
• Any treatment, services, or supplies provided by an individual who is related by blood or
marriage to you, your spouse, or your child, or who normally lives in your home.
• Any treatment, services, or supplies purchased or provided outside of the United States (or
its Territories), unless for a medical emergency. The decision of the Trustees in determining
whether an emergency existed will be final.
• Any treatment, services or supplies for or in connection with the pregnancy of a dependent
child except for preventive healthcare services. For example, ultrasounds, treatment
associated with a high-risk pregnancy, non-preventive care, and delivery charges are not
covered with respect to the pregnancy of a dependent child.
C
• Any treatment, services, or supplies for or in connection with the child of your dependent
child, unless such child meets the definition of a dependent (see page E-2) or the Fund is
required to provide benefits for such individual under applicable state law.
• Sex transformation.
• Reversal of a voluntary sterilization.
• Treatment for or in connection with infertility, including but not limited to fertility
treatment with the goal of becoming pregnant (including but not limited to in vitro
fertilization or similar procedures intended to promote conception).
• Weight loss programs or treatment, except to treat morbid obesity if the program is under
the direct supervision of a healthcare provider, or as covered as a preventive healthcare
service.
• Any elective procedure (other than sterilization or abortion, or as otherwise specifically
stated as covered) that is not for the correction or cure of a bodily injury or sickness.
UNITE HERE HEALTH or its designated representative must provide prior authorization
for such elective procedures.
• Services for preventive care or preventive treatment, other than preventive healthcare
services listed as covered.
• Any smoking cessation treatment, drug, or device to help you stop smoking or using
tobacco, other than preventive healthcare services.
• Hearing aids.
• Home construction for any reason.
• Supplies or equipment for personal hygiene, comfort or convenience such as, but not limited
to, air conditioning, humidifier, physical fitness and exercise equipment, tanning bed, or
water bed.
• Any expense or charge by a rest home, old age home, or a nursing home.
• Any charges incurred while you are confined in a hospital, nursing home, or other facility
or institution (or a part of such facility) which are primarily for education, training, or
custodial care.
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• Cosmetic, plastic, or reconstructive surgery, unless that surgery is for any of the following:
(1) to treat an accidental injury, and the surgery is performed within 24 months after
the accidental; (2) breast reconstruction following a mastectomy; (3) related to domestic
violence; or (4) medically necessary treatment, as determined by the Fund or its designated
representative, which is provided by a network provider for a life-threatening condition
(such as a medical complication). The Fund has the sole and exclusive judgment an
discretion to determine when and if exception No. 4 applies to a particular situation.
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• Christian Science practitioners and treatment.
• Any expense greater than the Plan’s maximum benefits, or any expense incurred before
eligibility for coverage begins or after eligibility terminates, unless specifically provided for
under the Plan.
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• Any charges incurred for treatment, services, or supplies as a result of a declared or
undeclared war or any act thereof; or any loss, expense or charge incurred while a person is
on active duty or in training in the Armed Forces, National Guard, or Reserves of any state
or any country.
• Any injury or sickness resulting from participation in an insurrection or riot, or
participation in the commission of a felonious act or assault.
• Massage therapy, rolfing, acupressure, or biofeedback training.
• Naturopathy or naprapathy.
• Athletic training.
• Services provided by or through a school, school district, or community or state-based
educational or intervention program, including but not limited to any part of an Individual
Education Plan (IEP).
• Court-ordered or court-provided treatment of any kind, including any treatment otherwise
covered by this Plan when such treatment is ordered as a part of any litigation, courtordered judgment or penalty.
• Treatment, therapy, or drugs designed to correct a harmful or potentially harmful habit
rather than to treat a specific disease, other than services or supplies specifically stated as
covered.
• Megavitamin therapy, primal therapy, psychodrama, or carbon dioxide therapy.
• Applied Behavioral Analysis therapy (ABA therapy) or similar programs, including, but not
limited to, ABA therapy, discrete trial training, pivotal response training, verbal behavioral
intervention, early intensive behavioral intervention, or the Early Start Denver Model.
• Genetic testing or counseling unless the result of the test will directly impact the treatment
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of a patient with a diagnosed medical condition, including pregnancy. The decision about
whether genetic testing will be covered is based on the medical policies established by or
selected by the Fund or its designated representative. However, in all cases, UNITE HERE
HEALTH makes the final determination as to whether genetic testing affects the patient’s
medical treatment. Genetic testing will not be covered for individuals not covered by the
Plan, to establish paternity, for administrative purposes, or for legal purposes. Genetic
testing on embryos will also not be covered.
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Plan 185
Coordination of benefits
Learn:
ӹӹ How benefits are paid if you are covered under this Plan plus other
plan(s).
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Plan 185
The Plan’s coordination of benefits provisions only apply to medical benefits. No coordination
of benefits applies to prescription drug benefits, life or AD&D insurance benefits, or short-term
disability benefits. Any coordination of benefits under the dental or vision benefits will be based
on the contract with Cigna or with VSP, as applicable.
If you or your dependents are covered under this Plan and are also covered under another group
health plan, the two plans will coordinate benefit payments. Coordination of benefits (COB)
means that two or more plans may each pay a portion of the allowable expenses. However, the
combined benefit payments from all plans will not be more than 100% of allowable expenses.
This Plan coordinates benefits with the following types of plans:
D
• Group, blanket, or franchise insurance coverage.
• Group Blue Cross or Blue Shield coverage.
• Any other group coverage, including labor-management trusteed plans, employee
organization benefit plans, or employer organization benefit plans.
• Any coverage under governmental programs or provided by any statute, except Medicaid.
• Any automobile insurance policies (including “no fault” coverage) containing personal
injury protection provisions.
This Plan will not coordinate benefits with Health Maintenance Organizations (HMOs) or reimburse an HMO for services provided.
Which plan pays first
The first step in coordinating benefits is to determine which plan pays first (the primary plan) and
which plan pays second (the secondary plan). If the Fund is primary, it will pay its full benefits.
However, if the Fund is secondary, the benefits it would have paid will be used to supplement the
benefits provided under the other plan, up to 100% of allowable expenses. Contact the Fund (see
page A-5) for more information about how the Plan determines allowable expenses when it is
secondary.
Order of payment
The general rules that determine which plan pays first are summarized below. Contact the Fund
(see page A-5) when you have any questions.
• Plans that do not contain COB provisions always pay before those that do.
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Plan 185
• Plans that have COB and cover a person as an employee always pay before plans that cover
the person as a dependent.
• Plans that have COB and cover a person as an active employee always pay before plans that
cover the person as a retired or laid off employee.
• With respect to plans that have COB and cover dependent children under age 18 whose
parents are not separated, plans that cover the parent whose birthday falls earlier in a year
pay before plans covering the parent whose birthday falls later in that year.
• With respect to plans that have COB and cover dependent children under age 18 whose
parents are separated or divorced:
ӹӹ Plans covering the parent whose financial responsibility for the child’s healthcare
expenses is established by court order pay first.
ӹӹ If there is no court order establishing financial responsibility, the plan covering the
D
parent with custody pays first.
ӹӹ If the parent with custody has remarried and the child is covered as a dependent under
the plan of the stepparent, the order of payment is as follows:
1.The plan of the parent with custody.
2.The plan of the stepparent with custody.
3.The plan of the parent without custody.
• With respect to plans that have COB and cover adult dependent children age 18 and older
under both parents’ plans, regardless of whether these parents are separated or divorced, or
not separated or divorced, the plan that covers the parent whose birthday falls earlier in a
year pays before the plan covering the parent whose birthday falls later in the year, unless a
court order requires a different order.
• With respect to plans that have COB and cover adult dependent children age 18 and older
under one or more parents’ plan and also under the dependent child’s spouse’s plan, the
plan that has covered the dependent child the longest will pay first.
If these rules do not determine the primary plan, the plan that has covered the person for the
longest period of time pays first.
COB and prior authorization
When this Plan is secondary (pays its benefits after the other plan) and the primary plan’s prior
authorization or utilization management requirements are satisfied, you or your dependent will
not be required to comply with this Plan’s prior authorization or utilization management requirements. The Plan will accept the prior authorization or utilization management determinations
made by the primary plan.
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Plan 185
Special rules for Medicare
If you are entitled to Medicare while covered by the Plan, Medicare is secondary to the Plan except as shown below:
• The Plan is primary for the first 30 months a person is eligible for and entitled to Medicare
because of end stage renal disease (ESRD).
• Medicare is primary with respect to any coverage under the Plan provided for you after
employment ends (such as COBRA coverage - see page E-20).
If you are entitled to Medicare benefits, the Plan will pay its benefits as if you have enrolled in
both Medicare Part A (Hospital Benefits) and Part B (Doctor’s Benefits), even if you have not
enrolled in Part A and/or Part B. If you are entitled to Medicare but do not enroll in Medicare,
you will have to pay 100% of the costs that would have been paid for under Medicare had you
enrolled.
D
If you and your dependent are both employees under this Plan
If both you and your spouse are covered as employees under this Plan and you or your spouse
cover the other person as your dependent, the Plan will coordinate benefits with itself. The person
who incurred the claim will still have to pay any cost sharing, such as deductibles and copays,
and any maximum benefits will still apply to the person.
This rule also applies when coordinating benefits for your children if you and your spouse are
both covered as employees under this Plan, or if you and your dependent child are both covered
as employees under the Plan.
Subrogation
Learn:
ӹӹ Your responsibilities and the Plan’s rights if your medical expenses are
from an accident or an act caused by someone else.
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Plan 185
Subrogation
The Plan’s subrogation provisions only apply to medical and prescription drug benefits. No subrogation applies to life or AD&D insurance benefits, or short-term disability benefits. Any subrogation under the dental benefits or the vision benefits will be based on the contract with Cigna or
with VSP, as applicable.
The Plan’s right to recover payments
When injury is caused by someone else
Sometimes, you or your dependent suffer injuries and incur medical expenses as a result of an
accident or act for which someone other than UNITE HERE HEALTH is financially responsible.
For benefit repayment purposes, “subrogation” means that UNITE HERE HEALTH takes over
the same legal rights to collect money damages that a participant had.
D
Typical examples include injuries sustained:
• In an automobile accident caused by someone else; or
• On someone else’s property, if that person is also responsible for causing the injury.
In these cases, the other person’s car insurance or property insurance may have to pay all or a
part of the resulting medical bills, even though benefits for the same expenses may be paid by the
Plan. By accepting benefits paid by the Plan, you agree to repay the Plan if you recover anything
from a third party.
Statement of facts and repayment agreement
Subrogation
Settling your claim
Before you settle your claim with a third party, you or your attorney should contact UNITE
HERE HEALTH (see page A-5) to obtain the total amount of medical bills paid. Upon settlement, UNITE HERE HEALTH is entitled to reimbursement for the amount of the benefits it has
paid or the full amount of the settlement or other recovery you or a dependent receive, whatever
is less.
If UNITE HERE HEALTH is not repaid, future benefits may be applied to the amounts due, even
if those benefits are not related to the injury. If this happens, no benefits will be paid on behalf of
you or your dependent (if applicable) until the amount owed UNITE HERE HEALTH is satisfied.
D
If the Plan unknowingly pays benefits resulting from an injury caused by an individual who may
have financial responsibility for any medical expenses associated with that injury, your acceptance of those benefits is considered your agreement to abide by the Plan’s subrogation rule,
including the terms outlined in the Repayment Agreement.
Although UNITE HERE HEALTH expects full reimbursement, there may be times when full
recovery is not possible. The Trustees may reduce the amount you must repay if special circumstances exist, such as the need to replace lost wages, ongoing disability, or similar considerations.
When your claim settles, if you believe the amount UNITE HERE HEALTH is entitled to should
be reduced, send your written request to:
Subrogation Coordinator
UNITE HERE HEALTH
P.O. Box 6020
Aurora, IL 60598-0020
In order to determine benefits for an injury caused by another party, UNITE HERE HEALTH
may require a signed Statement of Facts. This form requests specific information about the injury
and asks whether or not you intend to pursue legal action. If you receive a Statement of Facts, you
must submit a completed and signed copy to UNITE HERE HEALTH before benefits are paid.
Along with the Statement of Facts, you will receive a Repayment Agreement. If you decide to
pursue legal action or file a claim in connection with the accident, you and your attorney (if
one is retained) must also sign a Repayment Agreement before UNITE HERE HEALTH pays
benefits. The Repayment Agreement helps the Plan enforce its right to be repaid and gives
UNITE HERE HEALTH first claim, with no offsets, to any money you or your dependents recover from a third party, such as:
• The person responsible for the injury;
• The insurance company of the person responsible for the injury; or
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Plan 185
• Your own liability insurance company.
The Repayment Agreement also allows UNITE HERE HEALTH to intervene in, or initiate on
your behalf, a lawsuit to recover benefits paid for or in connection with the injury.
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Plan 185
Eligibility for coverage
Learn:
ӹӹ Who is eligible for coverage (who your dependents are).
ӹӹ How you enroll yourself and your dependents.
ӹӹ When and how you become eligible for coverage.
ӹӹ How you stay eligible for coverage.
ӹӹ When your dependents become eligible.
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Plan 185
ӹӹ When you can add and drop dependents.
You establish and maintain eligibility by working for an employer required by a Collective Bargaining Agreement (CBA) to make contributions to UNITE HERE HEALTH on your behalf.
There may be a waiting period under your CBA before your employer is required to begin making
those contributions. You may also have to satisfy other rules or eligibility requirements described
in your CBA before your employer is required to contribute on your behalf. Any hours you work
during a waiting period or before you meet all of the eligibility criteria described in your CBA do
not count toward establishing your eligibility under UNITE HERE HEALTH. You should look at
your CBA—it will tell you when your employer will start making contributions for your coverage,
as well as any other rules you may have to follow, or criteria you may have to meet, in order to
become eligible.
The eligibility rules described in this section will not apply to you until and unless your employer is required to begin making contributions on your behalf.
Who is eligible for coverage
E
Employees
You are eligible for coverage if you meet all of the following rules:
• You work for an employer who is required by a CBA to contribute to UNITE HERE
HEALTH on your behalf.
• The contributions required by that CBA are received by UNITE HERE HEALTH.
Contributions include any amounts you must pay for your share of the coverage.
• You meet the Plan’s eligibility rules. See page E-5 for more information about the eligibility
rules.
Your CBA states whether or not you must pay for part of the cost of your coverage (called a
“co-premium”). If so, you should arrange to have your employer take your co-premium out of
your paycheck (a payroll deduction). Your co-premiums are in addition to any cost sharing (for
example, deductibles, copays, or coinsurance) you pay for specific healthcare services and supplies.
You may be able to decline coverage under UNITE HERE HEALTH. You can do this during your
initial enrollment by agreeing to waive your coverage. You can decline coverage when you are
first given the chance to sign up for coverage. However, if you decline coverage, you must wait
until an open enrollment period or special enrollment period (see page E-8) before you have another chance to sign up. Call the Fund when you have questions about declining coverage, or how
to get coverage again if you have declined coverage.
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Plan 185
Dependents
If you have dependents when you become eligible for coverage, you can also sign up (enroll) your
dependents for coverage during your initial enrollment period. Your dependents’ coverage will
start when yours does (not before). You cannot decline coverage for yourself and sign up your
dependents.
You can add dependents after your coverage starts, but only at certain times. See page E-8 for
more information about enrollment events.
You must sign up any dependent you want covered and make any required co-premium for your
share of the cost of dependent coverage. You may have to pay for part of the cost of your dependents’ coverage, called a “co-premium.” If so, you should arrange to have your employer take your
co-premium out of your paycheck (a payroll deduction). Your co-premiums are in addition to any
cost sharing you pay for your specific healthcare services and supplies. Contact your employer
when you need more information about the amount of your co-premium for your share of your
or your dependent’s coverage, or for help setting up your payroll deduction. Contact the Fund for
more information about when your dependents’ coverage starts.
If you don’t sign up your dependent, or don’t make any required co-premiums for your dependent, the Plan will not pay benefits for that person.
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Who your dependents are
Your dependent is any of the following, provided you show proof of your relationship to them:
• Your legally married spouse.
• Your children who are under age 26, including:
ӹӹ Natural children.
ӹӹ Step-children.
ӹӹ Adopted children or children placed with you for adoption, if you are legally
responsible for supporting the children until the adoption is finalized.
ӹӹ Children for whom you are the legal guardian or for whom you have sole custody
under a state domestic relations law.
ӹӹ Children entitled to coverage under a Qualified Medical Child Support Order.
✓✓ Federal law requires UNITE HERE HEALTH to honor Qualified Medical Child Support
Orders. UNITE HERE HEALTH has established procedures for determining whether a
divorce decree or a support order meets federal requirements and for enrollment of any
child named in the Qualified Medical Child Support Order. To obtain a copy of these
procedures at no cost, or for more information, contact the Fund.
E-3
Your child may be covered after age 26 if he or she can’t support himself or herself because of a
Plan 185
mental or physical handicap. The handicap must have started before the child turned 19, and the
child must have been covered under the Plan on the day before his or her 19th birthday. For more
information, see page E-12 . (Special rules apply to children with a mental or physical handicap
that were covered under the employer’s plan when a new employer begins participation in the
Hospitality Plan. Contact the Fund with questions.)
Enrollment requirements
Employees
You must provide any information and documentation the Fund requires order to enroll. You
must provide information and appropriate documentation even if your employer pays the entire
cost of your coverage. You choose the level of coverage right for you:
• Coverage for just yourself (the employee),
E
• Coverage for yourself and your spouse, or
• Coverage for yourself and your children, or
• Coverage for yourself and your family (more than one dependent).
You must provide the required information by the end of your initial enrollment period. The
Plan will tell you the date the forms are due. If you don’t provide the required information by the
deadline, you will not be covered by UNITE HERE HEALTH. You must wait for the next open
enrollment or special enrollment period to sign up (see page E-8 for more information).
Dependents
✓✓ You cannot choose to cover only your dependents. You can only cover your dependents if
you enroll for coverage, too.
In order to enroll your dependents, you must provide information about them when you enroll.
You must provide the requested information during your initial enrollment period. UNITE
HERE HEALTH will tell you when this information is due. If you do not provide the requested
information by the due date, you may have to wait to enroll your dependents until the next open
enrollment or special enrollment period (see page E-8 for more information).
See page E-6 for information about when coverage for your dependents starts.
E-4
You must also show that each dependent you enroll meets the Fund’s definition of a dependent.
You must provide at least one of the following for each of your dependents:
• A certified copy of the marriage certificate.
• A certified copy of the birth certificate.
• A baptismal certificate.
• Hospital birth records.
• Written proof of adoption or legal guardianship.
• Court decrees requiring you to provide medical benefits for a dependent child.
• Notarized copies of your most recent federal tax return (Form 1040 or its equivalents).
• A certificate of creditable coverage.
• Documentation of dependent status issued and certified by the United States Immigration
and Naturalization Service (INS).
• Documentation of dependent status issued and certified by a foreign embassy.
Your or your spouse’s name must be listed on the proof document as the dependent child’s parent.
E
You must provide any required dependent proof documents by the date you must provide your
enrollment information (See page E-8 information about special enrollment rights). Remember,
you must provide any required proof documentation before claims will be paid on behalf of your
dependent.
When your coverage begins (initial eligibility)
You are eligible for coverage during the same month for which your employer makes contributions on your behalf. Your coverage begins at 12:01 a.m. on the first day of the month for which
your employer is first required to contribute on your behalf.
Example: Establishing Initial Eligibility
Your employer must contribute
You are covered in . . .
for your work in . . .
January
January
Suppose employer contributions are first required on your behalf for your work in January. Your
coverage will begin on January 1 and will continue for the rest of that month.
E-5
• A commemoration of marriage from a generally recognized denomination of organized
Plan 185
religion.
Plan 185
Continuing eligibility
When you become eligible for dependent coverage, you can choose coverage for just yourself, for
yourself plus your children, for yourself plus your spouse, or for yourself and your family. Your
cost for providing coverage may depend on which option you choose. Remember, you must enroll
your dependents before the Plan will pay benefits for these claims (see page E-4).
Once you establish eligibility, your eligibility continues each month for which your employer is
required to make a contribution on your behalf under the terms of your CBA.
Example: Continuing Eligibility
Your employer must contribute
You are covered in . . .
for your work in . . .
February
February
March
March
April
April
Suppose you became covered January 1 because your employer was required to make contributions on your behalf for January. If a contribution is required on your behalf for February, your
coverage continues during February. A contribution for March continues your coverage during
March, April continues your coverage during April, and so on.
E
Self-payments during remodeling or restoration
If your work place closes or partially closes because it’s being remodeled or restored, you may
make self-payments to continue your coverage until the remodeling or restoration is finished.
However, you may only make self-payments for up to 18 months from the date your work place
began remodeling or restoration.
Self-payments during a strike
You may also make self-payments to continue coverage if all of the following rules are met:
• Your CBA has expired.
• Your employer is involved in collective bargaining with the union and an impasse has been
reached.
• The Union certifies that affirmative actions are being taken to continue the collective
bargaining relationship with the Employer.
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Plan 185
If you enroll dependents when you become initially eligible
Coverage for your dependents begins the same time yours does, as long as you provide any required enrollment materials by the deadline to enroll, plus begin making payroll deductions for
the cost of your dependents’ coverage.
If you add dependents after you become initially eligible
• If you only chose coverage for yourself when you became initially eligible, you have to
wait until the next open enrollment or special enrollment period (see page E-8) to enroll
dependents.
eligible, you have to wait until the next open enrollment or special enrollment period to
enroll children.
• If you only chose coverage for yourself and your children when you became initially
eligible, you have to wait until the next open enrollment or special enrollment period to
enroll a spouse.
• If you elected coverage for yourself and your children, or coverage for yourself and your
family, when you became initially eligible, you can add children at any time. The child’s
coverage will start as explained below:
ӹӹ If you have a new child (a child is born, adopted or placed with you for adoption, or
moves to the US to live with you), this is considered a special enrollment event, and
the rules for special enrollment events (see page E-8) will determine when the child
becomes covered.
ӹӹ You can enroll other children who meet the Fund’s definition of “child” any time
during the year. You don’t have to wait for an open enrollment or special enrollment
event. As long as you provide all required proof documentation within 30 days of
telling the Fund you want to add the child, coverage for that child will start on the first
day of the month following the date you tell the Fund about the child.
You may make self-payments to continue your coverage for up to 12 months as long as you do not
engage in conduct inconsistent with the actions being taken by the union.
Continued coverage for dependents
When dependent coverage starts
Your dependents will remain covered as long as you remain eligible and you make any required
payments for your share of your dependents’ coverage. Payments for your share of the cost of dependent coverage must be made by payroll deduction. However, if you are on a temporary layoff
or an approved leave of absence, you must make any payments for your share of your dependents’
coverage directly to your employer.
Dependent coverage cannot start before your coverage starts. Dependent coverage cannot continue after your coverage ends.
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• If you only chose coverage for yourself and your spouse when you became initially
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Plan 185
Enrollment periods
If you have questions about special enrollment periods or when coverage becomes effective, contact UNITE HERE HEALTH.
Open enrollment periods
If you do not take advantage of a special enrollment period, you must wait until the next open
enrollment period or special enrollment period to enroll yourself or your dependents.
Open enrollment periods give you the chance to elect coverage for yourself and your dependents
if you declined coverage. It also gives you a chance to change your coverage tier (for example, you
decide to change your election from coverage for just yourself and your children to family coverage so your spouse is also covered), or if you only enrolled some of your dependents. If you want
to enroll yourself or more dependents, you must provide the required enrollment material and
arrange to make any required payments. Your open enrollment materials will describe the deadlines for enrollment and when coverage will start.
Special enrollment periods
In a few special circumstances, you do not need to wait for the open enrollment period to enroll
yourself or your dependents. You can enroll yourself or any dependents for coverage within 60
days after any of the following events:
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E
• Termination of other group health coverage, including COBRA continuation coverage, that
you had when you first became eligible for coverage under the Plan (or your dependents
first became eligible for coverage under the Plan), unless you lost that coverage because you
stopped making premium payments.
• Your marriage.
• The birth of your child.
• The adoption or placement for adoption of a child under age 26.
• A dependent previously residing in a foreign country comes to the United States and takes
up residence with you.
• The loss of your or a dependent’s eligibility for Medicaid or Child Health Insurance
Program (CHIP) benefits.
• When you or a dependent becomes eligible for state financial assistance under a Medicaid
or CHIP to help pay for the cost of UNITE HERE HEALTH’s Dependent Coverage.
As long as you enroll within 60 days and start making any required co-premiums, if you get
married or the other coverage terminates (including coverage for Medicaid or a CHIP plan), or
become eligible for state financial assistance under a Medicaid or a CHIP, coverage for you and/
or your dependents starts the first day of the month following that date.
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Plan 185
As long as you enroll within 60 days and start making any required co-premiums, if your child
is born, if you adopt a child, if a child is placed with you for adoption, or if a dependent comes
to the United States to take up residence with you, coverage for you and/or your dependents
starts on the date the child meets the definition of a dependent, or the date the child comes to the
United States to take up residence with you.
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Plan 185
Termination of coverage
Learn:
ӹӹ When your coverage and your dependents’ coverage ends.
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Plan 185
Your and your dependents’ coverage continues as long as you maintain your eligibility as described on page E-6 and you make any required payments for your share of your coverage
(called a “co-premium”). However, your coverage ends if one of the events described below happens. If your coverage terminates, you may be eligible to make self-payments to continue your
coverage (called COBRA continuation coverage). See page E-20.
If you (the employee) are absent from covered employment because of uniformed service, you
may elect to continue healthcare coverage under the Plan for yourself and your dependents
for up to 24 months from the date on which your absence due to uniformed service begins.
For more information, including the effect of this election on your COBRA rights, contact
UNITE HERE HEALTH at (855) 405-FUND (3863).
When employee coverage ends
Your (the employee’s) coverage ends on the earliest of any of the following dates:
E
• The date the Plan is terminated.
• The child’s handicap began before age 19; and
• The child was covered by the Plan on the day prior to his or her 19th birthday.
You must provide proof of the mental or physical handicap within 30 days after the date coverage
would end because of the child reaching age 26. You may also have to provide proof of the handicap periodically. (Special rules apply to children with a mental or physical handicap when a new
employer begins participation in the Hospitality Plan.) Contact the Fund for more information on
how to continue coverage for a child with a serious handicap.
Certificate of creditable coverage
You may request a certificate of creditable coverage within the 24 months immediately following
the date your or your dependents’ coverage ends. The certificate shows the persons covered by the
Plan and the length of coverage applicable to each. However, the Fund will not automatically send
you a certificate of creditable coverage. Contact the Fund when you have questions about certificates of creditable coverage.
E
• The last day of the month for which your employer was required to make a contribution on
your behalf. For example, if your employer’s last required contribution on your behalf was
for March, your coverage continues through the end of March.
• The last day of the month for which you last made a timely self-payment, if allowed to do so.
Special termination rules
Your coverage under the Plan will end if any of the following happens:
See page E-13 for special rules that apply if your employer’s CBA expires.
If: Your employer is no longer required to contribute because of decertification, disclaimer of
interest by the Union, or a change in your collective bargaining representative,
When dependent coverage ends
Then: Your coverage ends on the last day of the last month in which the decertification is determined to have occurred. If there is a change in your collective bargaining representative, your
coverage ends on the last day of the month for which your employer is required to contribute.
Dependent coverage ends on the earliest of any of the following dates:
• The date the Plan is terminated.
• Your (the employee’s) coverage ends.
• The dependent enters any branch of the uniformed services.
• The last day of the month for which you made a timely self-payment, if allowed to do so.
If: Your employer’s Collective Bargaining Agreement expires, a new Collective Bargaining
Agreement is not established during the 12-month period immediately following the CBA’s
expiration, and your employer does not make the required contributions to UNITE HERE
HEALTH,
Then: Your coverage ends no later than the last day of the month following the month in which
your employer’s contribution was due but was not made.
• The last day of the month in which your dependent no longer meets the Plan’s definition of
a dependent.
E-12
If your child is age 26 or older, his or her coverage may continue. In order to continue coverage,
the child must have been diagnosed with a physical or mental handicap, must not be able to
support himself or herself, and must continue to depend on you for support. Coverage for the
disabled child will continue as long as:
E-13
• You (the employee) remain eligible;
Plan 185
Plan 185
If: Your employer’s Collective Bargaining Agreement expires, a new Collective Bargaining
Agreement is not established, and your employer continues making the required contributions
to UNITE HERE HEALTH,
Then: Your coverage ends on the last day of the 12th month after the Collective Bargaining
Agreement expires.
If: Your employer withdraws in whole or in part from UNITE HERE HEALTH,
Then: Your coverage ends on the last day of the month for which your employer is required to
contribute to UNITE HERE HEALTH.
You should always stay informed about your union’s negotiations and how these negotiations may
affect your eligibility for benefits.
The effect of severely delinquent employer contributions
E
The Trustees may terminate eligibility for employees of an employer whose contributions to the
Fund are severely delinquent. Coverage for affected employees will terminate as of the last day of
the coverage period corresponding to the last work period for which the Fund grants eligibility by
processing the employer’s work report. The work report reflects an employee’s work history, which
allows the Fund to determine his or her eligibility.
The Trustees have the sole authority to determine when an employer’s contributions are severely
delinquent. However, because participants generally have no knowledge about the status of their
employer’s contributions to the Fund, participants will be given advance notice of the planned
termination of coverage.
Limited retroactive terminations of coverage allowed
Your coverage under the Plan may not be terminated retroactively (this is called a rescission of
coverage) except in the case of fraud or an intentional misrepresentation of material fact. In this
case, the Plan will provide at least 30 days advance notice before retroactively terminating coverage, and you will have the right to file an appeal.
If the Plan terminates coverage on a prospective basis, the prospective termination of coverage
(termination scheduled to occur in the future) is not a rescission. Additionally, the Plan may
retroactively terminate coverage in any of the following circumstances, and the termination is not
considered a rescission of coverage:
• Failure to make contributions or payments towards the cost of coverage, including COBRA
E-14
continuation coverage, when those payments are due.
• Untimely notice of death or divorce.
• As otherwise permitted by law.
Plan 185
Re-establishing eligibility
Learn:
ӹӹ How you can re-establish your and your dependents eligibility.
ӹӹ Special rules apply if you are on a leave of absence due to a call to
active military duty.
ӹӹ Special rules apply if you are on a leave of absence due to the Family
Medical Leave Act.
Re-establishing employee coverage
If you lose eligibility, and your loss of eligibility is less than 12 months, you can re-establish your
eligibility by satisfying the Plan’s continuing eligibility rules (see page G-5). If your loss of eligibility lasts for 12 months or more you must again satisfy the Plan’s initial eligibility rules (as of
the date this SPD was printed, the initial eligibility rules are the same as the continuing eligibility
rules). If you lose eligibility because of a leave of absence under the Uniformed Services Employment and Reemployment Rights Act, other rules apply.
Re-establishing dependent coverage
If you remain eligible but your dependents’ coverage terminates because you stop making the
required payments, you will not be able to re-enroll your dependents until the next special enrollment period or the next open enrollment period (see page E-8), whichever happens first.
However, if you stop making payments for your dependents’ coverage because you lose eligibility,
your dependents’ coverage will be re-established as follows:
E
Uniformed Services Employment and Reemployment Rights Act (USERRA)
leaves of absence
For losses of eligibility due to leaves of absence under USERRA, your dependents’ coverage will
be reestablished immediately upon your return to covered employment, as long as you also start
making any required payments for dependent coverage at the same time.
Family Medical Leave Act (FMLA) leaves of absence
For losses of eligibility due to a leave of absence under FMLA, your dependents’ coverage will be
reestablished on the first day of the month for which you once again begin making payroll deductions for dependent coverage, as long as your payroll deductions begin as soon as you return to
covered employment.
Loss of eligibility other than termination of employment
For losses of eligibility for reasons other than termination of your employment, your dependents’
coverage will be re-established on the first day of the month for which you once again begin making payroll deductions for dependent coverage, as long as your payroll deductions begin immediately upon your return to covered employment.
E-16
Plan 185
Portability
If you are covered by one UNITE HERE HEALTH Plan Unit when your employment ends but
you start working for an employer participating in another UNITE HERE HEALTH Plan Unit
within 90 days of your termination of employment with the original employer, you will become
eligible under the new Plan Unit on the first day of the month for which your new employer is
required to make contributions on your behalf.
• In order to qualify under this rule, within 60 days after you begin working for your new
employer, you, the union, or the new employer must send written notice to the Services and
Operations Department of UNITE HERE HEALTH stating that your eligibility should be
provided under the portability rules. Your eligibility under the new Plan Unit will be based
on that Plan Unit’s rules to determine eligibility for the employees of new contributing
employers (immediate eligibility).
• If written notice is not provided within 60 days after you begin working for your new
employer, your eligibility under the new Plan Unit will be based on that Plan Unit’s rules to
determine eligibility for the employees of current contributing employers.
Family and Medical Leave Act (FMLA)
E
✓✓ Eligibility will be continued for you and your dependents during your leave of absence
under the Family and Medical Leave Act (FMLA).
If you are making payments for dependent coverage when FMLA leave begins, you can maintain
your and your dependents’ coverage during the leave by making the required payments for dependent coverage to your employer. If you stop making payments, your dependents’ coverage will
terminate. Your dependents will become eligible again on the first day of the month for which
your employer is required to make a contribution on your behalf after your return to work, as
long as you start making self-payments for dependent coverage immediately upon your return to
work.
The effect of uniformed service
If you are honorably discharged and returning from military service (active duty, inactive duty
training, or full-time National Guard service), or from absences to determine your fitness to serve
in the military, your coverage and your dependents’ coverage will be reinstated immediately upon
your return to covered employment if all of the following are met:
• You provide your employer with advance notice of your absence, whenever possible.
• Your cumulative length of absence for “eligible service” is not more than 5 years.
E-17
Plan 185
• You report or submit an application for re-employment within the following time limits:
ӹӹ For service of less than 31 days or for an absence of any length to determine your
fitness for uniformed service, you must report by the first regularly scheduled work
period after the completion of service PLUS a reasonable allowance for time and travel
(8 hours).
ӹӹ For service of more than 30 days but less than 181 days, you must submit an application
no later than 14 days following the completion of service.
ӹӹ For service of more than 180 days, you must return to work or submit an application to
return to work no later than 90 days following the completion of service.
However, if your service ends and you are hospitalized or convalescing from an injury or sickness
that began during your uniformed service, you must report or submit an application, whichever
is required, at the end of the period necessary for recovery. Generally the period of recovery may
not exceed 2 years.
E
No waiting periods will be imposed on reinstated coverage, and upon reinstatement coverage
shall be deemed to have been continuous for all Plan purposes.
✓✓ Your rights to reinstate coverage are governed by The Uniformed Services Employment
and Reemployment Rights Act of 1994 (USERRA). If you have any questions, or if you
need more information, contact the Fund.
COBRA continuation coverage
Learn:
ӹӹ How you can make self-payments to continue your coverage.
E-18
Plan 185
COBRA continuation coverage is not automatic. It must be elected and the required premiums
must be paid when due. A premium will be charged under COBRA as allowed by federal law.
If you or your dependents lose coverage under the Plan, you have the right in certain situations to
temporarily continue coverage beyond the date it would otherwise end. This right is guaranteed
under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA).
Who can elect COBRA continuation coverage?
Only qualified beneficiaries are entitled to COBRA continuation coverage, and each qualified
beneficiary has the right to make an election.
You or your dependent is a qualified beneficiary if you or your dependent loses coverage due to
a qualifying event and you or your dependent were covered by the Plan on the day before the
earliest qualifying event occurs. However, a child born to, or placed for adoption with, you (the
employee) while you have COBRA continuation coverage is also a qualified beneficiary.
E
If you want to continue dependent coverage or add a new dependent after you elect COBRA continuation coverage, you may do so in the same way as active employees do under the Plan.
What is a qualifying event?
A qualifying event is any of the following events if it would result in a loss of coverage:
• Your death.
• Your loss of eligibility due to:
ӹӹ Termination of your employment (except for gross misconduct).
ӹӹ A reduction in your work hours below the minimum required to maintain eligibility.
• The last day of a leave of absence under FMLA if you don’t return to work at the end of that
leave.
• Divorce or legal separation from your spouse.
• A child no longer meeting the Plan’s definition of dependent (see page E-2).
• Your coverage under Medicare. (Medicare coverage means you are eligible to receive
coverage under Medicare; you have applied or enrolled for that coverage, if an application is
necessary; and your Medicare coverage is effective.)
E-20
• Your employer withdraws from UNITE HERE HEALTH.
What coverage can be continued?
By electing COBRA continuation coverage, you have the same benefit options and can continue
the same healthcare coverage available to other employees who have not had a qualifying event.
Your COBRA coverage options are based on which benefit options you had on the day before the
qualifying event. For example, if you had declined medical benefits but opted to take dental and
vision benefits, your COBRA coverage options will not include medical benefits.
In addition to medical benefits, COBRA continuation coverage includes prescription drug benefits, vision benefits (if you had vision benefits on the day before the qualifying event), and dental
benefits (if you had dental benefits on the day before the qualifying event). Life and AD&D and
short-term disability benefits cannot be continued. However, you may be able to convert your life
insurance to an individual policy. Contact the Fund for more information.
How long can coverage be continued?
E
The maximum period of time for which you can continue your coverage under COBRA depends
upon the type of qualifying event and when it occurs:
• Coverage can be continued for up to 18 months from the date coverage would have
otherwise ended, when:
ӹӹ Your employment ends.
ӹӹ Your work hours are reduced below the minimum required to maintain eligibility.
ӹӹ You fail to make voluntary self-payments.
ӹӹ Your ability to make self-payments ends.
ӹӹ You fail to return to employment from a leave of absence under FMLA.
ӹӹ Your employer withdraws from UNITE HERE HEALTH.
However, you may be able to continue coverage for yourself and your dependents for up
to an additional 11 months, for a total of 29 months. The Social Security Administration
must determine that you or a covered dependent are disabled according to the terms of
the Social Security Act of 1965 (as amended) any time during the first 60 days of continuation coverage.
• Up to 36 months from the date coverage would have originally ended for all other
qualifying events, as long as those qualifying events would have resulted in a loss of
coverage despite the occurrence of any previous qualifying event.
However, the following rules determine maximum periods of coverage when multiple qualifying
events occur:
E-21
• Qualifying events shall be considered in the order in which they occur.
Plan 185
Plan 185
• If additional qualifying events, other than your coverage by Medicare, occur during an
• For divorce or legal separation: spouse’s name, Social Security number, address, telephone
• If you are covered by Medicare and subsequently experience a qualifying event,
• For a dependent child’s loss of eligibility: the name, Social Security number, address,
18-month or 29-month continuation period, affected qualified beneficiaries may continue
their coverage up to 36 months from the date coverage would have originally ended.
continuation coverage for your dependents can only be continued for up to 36 months from
the date you were covered by Medicare.
• If continuation coverage ends because you subsequently become covered by Medicare,
continuation coverage for your dependents can only be continued for up to 36 months from
the date coverage would have originally ended.
These rules only apply to persons who were qualified beneficiaries as the result of the first qualifying event and who are still qualified beneficiaries at the time of the second qualifying event.
Notifying UNITE HERE HEALTH when qualifying events
occur
E
Your employer must notify UNITE HERE HEALTH of your death, termination of employment, reduction in hours, or failure to return to work at the end of a FMLA leave of absence.
UNITE HERE HEALTH uses its own records to determine when a participant’s coverage under
the Plan ends.
You or a dependent must inform UNITE HERE HEALTH within 60 days of the following:
• Your divorce or legal separation.
• The date your child no longer qualifies as a dependent under the Plan.
• The occurrence of a second qualifying event.
E-22
Plan 185
number, date of birth, and a copy of one of the following: a divorce decree or legal
separation agreement.
telephone number, date of birth of the child, date on which the child no longer qualified as
a dependent under the plan; and the reason for the loss of eligibility (i.e., age, or ceasing to
meet the definition of a dependent).
• For your death: the date of death, the name, Social Security number, address, telephone
number, date of birth of the eligible dependent, and a copy of the death certificate.
• For your or your dependent’s disability status: the disabled person’s name, the date on
which the disability began or ended, and a copy of the Social Security Administration’s
determination of disability status.
If you or your dependent does not provide the required notice and documentation, you or your
dependent will lose the right to elect COBRA continuation coverage.
In order to protect your family’s rights, you should keep the Fund informed of any changes in the
addresses of family members. You should also keep a copy, for your records, of any notices you
send to the Fund or that the Fund sends you.
Election and payment deadlines
COBRA continuation coverage is not automatic. You must elect COBRA continuation coverage,
and you must pay the required payments when they are due.
When the Fund gets notice of a qualifying event, it will determine if you or your dependents are
entitled to COBRA continuation coverage.
You must inform the Fund before the end of the initial 18 months of continuation coverage if
Social Security determines you to be disabled. You must also inform the Fund within 30 days of
the date you are no longer considered disabled by Social Security. You can inform the Fund by
contacting the Fund.
• If you or your dependents are not entitled to COBRA continuation coverage, you or your
You should use UNITE HERE HEALTH’s forms to provide notice of any qualifying event, if you
or a dependent are determined by the Social Security Administration to be disabled, or if you are
no longer disabled. You can get a form by calling the Fund.
• If you or your dependents are entitled to COBRA continuation coverage, you or the
If you don’t use UNITE HERE HEALTH’s forms to provide the required notice, you must submit information describing the qualifying event, including your name, Social Security number,
address, telephone number, date of birth, and your relationship to the qualified beneficiary, to
UNITE HERE HEALTH in writing. Be sure you sign and date your submission.
However, regardless of the method you use to notify the Fund, you must also include the additional information described below, depending on the event that you are reporting:
E
dependent will be mailed a notice that COBRA continuation coverage is not available
within 14 days after UNITE HERE HEALTH has been notified of the qualifying event. The
notice will explain why COBRA continuation coverage is not available.
dependent will be mailed a description of your COBRA continuation coverage rights and
the applicable election forms. The description of COBRA continuation coverage rights
and the election forms will be mailed within 45 days after UNITE HERE HEALTH has
been notified of the qualifying event. These materials will be mailed to those entitled to
continuation coverage at the last known address on file.
If you or your dependents want COBRA continuation coverage, the completed election form must
be mailed to UNITE HERE HEALTH within 60 days from the earliest of the following dates:
E-23
• The date coverage under the Plan would otherwise end.
Plan 185
• The date the Fund sends the election form and a description of the Plan’s COBRA
continuation coverage rights and procedures, whichever occurs later.
If your or your dependents’ election form is received within the 60-day election period, you or
your dependents will be sent a premium notice showing the amount owed for COBRA continuation coverage. The amount charged for COBRA continuation coverage will not be more than the
amount allowed by federal law.
• The date coverage begins under any other group health plan.
If termination of continuation coverage ends for any of the reasons listed above, you will be
mailed an early termination notice shortly after coverage terminates. The notice will specify the
date coverage ended and the reason why.
• UNITE HERE HEALTH must receive the first payment within 45 days after the date it
To get more information
• After the first payment, additional payments are due on the first day of each month for
For more information about health insurance options available through a Health Insurance Marketplace, visit www.healthcare.gov.
receives your election form. The first payment must equal the premiums due from the date
coverage ended until the end of the month in which payment is being made. This means
that your first payment may be for more than one month of COBRA continuation coverage.
which coverage is to be continued. To continue coverage, each monthly payment must be
postmarked no later than 30 days after the payment is due.
If you have any questions about COBRA continuation coverage, your rights, or the Plan’s notification procedures, please call UNITE HERE HEALTH at (855) 405-FUND (3863).
Payments for COBRA continuation coverage must be made by check or money order, payable to
UNITE HERE HEALTH, and mailed to:
E
E
UNITE HERE HEALTH
Attn: Service & Operations Department
P. O. Box 6557
Aurora, IL 60598-0557
Termination of COBRA continuation coverage
COBRA continuation coverage will end when the maximum period of time for which coverage
can be continued is reached.
However, on the occurrence of any of the following, continuation coverage may end on the first to
occur of any of the following:
• The end of the month for which a premium was last paid, if you or your dependents do not
pay any required premium when due.
• The date the Plan terminates.
• The date Medicare coverage becomes effective if it begins after the person’s election of
COBRA (Medicare coverage means you are entitled to coverage under Medicare; you
have applied or enrolled for that coverage, if application is necessary; and your Medicare
coverage is effective).
E-24
• The date the Plan’s eligibility requirements are once again satisfied.
• The end of the month occurring 30 days after the date disability under the Social Security
E-25
Act ends, if that date occurs after the first 18 months of continuation coverage have expired.
Plan 185
Plan 185
Claim filing and
appeal provisions
Learn:
ӹӹ How to file a claim.
ӹӹ How to appeal a denied claim.
E-26
Plan 185
Claim filing and appeal provisions
Neither you, your beneficiary, nor any other claimant may commence a lawsuit against the Plan
(or its Trustees, providers or staff) for benefits denied until the Plan’s internal appeal procedures
have been exhausted. The internal appeal procedures do not include your right to an external
review by an independent review organization (”IRO”) under the Affordable Care Act.
If you finish all internal appeals and decide to file a lawsuit against the Plan, that lawsuit must be
commenced no more than 12 months after the date of the appeal denial letter. If you fail to commence your lawsuit within this 12-month time frame, you will permanently and irrevocably lose
your right to challenge the denial in court or in any other manner or forum. This 12-month rule
applies to you and to your beneficiaries and any other person or entity making a claim on your
behalf.
Non-assignment of claims
You may not assign your claim for benefits under the Plan to a non-network provider without the
Plan’s express written consent. A non-network provider is any doctor, hospital or other provider
that is not in a PPO or similar network of the Plan.
This rule applies to all non-network providers, and providers are not permitted to change this
rule or make exceptions on their own. If you sign an assignment with a provider without the
Plan’s written consent, it will not be valid or enforceable against the Plan. This means that a
non-network provider will not be entitled to payment directly from the Plan and that you may be
responsible for paying the provider on your own and then seeking reimbursement for a portion of
the charges under the Plan rules.
F
Plan 185
• Your Social Security number.
• A description of the injury, sickness, symptoms, or other condition upon which your claim
is based.
A claim for healthcare benefits should include any of the following information that applies:
• Diagnoses.
• Dates of service(s).
• Identification of the specific service(s) furnished.
• Charges incurred for each service(s).
• Name and address of the provider.
• When applicable, your dependent’s name, Social Security number, and your relationship to
the patient.
All claims for benefits must be made as shown below. If you need help filing a claim, contact the
Fund at (855) 405-FUND (3863).
See page F-9 for rules on filing dental, vision, and life insurance appeals.
F
Healthcare claims
Network providers will generally file the claim for you. However, if you need to file a claim for
hospital, medical, or surgical treatment (for example because you used a non-network provider),
you should send it to:
Regardless of this prohibition on assignment, the Plan may, in its sole discretion and under certain limited circumstances, elect to pay a non-network provider directly for covered services rendered to you. Payment to a non-network provider in any one case shall not constitute a waiver of
any of the Plan’s rules regarding non-network providers, and the Plan reserves of all of its rights
and defenses in that regard.
Prescription drug claims
Filing claims
(other than dental, vision, or life/AD&D insurance)
If you use a participating pharmacy, the pharmacy should file a claim for you. No benefits are
payable if you use a pharmacy that does not participate in the pharmacy network. However, if
you need to file a claim for a prescription drug purchased at a participating pharmacy, you should
send it to:
This section and the next section describe the steps you can take if your claim for benefits is
denied, in whole or in part. It’s important that you review the time limits for filing claims and
appeals and make sure you meet them.
F-2
In all cases, your claim for benefits must include all of the following information:
• Your name.
Blue Cross and Blue Shield of Illinois
P.O. Box 805107
Chicago, Illinois 60680-4112
UNITE HERE HEALTH
Attn: HospitalityRx
P.O. Box 6020
Aurora, IL 60598-0020
F-3
Plan 185
All other benefit claims
All short-term disability claims, and any claims for any services or supplies denied because you
are not eligible or because you missed a payment or application deadline, should be mailed to:
UNITE HERE HEALTH
P.O. Box 6020
Aurora, IL 60598-0020
The time limits above are different for different types of claims, as explained here:
• Urgent claim is a pre-service claim where any delay could seriously jeopardize the patient’s
life, health, or ability of the claimant to regain maximum bodily function or cause severe
pain, and the claim indicates the claim is urgent.
• Pre-service claim is a claim for benefits before treatment, but only when the Plan requires
Deadline for filing claims
Only those benefit claims that are filed in a timely manner will be considered for payment.
Claims for short-term disability benefits and healthcare benefits, including medical/surgical
claims, mental health/substance abuse claims, and prescription drug claims, must be filed no later
than 18 months after the date of service.
For claims filed after the time limits shown above to be accepted by the Plan, there must be a
demonstration that the claim could not have been filed within the time limits.
Who may file a benefit claims
You, your health care provider, or your authorized representative may file a claim. A spouse or
certain other representatives can act for you if you are incapable of doing so for health reasons.
Except for an urgent care claim, you must sign a form acceptable to the Fund stating who you
want to file the claim for you. You can call the Fund to get this form.
F
For on-going treatment, your claim will be decided before ending your course of treatment or
within 24 hours when your request to extend on-going treatment is denied.
prior authorization.
• Post-service claims are claims made after treatment.
• Disability claims are requests for benefits where the plan must make a determination of
disability to decide the claim
• On-going (concurrent) treatment claims happen when your course of treatment is reduced
or ended by the Plan, or your request to extend treatment is denied, and it will be treated as
post-service, pre-service or urgent (as the case may be) except as indicated.
Claim denials
If your claim is denied, you will receive written notice explaining why, instructions on how to file
an appeal, and other necessary information.
F
Appeal forms are available at the regional offices and on the Fund’s website: www.uhh.org.
Incomplete claims
If the Plan receives a claim that’s missing information or not filed correctly, the Plan will let you
know what else is needed within 24 hours for urgent claims, within 5 days for other pre-service
claims, and within the time limits described below for post-service or disability claims. Keep in
mind that the time limits for deciding a claim or appeal (in this section or the next) are extended
during any time the Plan is waiting for additional information requested from you. You will always have at least 45 days (48 hours for urgent claims) to provide the requested information.
When will your claim be decided?
F-4
Plan 185
Urgent
Pre-Service Claims
Post-Service Claims
Disability Claims
within 72 hours
15 days
30 days
45 days
(or 48 hours after
requested missing
information is
received)
(plus 15 more days if the
Plan notifies you of the
need for the additional
time)
(plus 15 more days if the Plan
notifies you of the need for
additional time)
(plus 30 more days if the
Plan notifies you of the
need for additional time;
the Plan can also take a
second 30-day extension)
Filing appeals
(other than dental, vision, and life/AD&D insurance)
If your claim for a service or supply is denied in whole or in part, you may file an appeal. An
appeal may be for any service or supply the Plan does not cover completely, such as a claim processed at non-PPO rates, a claim denial for a benefit that is not covered under the Plan, a denial of
eligibility, or a denial because the care did not meet the Plan’s utilization management guidelines.
All appeals must be in writing (except for appeals involving urgent care), signed, and should
include the claimant’s name, address, and date of birth, and your (the employee’s) Social Security
number. You should also provide any documents or records that support your claim. If you are
appealing a denial of benefits that qualifies as a request for urgent or emergency care, you can
orally request an expedited (accelerated) appeal of the denial by calling (855) 405-FUND (3863).
All necessary information may be sent by telephone, facsimile or any other available reasonably
effective method.
See page F-9 for rules on filing dental, vision, and life insurance appeals.
F-5
Plan 185
Two levels of appeal for prior authorization denials made by Nevada Health
Solutions
First level of appeal. If the claim is for a denial made by Nevada Health Solutions through the
prior authorization program (See page B-2), the claim has two levels of appeal. Claims with
two levels of appeal include medical/surgical or mental health/substance abuse claims that were
denied when you asked for prior authorization; claims for which you should have gotten prior
authorization but didn’t; and extensions of treatment beyond limits that were already approved
through prior authorization.
One level of appeal for most other claims
If you disagree with all or any part of a short-term disability claim or healthcare claim denial, and
you wish to appeal the decision, you must follow the steps in this section. (For steps on appealing
a prior authorization denial by Nevada Health Solutions, see page F-6. For steps on appealing a
prescription drug denial, see page F-6.) You must submit an appeal within 12 months of the date
the short-term disability or healthcare claim was denied to:
The Appeals Subcommittee
UNITE HERE HEALTH
711 N. Commons Drive
Aurora, Illinois 60504
The first appeal of a prior authorization denial must be sent within 180 days of the date on the
Nevada Health Solutions’ denial letter to:
Attn: Appeals Department
P.O. Box 61440
Las Vegas NV 89160
Second level of appeal. If all or any part of the original denial is upheld (meaning that the claim
is still denied, in whole or in part, after your first appeal) and you still think the claim should be
paid, you or your authorized representative must submit a second appeal of a prior authorization
denial within 45 days of the date the first level denial was upheld to:
F
UNITE HERE HEALTH
Two levels of appeals for prescription drug denials made by HospitalityRx
First level of appeal. If a prescription drug claim, including a prior authorization claim, is denied, the claim has two levels of appeals.
The first appeal of a prescription drug claim denial must be sent within 180 days of the date on
HopsitalityRx’s denial letter to:
UNITE HERE HEALTH, Attn: HospitalityRx
P.O. Box 6020
Aurora, IL 60598-0020
Second level of appeal. If all or any part of the original denial is upheld (meaning that the claim
is still denied, in whole or in part, after your first appeal) and you still think the claim should be
paid, you or your authorized representative must submit a second appeal within 45 days of the
date the first level denial was upheld to:
F-6
Plan 185
UNITE HERE HEALTH
The Appeals Subcommittee will not enforce the 12-month filing limit when:
• You could not reasonably file the appeal within the 12-month filing limit because of:
ӹӹ Circumstances beyond your control, as long as you file the appeal as soon as reasonably
possible.
ӹӹ Circumstances in which the claim was not processed according to the Plan’s claim
processing requirements.
• The Appeals Subcommittee would have overturned the original benefit denial based on its
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standard practices and policies.
One level of appeal for late payments or late applications for coverage
The Trustees have given the Plan Administrator sole and final authority to decide all appeals for
late payments or late applications. These appeals are for:
• UNITE HERE HEALTH’s refusal to accept self-payments made after the due date.
• Late COBRA payments and applications to continue coverage under the COBRA provisions.
• Late applications, including late applications to enroll for dependent coverage.
You must submit your appeal within 12 months of the date the late self-payment or late application was refused. Send your written application for appeal to:
The Plan Administrator
UNITE HERE HEALTH
Aurora, Illinois 60504-4197
What are your appeal rights?
During an appeal, you have the right to review certain Plan records that apply to your appeal
and to provide additional records and information to the Plan. All relevant information will be
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reviewed. In certain cases, outside healthcare professionals will be consulted. All appeal denials
will explain why the appeal was denied and provide other specific information, including relevant
medical explanations and your right to file a lawsuit against the Plan.
to the Plan and the eligible person. If the healthcare professional files the request on behalf of the
patient, then the healthcare professional would be notified as well. The Plan will provide denial
letters with the specific reason for the denial and the contact information for the HHS Office of
Consumer Assistance.
When will your appeal be decided?
Urgent
Pre-Service Claims
Post-Service Claims
Disability Claims
within 72 hours
30 days
60 days
45 days
When there are two levels of appeal, the times listed in the table above are divided in half for each
of the two appeal stages. (For example, Nevada Health Solutions has 30 days to review a post-service claim, and the Fund has the remaining 30 days.)
Claimants in certain situations may request an expedited independent external review if:
• The claimant receives an adverse benefit determination involving urgent care and claimant
has filed for an expedited internal review; or
• The claimant
receives a final internal adverse benefit determination where:
ӹӹ The time frame for the completion of a standard external review (45 days) would
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Filing dental, vision, and life/AD&D insurance claims and
appeals
The rules for filing and appealing claim denials for dental or vision care and life/AD&D insurance are governed by the Fund’s contracts with Cigna,VSP, and Dearborn National, and so are
different from the other claims and appeals rules.
Dental claims
Generally you do not need to file a claim for dental care. Cigna providers will file the claim on
your behalf. No benefits are generally available if you use a non-network dentist, except in an
emergency. If you do need to file a claim for dental care, you can get a claim form from Cigna by
calling (800) 244-6224 or visiting www.mycigna.com. You will need to provide all information
Cigna needs to process the claim. Claims can be mailed to:
Cigna
P.O. Box 188037
Chattanooga, TN 37422-8037
seriously jeopardize the life or health of the claimant or would jeopardize the
claimant’s ability to regain maximum function, or
ӹӹ The determination concerns an admission, availability of care, continued stay, or
health care items or services for a condition for which the claimant received emergency
services, but has not been discharged from a facility.
External appeals (independent review organization)
An external review is only available for appeals involving rescission or a medical judgment including medical necessity, level of care, or a determination as to whether a treatment or procedure
is experimental or investigational. When an eligible person initiates an external appeal request
with an Independent Review Organization (IRO), the Plan will provide the claim information,
Plan exclusion and coverage criteria documentation, and clinical review criteria to the IRO. This
external appeal request must be made within four months after the final internal appeal decision.
External appeal requests will be assigned and rotated to one of at least three IROs in succession to
avoid selection bias. The IRO will convey a final decision to the Plan within 45 days for standard
reviews and within 72 hours for expedited reviews. Expedited reviews are permitted when standard review time frames would seriously jeopardize the life or health of the person.
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If the IRO reverses the Plan’s adverse redetermination decision, then the Plan will provide coverage and/or payment of the claim within twenty-four hours of notification of the IRO decision. If
the IRO upholds the adverse redetermination decision, the IRO will communicate the decision
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Contact Cigna or refer to your Cigna plan booklet/certificate of coverage for more information
about how to file a claim, the claim processing rules, time limits, and appeal procedures. Contact
Cigna if you need a plan booklet/certificate of coverage, if you need help filing a claim or appeal,
or if you have questions about the dental claim and appeal process.
Vision claims
Generally, if you use a VSP provider, you do not need to file a claim for vision care because VSP
providers will file the claim on your behalf. However, you will need to file a claim if you use a
provider who is not in the VSP network. If you need to file a claim for vision care, you can get a
claim form from VSP by calling (800) 852-7600 or visiting www.vsp.com. You will need to provide all information VSP needs to process the claim. Fill out the claim form and send it, within
365 days of the date services or supplies were provided, to:
VSP
3333 Quality Drive
Rancho Cordova, CA 95670
The claim processing rules, time limits, and appeal procedures VSP must follow are described in
the VSP contract. Generally, if a claim is denied, you must request a review within 180 days of the
denial. VSP will respond to your appeal within 30 days. If you appeal the first-level appeal, you
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can file a second-level appeal within 60 days of VSP’s decision on your first-level appeal. VSP will
generally respond to your second-level appeal within 30 days. If you need help filing a claim or
appeal, or have questions about how VSP’s claim and appeal process works, contact VSP.
Life and AD&D insurance claims
Contact UNITE HERE HEALTH to file a claim for benefits:
UNITE HERE HEALTH
P.O. Box 6020
Aurora, IL 60598-0020
(855) 405-FUND (3863)
After you have contacted the Fund about an employee’s death, Dearborn National will contact
you to complete the claim filing process.
• No filing deadlines apply to claims for life benefits.
• A claim for life or AD&D insurance benefits must include a certified copy of the death
certificate.
Definitions
• For AD&D claims, Dearborn National must receive written notice of your covered AD&D
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loss within 31 days of the loss, or as soon as reasonably possible. Dearborn National must
receive written proof of your loss within 90 days of the loss, or as soon as reasonably
possible. Generally, Dearborn will not pay for claims submitted more than one year after
the proof is due. However, Dearborn may extend this claim filing deadline. Other deadlines
may apply to your additional AD&D insurance benefits—your certificate of coverage
provides more information.
The claim processing rules, time limits, and appeal procedures Dearborn must follow are described in the contract with Dearborn. Generally, Dearborn will respond to your claim within
90 days (but Dearborn may request a 90-day extension). You can file an appeal within 60 days
of Dearborn’s decision. Dearborn will generally respond to your appeal within 60 days (but may
request a 60-day extension). If you have questions about how Dearborn’s claim and appeal process
works, contact Dearborn at (800) 348-4512.
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Learn:
ӹӹ Definitions of some of the terms the Plan uses.
Call the Fund if you aren’t sure what a word or phrase means.
Definitions
Allowable charges
An allowable charge is the amount of charges for covered treatments, services, or supplies that
the Plan uses to calculate the benefits it pays for a claim. The allowable charge may be less than
the provider’s actual charges. This usually happens if you choose a non-network provider. You
must pay any difference between the provider’s actual charges and the allowable charges. Any
charges that are more than the allowable charge are not covered. The Plan will not pay benefits for
charges that are more than the allowable charge.
The Board of Trustees has the sole authority to determine the level of allowable charges the Plan
will use. In all cases the Trustees’ determination will be final and binding.
• Allowable charges for services furnished by network providers are based on the rates
specified in the contract between UNITE HERE HEALTH and the provider network.
Providers in the network usually offer discounted rates to you and your family. This means
lower out-of-pocket costs for you and your family.
Definitions
allowable charge for the service. You pay your coinsurance plus any deductibles or copays. For
example, if the allowable charge for network durable medical equipment is $100, your 25% coinsurance equals $25. (Under the Silver Plan, this assumes you have met your $1,500 deductible.)
Your coinsurance counts toward your out-of-pocket limits.
Cosmetic or reconstructive surgery
Cosmetic or reconstructive surgery is any surgery intended mainly to improve physical appearance or to change appearance or the form of the body without fixing a bodily malfunction. Cosmetic or reconstructive surgery includes surgery to prevent or treat a mental health or substance
abuse disorder by changing the body.
Mastectomies, and reconstruction following a mastectomy, will not be considered cosmetic or
reconstructive surgery (see page C-9).
• Treatment by a non-network provider means you pay more out-of-pocket costs. The Plan
calculates benefits for non-network providers based on established discounted rates, like
the BCBSIL rate. The Plan will not pay the difference between what a non-network provider
actually charges, and what the Plan considers an allowable charge. You pay this difference
in cost. (This is sometimes called “balance billing.”)
The allowable charge for dental benefits will be determined by Cigna. The allowable charge for
vision benefits will be determined by VSP. This definition does not apply to benefits provided
through Cigna or VSP.
Covered expense
A treatment, service or supply for which benefits are paid under the Plan. Covered expenses are
limited to the allowable charge.
Deductible
The amount you owe for covered expenses before the Fund begins paying benefits.
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Copay or copayment
A fixed amount (for example, $10) you pay for a covered health care service, usually when you
receive the service. The amount can vary by the type of covered health care service. Usually, once
you have paid your copay, the Plan pays the rest of the covered expenses.
For example, under the Gold Plan, each time you go to your network PCP, a $20 copay applies.
Each time you go to the emergency room, a $150 copay applies. Under the Silver Plan, each time
you go to your network PCP, a $25 copay applies. Each time you go to the emergency room, a
$200 copay applies.
Your copayments count toward your out-of-pocket limits.
You can get more information about your medical, prescription drug, dental, or vision copays in
the appropriate section of this SPD. (See the beginning of the SPD for the table of contents.)
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Coinsurance
Your share of the costs of a covered expense, calculated as a percent (for example, 20%) of the
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For example, under the Silver Plan, the Fund will not start paying medical benefits on your behalf
until you meet your $1,500 individual deductible. Your deductible applies to both network and
non-network expenses. You only have to pay the deductible once each year. Once you have paid
your deductible (sometimes called “satisfying your deductible”), you do not have to make any
more payments toward your deductible for the rest of that year. The same rule applies if two or
more members of your family satisfy the $3,000 family deductible. Once your family deductible
has been satisfied, no one else in your family has to pay deductibles for the rest of that year.
The deductible may not apply to all services, including services that have a copay. For example,
under the Silver Plan, emergency room visits, network office visits, or network laboratory services
will be paid by the Fund before your or your family’s deductible is met.
Amounts you pay for healthcare the Plan does not cover will not count toward your deductible.
This includes but is not limited to, excluded services and supplies, charges that are more than the
allowable charge, amounts over a benefit maximum or limit, and other charges for which the Plan
does not pay benefits.
Your deductibles count toward your out-of-pocket limits.
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Definitions
You can get more information about your medical deductibles in the appropriate section of this
SPD. (See the beginning of the SPD for the table of contents.)
Durable medical equipment (DME)
Durable medical equipment (DME) must meet all of the following rules:
• Mainly treats or monitors injuries or sicknesses.
• Withstands repeated use.
• Improves your overall medical care in an outpatient setting.
• Is approved for payment under Medicare.
Some examples of DME are: wheelchairs, hospital-type beds, respirators and associated support
systems, infusion pumps, home dialysis equipment, monitoring devices, home traction units, and
other similar medical equipment or devices. The supplies needed to use DME are also considered
DME.
Experimental, investigational, or unproven (experimental or
investigational)
Experimental, investigational, or unproven procedures or supplies are those procedures or
supplies which are classified as such by agencies or subdivisions of the federal government, such
as the Food and Drug Administration (FDA) or the Office of Health Technology Assessment of
the Centers for Medicare & Medicaid Services (CMS); or according to CMS’s Medicare Coverage
Issues Manual.
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However, routine patient costs associated with clinical trials are not considered experimental,
investigational, or unproven.
The definition of experimental or investigational for dental benefits will be determined by Cigna,
and the definition of experimental or investigational for vision benefits will be determined by
VSP. This definition does not apply to benefits provided through Cigna or VSP.
Emergency medical treatment
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Emergency medical treatment means covered medical services used to treat a medical condition
displaying acute symptoms of sufficient severity (including severe pain) that an individual with
average knowledge of health and medicine could expect that not receiving immediate medical
attention could place the health of a patient, including an unborn child, in serious jeopardy or
result in serious impairment of bodily functions or bodily organs or body parts.
Definitions
Healthcare provider
A healthcare provider is any person who is licensed to practice any of the branches of medicine
and surgery by the state in which the person practices, as long as he or she is practicing within
the scope of his or her license.
A primary care provider (PCP) is defined as a provider who specializes in:
• Family medicine.
• General practice.
• Internal medicine.
• Pediatric medicine (for children).
• Obstetrics or gynecology (while you or a dependent is pregnant).
A specialist is a healthcare provider who does not practice in one of the specialties listed above.
Although an OB/GYN (or other provider specializing in obstetrics or gynecology) is not considered a PCP unless you are pregnant, the PCP copay applies to each network office visit to an OB/
GYN.
You do not need prior authorization in order to access obstetrical or gynecological care from a
network healthcare provider who specializes in obstetrics or gynecology. The healthcare provider,
however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making
referrals. For help finding participating healthcare providers who specialize in obstetrics or gynecology, contact the Fund at (855) 405-FUND (3863).
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A dentist is a healthcare provider licensed to practice dentistry or perform oral surgery in the
state in which he or she is practicing, as long as he or she practices within the scope of that license. Another type of healthcare provider may be considered a dentist if the healthcare provider
is performing a covered dental service and otherwise meets the definition of “healthcare provider.”
A provider may be an individual providing treatment, services, or supplies, or a facility (such as a
hospital or clinic) that provides treatment, services, or supplies.
Injuries and sicknesses
The Plan only pays benefits for the treatment of injuries or sicknesses that are not related to employment (non-occupational injuries or sicknesses).
Sickness also includes mental health conditions and substance abuse. For employees and spouses
only, sickness also includes pregnancy and pregnancy-related conditions, including abortion.
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Plan 185
Definitions
The Plan only pays benefits for preventive healthcare for a pregnant dependent child. Maternity
charges for a pregnant dependent child that are not preventive healthcare (See page G-7) are
not covered by the Plan. “Non-preventive maternity care” includes but is not limited to ultrasounds, care for a high-risk pregnancy, and the actual childbirth and delivery. No benefits are
payable for the child of your child (unless the child meets the Plan’s definition of a dependent—
see page E-2).
The Plan will also consider voluntary sterilization procedures for you, your spouse, and your
female children who meet the definition of a dependent, to be a sickness.
Treatment of infertility, including fertility treatments such as in-vitro fertilization or other such
procedures, is not considered a sickness or an injury.
Medically necessary
Medically necessary services, supplies, treatment are:
Definitions
Out-of-Pocket limit for network care and treatment
In order to protect you and your family, the Plan limits what you have to pay for your cost-sharing (copays, coinsurance, and deductibles) for medical care and for prescription drugs. This is
called an out-of-pocket limit. Once your out-of-pocket costs for network covered expenses meets
the out-of-pocket limit, the Plan will usually pay 100% for your (or your family’s) network covered expenses during the rest of that year.
Amounts you pay out-of-pocket for services and supplies that are not covered, such as amounts
over the allowable charges, or care or treatment once you have met a maximum benefit, do not
count toward your out-of-pocket limit. Non-network care or treatment does not count toward
your out-of-pocket limit. The Plan will not pay 100% for services or supplies that are not covered,
or that are provided by a non-network provider, even if you have met your out-of-pocket limit for
the year.
You can get more information about your medical and prescription drug out-of-pocket limits in
the appropriate section of this SPD. (See the beginning of the SPD for the table of contents.)
• Consistent with and effective for the injury or sickness being treated;
• Considered good medical practice according to standards recognized by the organized
Plan Document
• Not experimental or investigational (see page G-4), nor unproven as determined by
The rules and regulations governing the Plan of benefits provided to eligible employees and dependents participating in the Hospitality Plan.
medical community in the United States; and
appropriate governmental agencies, the organized medical community in the United States,
or standards or procedures adopted from time-to-time by the Trustees.
However, with respect to mastectomies and associated reconstructive treatment, allowable
charges for such treatment is considered medically necessary for covered expenses incurred based
on the treatment recommended by the patient’s healthcare provider, as required under federal
law.
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The Board of Trustees has the sole authority to determine whether care and treatment is medically necessary, and whether care and treatment is experimental or investigational. In all cases,
the Trustees’ determination will be final and binding. However, determinations of medical necessity and whether or not a procedure is experimental or investigative are solely for the purpose of
establishing what services or courses of treatment are covered by the Plan. All decisions regarding medical treatment are between you and your healthcare provider and should be based on all
appropriate factors, only one of which is what benefits the Plan will pay.
The definition of medically necessary for dental benefits will be determined by Cigna. The definition of medically necessary for vision benefits will be determined by VSP. This definition does not
apply to benefits provided through Cigna or VSP.
G-6
Preventive healthcare
Under the medical and prescription drug benefits, the Plan covers preventive healthcare at
100%—there is no cost to you—when you use a network provider and meet any age, risk, or frequency rules. Preventive healthcare is defined under federal law as:
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• Services rated “A” or “B” by the United States Preventive Services Task Force (USPSTF).
• Immunization recommended by the Advisory Committee on Immunization Practices of
the Center for Disease Control and Prevention.
• Preventive care and screenings for women as recommended by the Health Resources and
Services Administration.
• Preventive care and screenings for infants, children, and adolescents provided in the
comprehensive guidelines supported by the Health Resources and Services Administration.
• PSA tests (prostate-specific antigen tests) for males between ages 40 and 69.
You may need a prescription in order to get preventive healthcare under the prescription drug
benefits.
G-7
The Plan may cover certain preventive healthcare more liberally (for example, more frequently or
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Plan 185
Definitions
at earlier/later ages) than required. For example, mammograms may be covered for women under
age 40 who are at high risk for developing breast cancer.
Contact the Fund with questions about what types of preventive care is covered, and to find out if
any age, risk, or frequency limitations apply. You can also go to: https://www.healthcare.gov/preventive-care-benefits for a summary.
The list of covered preventive care changes from time to time as preventive care services and supplies are added to or taken off of the list of required preventive care. The Fund follows federal law
that determines when these changes take effect.
Other important information
Learn:
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ӹӹ Important information about UNITE HERE HEALTH and
your benefits.
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Plan 185
Who pays for your benefits?
In general, Plan benefits are provided by the money (contributions) employers participating in the
Plan must contribute on behalf of eligible employees under the terms of the Collective Bargaining
Agreements (CBAs) negotiated by your union. Plan benefits are also funded by amounts you may
be required to pay for your share of your or your dependent’s coverage.
What benefits are provided through insurance companies?
The Plan provides the medical benefits, the prescription drug benefits, and short-term disability
benefits on a self-funded basis. Self-funded means that none of these benefits are funded by insurance contracts. Benefits and associated administrative expenses are paid directly from UNITE
HERE HEALTH.
The Plan provides dental benefits, vision benefits, and life and accidental death & dismemberment
(AD&D) benefits through fully insured contracts. Dental benefits are funded and guaranteed
under a group contract with Cigna Health and Life Insurance Company (Cigna). Vision benefits
are funded and guaranteed under a group contract with Vision Service Plan (VSP). The life and
AD&D benefits are funded and guaranteed under a group contract underwritten by Dearborn
National.
The Plan also contracts with other organizations to help administer certain benefits. Prescription
drug benefits are administered by HospitalityRx, a wholly owned subsidiary of UNITE HERE
HEALTH. Prior authorization and other utilization review services, and case management for
the Plan’s medical benefits are provided by Nevada Health Solutions, a wholly owned subsidiary
of UNITE HERE HEALTH.
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Remedies for fraud
If you or a dependent submit information that you know is false or if you purposely do not submit or you conceal important information in order to get any Plan benefit, the Trustees may take
actions to remedy the fraud, including: asking for you to repay any benefits paid, denying payment of any benefits, deducting amounts paid from future benefit payments, and suspending and
revoking coverage.
Interpretation of Plan provisions
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Plan 185
For claims subject to independent external review (see page F-8), the IRO has the authority to
make decisions about benefits, and decide all questions about claims, submitted for independent
external review.
For dental benefits provided through the Cigna contact, Cigna has the authority to make decisions about benefits, and decide all questions about dental claims.
For vision benefits provided through the VSP contact, VSP has the authority to make decisions
about benefits, and decide all questions about vision claims.
All other authority rests with the Board of Trustees. The Board of Trustees of UNITE HERE
HEALTH has sole and exclusive authority to:
• Make the final decisions about applications for or entitlement to Plan benefits, including:
ӹӹ The exclusive discretion to increase, decrease, or otherwise change Plan provisions for
the efficient administration of the Plan or to further the purposes of UNITE HERE
HEALTH,
ӹӹ The right to obtain or provide information needed to coordinate benefit payments with
other plans,
ӹӹ The right to obtain second medical opinions or to have an autopsy performed when not
forbidden by law;
• Interpret all Plan provisions and associated administrative rules and procedures;
• Authorize all payments under the Plan or recover any amounts in excess of the total
amounts required by the Plan.
The Trustees’ decisions are binding on all persons dealing with or claiming benefits from the
Plan, unless determined to be arbitrary or capricious by a court of competent jurisdiction. Benefits under this Plan will be paid if the Board of Trustees of UNITE HERE HEALTH, in their sole
and exclusive discretion, decide that the applicant is entitled to them.
The Plan gives the Trustees full discretion and sole authority to make the final decision in all
areas of Plan interpretation and administration, including eligibility for benefits, the level of benefits provided, and the meaning of all Plan language (including this Summary Plan Description).
In the event of a conflict between this Summary Plan Description and the Plan Document, the
Plan Document will govern. The decision of the Trustees is final and binding on all those dealing with or claiming benefits under the Plan, and if challenged in court, the Plan intends for the
Trustees’ decision to be upheld unless it is determined to be arbitrary and capricious.
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Amendment or termination of the Plan
The Trustees intend to continue the Plan within the limits of the funds available to them. However, they reserve the right, in their sole discretion, to amend or terminate the Plan, in its entirety
or in part, without prior notice. An insurance contract under which benefits are paid is not necessarily the same as the Plan. Therefore, termination of an insurance contract does not necessarily
terminate the Plan.
If the Plan is terminated, benefits for claims incurred before the termination date will be paid
based on available assets. Full benefits may not be available if the Plan owes more than the assets available. If there is money left over, the Trustees may use it in a method consistent with the
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Plan 185
purposes for which the Plan was created or they may transfer it to another fund providing similar
benefits.
Free choice of provider
Plan administrator and agent for service of legal process
The Plan Administrator and the agent for service of legal process is the Chief Executive Officer
(CEO) of the UNITE HERE HEALTH. Service of legal process may also be made upon a Plan
trustee. The CEO’s address and phone number are:
UNITE HERE HEALTH
Chief Executive Officer
711 North Commons Drive
Aurora, IL 60504
(630) 236-5100
The decision to use the services of particular hospitals, clinics, doctors, dentists, or other healthcare providers is voluntary, and the Plan makes no recommendation as to which specific provider
you should use, even when benefits may only be available for services furnished by providers
designated by the Plan. You should select a provider or treatment based on all appropriate factors,
only one of which is coverage under the Plan.
Providers are not agents or employees of UNITE HERE HEALTH, and the Plan makes no representation regarding the quality of service provided.
Workers’ compensation
The Employer Identification Number assigned by the Internal Revenue Service to the Board of
Trustees is EIN# 23-7385560.
The Plan does not replace or affect any requirements for coverage under any state Workers’ Compensation or Occupational Disease Law. If you suffer a job-related sickness or injury, notify your
employer immediately.
Plan number
Type of Plan
Plan year
The Plan is a welfare plan providing healthcare and other benefits, including life insurance and
accidental death and dismemberment protection. The Plan is maintained through Collective
Bargaining Agreements between UNITE HERE and certain employers. These agreements require
contributions to UNITE HERE HEALTH on behalf of each eligible employee. For a reasonable
charge, you can get copies of the Collective Bargaining Agreements by writing to the Plan Administrator. Copies are also available for review at the Aurora, Illinois, Office, and within 10 days
of a request to review, at the following locations: regional offices, the main offices of employers at
which at least 50 participants are working, or the main offices or meeting halls of local unions.
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Employer identification number
The Plan Number is 501.
The Plan year is the 12-month period set by the Board of Trustees for the purpose of maintaining
UNITE HERE HEALTH’s financial records. Plan years begin each April 1 and end the following
March 31.
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Employer and employee organizations
You can get a complete list of employers and employee organizations participating in the Plan
by writing to the Plan Administrator. Copies are also available for review at the Aurora, Illinois,
Office and, within 10 days of a request for review, at the following locations: regional offices, the
main offices of employers at which at least 50 participants are working, or the main offices or
meeting halls of local unions.
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Plan 185
Your
rights
under ERISA
Your rights
under ERISA
As a participant in the Plan, you are entitled to certain rights and protections under the Employee
Retirement Income Security Act of 1974 (ERISA).
If you have any questions about this statement or your rights under ERISA, you should contact
the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor,
listed in your telephone directory, or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Dept. of Labor, 200 Constitution Avenue, N.W., Washington, DC 20210.
Receive information about your Plan and benefits
ERISA provides that all Plan participants shall be entitled to:
• Examine, without charge, at the Plan Administrator’s office and at other specified locations,
such as work sites and union halls, all documents governing the Plan, including insurance
contracts and Collective Bargaining Agreements, and a copy of the latest annual report
(Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the
Public Disclosure Room of the Employee Benefits Security Administration.
• Obtain, upon written request to the Plan Administrator, copies of documents governing the
operation of the Plan, including insurance contracts and Collective Bargaining Agreements,
and copies of the latest annual report (Form 5500 Series) and updated Summary Plan
Description. The administrator may make a reasonable charge for copies not required by
law to be furnished free-of-charge.
• Receive a summary of the Plan’s annual financial report. The Plan Administrator is required
by law to furnish each participant with a copy of this summary annual report.
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Continue group health Plan coverage
ERISA also provides that all Plan participants shall be entitled to continue healthcare coverage
for themselves, their spouses, or their dependents if there is a loss of coverage under the Plan as
a result of a qualifying event. You or your dependents may have to pay for such coverage. Review
this Summary Plan Description and the documents governing the Plan for the rules governing
your COBRA continuation coverage rights.
Your rights under ERISA
Enforce your rights
If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to
know why this was done, to obtain copies of documents relating to the decision without charge,
and to appeal any denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you make
a written request for a copy of Plan documents or the latest annual report from the Plan and do
not receive them within 30 days, you may file suit in a federal court. In such a case, the court may
require the Plan Administrator to provide the materials and pay you up to $110 a day until you
receive the materials, unless the materials were not sent because of reasons beyond the control of
the administrator.
If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit
in state or federal court. In addition, if you disagree with the Plan’s decision or lack thereof concerning the qualified status of a domestic relation’s order or a medical child support order, you
may file suit in federal court.
If it should happen that Plan Fiduciaries misuse the Plan’s money, or if you are discriminated
against for asserting your rights, you may seek assistance from the U.S. Department of Labor or
you may file suit in federal court. The court will decide who should pay court costs and legal fees.
If you are successful the court may order the person you have sued to pay these costs and fees. If
you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is
frivolous.
Assistance with your questions
G
If you have any questions about your Plan, you should contact the Plan Administrator.
If you have any questions about this statement or about your rights under ERISA, or if you need
assistance in obtaining documents from the Plan Administrator, you should contact the nearest
office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your
telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits
Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington,
D.C. 20210. You may also obtain certain publications about your rights and responsibilities under
ERISA by calling the publications hotline of the Employee Benefits Security Administration.
Prudent actions by Plan fiduciaries
G-14
Plan 185
In addition to creating rights for plan participants, ERISA imposes duties upon the people who
are responsible for the operation of the employee benefit plan. The people who operate your Plan,
called “fiduciaries” of the Plan, have a duty to do so prudently and in the interest of you and other
Plan participants and beneficiaries. No one, including your employer, your union, or any other
person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.
G-15
Plan 185
Important contact
information
Important contact information
Blue Cross and Blue Shield of Illinois
300 East Randolph Street
Chicago, IL 60601-5099
(312) 653-6000
Cigna Health and Life Insurance Company (Cigna)
900 Cottage Grove Road
Bloomfield, CT 06002
(800) 244-6224
ConsejoSano
2230 California St. N.W. Suite 4DW
Washington, D.C. 20008
(855) 785-7885
Dearborn National
1020 31st Street
Downers Grove, IL 60515-5591
(800) 348-4512
Doctor on Demand
121 Spear Street (Rincon 2), Suite 420
San Francisco, CA 94105
(800) 997-6196
HospitalityRx
P.O. Box 6020
Aurora, IL 60598-0020
(855) 405-FUND
G
P.O. Box 61440
Las Vegas NV 89160
(855) 487-0353
VSP
3333 Quality Drive
Rancho Cordova, CA 95670
(800) 852-7600
Walgreens Specialty Pharmacy
60173-6801
(877) 647-5807
G-16
Plan 185
WellDyneRx
7472 Tucson Way, Suite 100A
Centennial, CO 80112
(844) 813-3860
UNITE HERE HEALTH
Board of Trustees
UNITE HERE HEALTH Board of Trustees
Union Trustees
Employer Trustees
Chairman of the Board
D. Taylor
Terry Greenwald
Leonard O’Neill
Secretary of the Board
Arnold F. Karr
Geoconda Arguello-Kline
Connie Holt
Henry Tamarin
President
UNITE HERE
1630 S. Commerce Street
Las Vegas, NV 89102
Secretary/Treasurer
Culinary Union Local 226
1630 S. Commerce Street
Las Vegas, NV 89102
William Biggerstaff
UNITE HERE International Executive Vice President/Financial
Secretary-Treasurer
UNITE HERE Local 450
7238 West Roosevelt Road
Forest Park IL 60130
Donna DeCaprio
Financial Secretary Treasurer
UNITE HERE Local 54
1014 Atlantic Avenue
Atlantic City, NJ 08401
G
UNITE HERE HEALTH Board of Trustees
Jim DuPont
Director, Food Service Division
UNITE HERE
c/o UNITE HERE HEALTH
Aurora, IL 60504
Bill Granfield
President
275 Seventh Avenue, 10th Floor
New York, NY 10001
Secretary-Treasurer
Bartenders Local 165
4825 W. Nevso Drive
Las Vegas, NV 89103
Connecticut Director
425 College Street
New Haven, CT 06511
Karen Kent
President
UNITE HERE Local 1
218 S. Wabash Avenue, 7th floor
Chicago, IL 60604
Secretary-Treasurer
702C Forest Avenue
Pacific Grove, CA 93950
UNITE HERE Local 1
218 S. Wabash Avenue, 7th floor
Chicago, IL 60604
Tom Walsh
President
UNITE HERE Local 11
464 S. Lucas Avenue, Suite 201
Los Angeles, CA 90017
President
Karr & Associates
Aurora, IL 60504
Paul Ades
Senior Vice President Labor
Relations
Hilton Worldwide
7930 Jones Branch Drive
McLean, VA 22102
James Anderson
George Greene
Vice President Labor Relations
Starwood Hotels and Resorts
715 W. Park Avenue, Unit 354
Oakhurst, NJ 07755
Cynthia Kiser Murphey
President & Chief Operating
Officer
New York-New York
3790 Las Vegas Blvd. South
Las Vegas, NV 89109
Robert Kovacs
Aurora, IL 60504
VP Total Rewards North America
Compass Group
2400 Yorkmont Road
Charlotte, NC 28217
UNITE HERE International
Union
218 S. Wabash Avenue, 7th Floor
Chicago, IL 60604
Richard Betty
Russ Melaragni
Brian Lang
James L. Claus
Rev. Clete Kiley
President
UNITE HERE Local 26
33 Harrison Avenue, 4th floor
Boston, MA 02111
C. Robert McDevitt
President
UNITE HERE Local 54
1014 Atlantic Avenue
Atlantic City, NJ 08401
Aurora, IL 60504
Executive Vice President
Tishman Hotel Corporation
100 Park Avenue, 18th Floor
New York, NY 10017
Richard Ellis
Vice President/Labor Relations
ARAMARK
1101 Market Street, 6th Floor
Philadelphia, PA 19107
James Stamas
Dean Emeritus
Boston University School of
Hospitality
Aurora, IL 60504
Harold Taegel
Senior Director Labor Relations
Sodexo
Aurora, IL 60504
George Wright
Aurora, IL 60504
Vice President of Associate &
Labor Relations
Hyatt Hotels & Resorts
71 S. Wacker Drive
Chicago, IL 60606
G
Frank Muscolina
Vice President Corporate Labor
Relations
Caesars Palace
Aurora, IL 60504
William Noonan
Senior Vice President Administration
Boyd Gaming
3883 Howard Hughes Parkway
9th Floor
Las Vegas, NV 89118
G-18
G-19
Plan 185
Plan 185
UNITE HERE HEALTH
P.O. Box 6020
Aurora, IL 60598-0020
(630) 236-5100
L1-09
cigna dental care® (*DHMO)
patient charge schedule
This Patient Charge Schedule lists the benefits of the Dental Plan including
covered procedures and patient charges.
Important Highlights
• This Patient Charge Schedule applies only when covered dental services are
performed by your Network Dentist, unless otherwise authorized by Cigna Dental
as described in your plan documents. Not all Network Dentists perform all listed
services and it is suggested to check with your Network Dentist in advance of
receiving services.
• This Patient Charge Schedule applies to Specialty Care when an appropriate referral
is made to a Network Specialty Periodontist or Oral Surgeon. You must verify with
the Network Specialty Dentist that your treatment plan has been authorized for
payment by Cigna Dental. Prior authorization is not required for specialty referrals
for Pediatric, Orthodontic and Endodontic services. You may select a Network
Pediatric Dentist for your child under the age of 7 by calling Customer Service at
1.800.Cigna24 to get a list of Network Pediatric Dentists in your area. Coverage
for treatment by a Pediatric Dentist ends on your child’s 7th birthday; however,
exceptions for medical reasons may be considered on an individual basis. Your
Network General Dentist will provide care upon your child’s 7th birthday.
• Procedures not listed on this Patient Charge Schedule are not covered and are
the patient’s responsibility at the dentist’s usual fees.
• The administration of IV sedation, general anesthesia, and/or nitrous oxide is
not covered except as specifically listed on this Patient Charge Schedule. The
application of local anesthetic is covered as part of your dental treatment.
• Cigna Dental considers infection control and/or sterilization to be incidental to
and part of the charges for services provided and not separately chargeable.
92249
856609 02/13 L1-09
cigna dental care®
patient charge schedule (L1-09)
Important Highlights (continued)
• This Patient Charge Schedule is subject to annual change in accordance with the
terms of the group agreement.
• Procedures listed on the Patient Charge Schedule are subject to the plan
limitations and exclusions described in your plan book/certificate of coverage
and/or group contract.
• All patient charges must correspond to the Patient Charge Schedule in effect on
the date the procedure is initiated.
• The American Dental Association may periodically change CDT Codes or
definitions. Different codes may be used to describe these covered procedures.
Code
Patient
Charge
Procedure Description
Diagnostic/preventive – Oral evaluations are limited to a combined total of 4
of the following evaluations during a 12 consecutive month period: Periodic oral
evaluations (D0120), comprehensive oral evaluations (D0150), comprehensive
periodontal evaluations (D0180), and oral evaluations for patients under 3 years
of age (D0145).
D9310
Consultation (diagnostic service provided by dentist or
physician other than requesting dentist or physician)
$0.00
D9430
Office visit for observation – No other services performed
$0.00
D9450
Case presentation – Detailed and extensive
treatment planning
$0.00
D0120
Periodic oral evaluation – Established patient
$0.00
D0140
Limited oral evaluation – Problem focused
$0.00
D0145
Oral evaluation for a patient under 3 years of age and
counseling with primary caregiver
$0.00
D0150
Comprehensive oral evaluation – New or established patient
$0.00
D0160
Detailed and extensive oral evaluation – problem focused,
by report (limit 2 per calendar year; only covered in conjunction
with Temporomandibular Joint (TMJ) evaluation)
$0.00
D0170
Reevaluation – Limited, problem focused (not
postoperative visit)
$0.00
-2-
cigna dental care®
Patient
Charge
Code
D0180
Comprehensive periodontal evaluation – New or
established patient
D0210
X-rays intraoral – Complete series of radiographic images
(limit 1 every 3 years)
$0.00
D0220
X-rays intraoral – Periapical – First radiographic image
$0.00
D0230
X-rays intraoral – Periapical – Each additional
radiographic image
$0.00
D0240
X-rays intraoral – Occlusal radiographic image
$0.00
D0270
X-rays (bitewing) – Single radiographic image
$0.00
D0272
X-rays (bitewings) – 2 radiographic images
$0.00
D0273
$0.00
D0274
$0.00
D0277
X-rays (bitewings, vertical) – 7 to 8 radiographic images
$0.00
D0330
X-rays (panoramic radiographic image) – (limit 1 every
3 years)
$0.00
D0368
Cone beam CT capture and interpretation for TMJ series
including two or more exposures (limit 1 per calendar year;
only covered in conjunction with Temporomandibular Joint
(TMJ) evaluation)
D0431
Oral cancer screening using a special light source
$50.00
D0460
Pulp vitality tests
$14.00
D0470
Diagnostic casts
$0.00
D0472
Pathology report – Gross examination of lesion (only when
tooth related)
$0.00
D0473
Pathology report – Microscopic examination of lesion
(only when tooth related)
$0.00
D0474
Pathology report – Microscopic examination of lesion and
area (only when tooth related)
$0.00
D1110
Prophylaxis (cleaning) – Adult (limit 2 per calendar year)
$0.00
Additional prophylaxis (cleaning) – In addition to the
2 prophylaxes (cleanings) allowed per calendar year
-3-
$45.00
$240.00
$45.00
cigna dental care®
Patient
Charge
Code
D1120
Prophylaxis (cleaning) – Child (limit 2 per calendar year)
Additional prophylaxis (cleaning) – In addition to the
2 prophylaxes (cleanings) allowed per calendar year
D1206
D1208
Topical application of fluoride varnish (limit 2 per calendar
year). There is a combined limit of a total of 2 D1206s and/or
D1208s per calendar year.
$0.00
$30.00
$0.00
Additional topical application of fluoride varnish – In addition
to any combination of two (2) D1206s (topical application
of fluoride varnish) and/or D1208s (topical application of
fluoride) per calendar year.
$15.00
Topical application of fluoride (limit 2 per calendar year).
There is a combined limit of a total of 2 D1208s and/or D1206s
per calendar year.
$0.00
Additional topical application of fluoride – In addition to
any combination of two (2) D1206s (topical applications
of fluoride varnish) and/or D1208s (topical application of
fluoride) per calendar year.
$15.00
D1330
Oral hygiene instructions
D1351
Sealant – Per tooth
$17.00
D1352
Preventive resin restoration in a moderate to high caries
risk patient – Permanent tooth
$17.00
D1510
Space maintainer – Fixed – Unilateral
$110.00
D1515
Space maintainer – Fixed – Bilateral
$170.00
D1555
Removal of fixed space maintainer
$0.00
$0.00
Restorative (fillings, including polishing)
D2140
Amalgam – 1 surface, primary or permanent
$6.00
D2150
Amalgam – 2 surfaces, primary or permanent
$6.00
D2160
Amalgam – 3 surfaces, primary or permanent
$12.00
D2161
Amalgam – 4 or more surfaces, primary or permanent
$18.00
D2330
Resin-based composite – 1 surface, anterior
$6.00
D2331
Resin-based composite – 2 surfaces, anterior
$13.00
-4-
cigna dental care®
Patient
Charge
Code
D2332
Resin-based composite – 3 surfaces, anterior
$18.00
D2335
Resin-based composite – 4 or more surfaces or involving
incisal angle, anterior
$88.00
D2390
Resin-based composite crown, anterior
$88.00
D2391
Resin-based composite – 1 surface, posterior
$47.00
D2392
Resin-based composite – 2 surfaces, posterior
$59.00
D2393
Resin-based composite – 3 surfaces, posterior
$82.00
D2394
Resin-based composite – 4 or more surfaces, posterior
$115.00
Crown and bridge – All charges for crown and bridge (fixed partial denture)
are per unit (each replacement or supporting tooth equals 1 unit). Coverage for
replacement of crowns and bridges is limited to 1 every 5 years.
Per tooth charge for crowns, inlays, onlays, post and cores,
and veneers if your dentist uses same day in-office CAD/CAM
(ceramic) services. Same day in-office CAD/CAM (ceramic)
services refer to dental restorations that are created in
the dental office by the use of a digital impression and an
in-office CAD/CAM milling machine.
$150.00
D2510
Inlay – Metallic – 1 surface
$380.00
D2520
Inlay – Metallic – 2 surfaces
$380.00
D2530
Inlay – Metallic – 3 or more surfaces
$380.00
D2542
Onlay – Metallic – 2 surfaces
$440.00
D2543
Onlay – Metallic – 3 surfaces
$440.00
D2544
Onlay – Metallic – 4 or more surfaces
$440.00
D2740
Crown – Porcelain/ceramic substrate
$460.00
D2750
Crown – Porcelain fused to high noble metal
$420.00
D2751
Crown – Porcelain fused to predominantly base metal
$370.00
D2752
Crown – Porcelain fused to noble metal
$400.00
D2780
Crown – 3/4 cast high noble metal
$430.00
D2781
Crown – 3/4 cast predominantly base metal
$380.00
-5-
cigna dental care®
Code
Patient
Charge
D2782
Crown – 3/4 cast noble metal
$410.00
D2790
Crown – Full cast high noble metal
$430.00
D2791
Crown – Full cast predominantly base metal
$380.00
D2792
Crown – Full cast noble metal
$410.00
D2794
Crown – Titanium
$430.00
D2910
Recement inlay – Onlay or partial coverage restoration
$12.00
D2915
Recement cast or prefabricated post and core
$12.00
D2920
Recement crown
$12.00
D2929
Prefabricated porcelain/ceramic crown – Primary tooth
D2930
Prefabricated stainless steel crown – Primary tooth
$92.00
D2931
Prefabricated stainless steel crown – Permanent tooth
$92.00
D2932
Prefabricated resin crown
$120.00
D2933
Prefabricated stainless steel crown with resin window
$145.00
D2934
Prefabricated esthetic coated stainless steel crown –
Primary tooth
$145.00
D2940
Protective Restoration
$13.00
D2950
Core buildup – Including any pins
$97.00
D2951
Pin retention – Per tooth – In addition to restoration
$18.00
D2952
Post and core – In addition to crown, indirectly fabricated
$150.00
D2954
Prefabricated post and core – In addition to crown
$125.00
D2960
Labial veneer (resin laminate) – Chairside
$105.00
D6210
Pontic – Cast high noble metal
$420.00
D6211
Pontic – Cast predominantly base metal
$380.00
D6212
Pontic – Cast noble metal
$410.00
D6214
Pontic – Titanium
$430.00
D6240
Pontic – Porcelain fused to high noble metal
$420.00
D6241
Pontic – Porcelain fused to predominantly base metal
$380.00
-6-
$145.00
cigna dental care®
Code
Patient
Charge
D6242
Pontic – Porcelain fused to noble metal
$410.00
D6245
Pontic – Porcelain/ceramic
$425.00
D6602
Inlay – Cast high noble metal, 2 surfaces
$420.00
D6603
Inlay – Cast high noble metal, 3 or more surfaces
$430.00
D6604
Inlay – Cast predominantly base metal, 2 surfaces
$370.00
D6605
Inlay – Cast predominantly base metal, 3 or more surfaces
$370.00
D6606
Inlay – Cast noble metal, 2 surfaces
$390.00
D6607
Inlay – Cast noble metal, 3 or more surfaces
$400.00
D6610
Onlay – Cast high noble metal, 2 surfaces
$430.00
D6611
Onlay – Cast high noble metal, 3 or more surfaces
$430.00
D6612
Onlay – Cast predominantly base metal, 2 surfaces
$370.00
D6613
Onlay – Cast predominantly base metal, 3 or more surfaces
$370.00
D6614
Onlay – Cast noble metal, 2 surfaces
$390.00
D6615
Onlay – Cast noble metal, 3 or more surfaces
$410.00
D6624
Inlay – Titanium
$420.00
D6634
Onlay – Titanium
$420.00
D6740
Crown – Porcelain/ceramic
$470.00
D6750
Crown – Porcelain fused to high noble metal
$430.00
D6751
Crown – Porcelain fused to predominantly base metal
$380.00
D6752
Crown – Porcelain fused to noble metal
$410.00
D6780
Crown – 3/4 cast high noble metal
$430.00
D6781
Crown – 3/4 cast predominantly base metal
$380.00
D6782
Crown – 3/4 cast noble metal
$410.00
D6790
Crown – Full cast high noble metal
$430.00
D6791
Crown – Full cast predominantly base metal
$380.00
D6792
Crown – Full cast noble metal
$410.00
D6794
Crown – Titanium
$430.00
-7-
cigna dental care®
Code
Patient
Charge
Complex rehabilitation – Additional charge per unit
for multiple crown units/complex rehabilitation (6 or
more units of crown and/or bridge in same treatment plan
requires complex rehabilitation for each unit – ask your
dentist for the guidelines)
D6930
Recement fixed partial denture
$135.00
$12.00
Endodontics (root canal treatment, excluding final restorations)
D3110
Pulp cap – Direct (excluding final restoration)
$14.00
D3120
Pulp cap – Indirect (excluding final restoration)
$14.00
D3220
Pulpotomy – Removal of pulp, not part of a root canal
$89.00
D3221
Pulpal debridement (not to be used when root canal is done
on the same day)
$83.00
D3222
Partial pulpotomy for apexogenesis – Permanent tooth with
incomplete root development
$89.00
D3310
Anterior root canal – Permanent tooth (excluding
final restoration)
$275.00
D3320
Bicuspid root canal – Permanent tooth (excluding
$320.00
D3330
Molar root canal – Permanent tooth (excluding
$440.00
D3331
Treatment of root canal obstruction – Nonsurgical access
$130.00
D3332
Incomplete endodontic therapy – Inoperable, unrestorable
or fractured tooth
$130.00
D3333
Internal root repair of perforation defects
$130.00
D3346
Retreatment of previous root canal therapy – Anterior
$395.00
D3347
Retreatment of previous root canal therapy – Bicuspid
$445.00
D3348
Retreatment of previous root canal therapy – Molar
$565.00
D3410
Apicoectomy/periradicular surgery – Anterior
$360.00
D3421
Apicoectomy/periradicular surgery – Bicuspid (first root)
$385.00
D3425
Apicoectomy/periradicular surgery – Molar (first root)
$420.00
-8-
cigna dental care®
Code
Patient
Charge
D3426
Apicoectomy/periradicular surgery (each additional root)
$150.00
D3430
Retrograde filling – Per root
$89.00
Periodontics (treatment of supporting tissues [gum and bone] of the teeth)
periodontal regenerative procedures are limited to 1 regenerative procedure per
site (or per tooth, if applicable), when covered on the patient charge schedule.
The relevant procedure codes are D4263, D4264, D4266 and D4267. Localized
delivery of antimicrobial agents is limited to 8 teeth (or 8 sites, if applicable) per
12 consecutive months, when covered on the patient charge schedule.
D4210
Gingivectomy or gingivoplasty – 4 or more teeth
per quadrant
$240.00
D4211
Gingivectomy or gingivoplasty – 1 to 3 teeth per quadrant
$105.00
D4212
Gingivectomy or gingivoplasty to allow access for restorative
procedure, per tooth
$105.00
D4240
Gingival flap (including root planing) – 4 or more teeth
per quadrant
$305.00
D4241
Gingival flap (including root planing) – 1 to 3 teeth
per quadrant
$165.00
D4245
Apically positioned flap
$280.00
D4249
Clinical crown lengthening – Hard tissue
$340.00
D4260
Osseous surgery – 4 or more teeth per quadrant
$540.00
D4261
Osseous surgery – 1 to 3 teeth per quadrant
$310.00
D4263
Bone replacement graft – First site in quadrant
$290.00
D4264
Bone replacement graft – Each additional site in quadrant
$225.00
D4266
Guided tissue regeneration – Resorbable barrier per site
$380.00
D4267
Guided tissue regeneration – Nonresorbable barrier per site
(includes membrane removal)
$430.00
D4270
Pedicle soft tissue graft procedure
$415.00
D4275
Soft tissue allograft
$415.00
D4277
Free soft tissue graft procedure (including donor site
surgery), first tooth or edentulous (missing) tooth position
in graft
$415.00
-9-
cigna dental care®
Patient
Charge
Code
D4278
Free soft tissue graft procedure (including donor site
surgery), each additional contiguous tooth or edentulous
(missing) tooth position in same graft site
$210.00
D4341
Periodontal scaling and root planing – 4 or more teeth per
quadrant (limit 4 quadrants per consecutive 12 months)
$110.00
D4342
Periodontal scaling and root planing – 1 to 3 teeth per
quadrant (limit 4 quadrants per consecutive 12 months)
$60.00
D4355
Full mouth debridement to allow evaluation and diagnosis
(1 per lifetime)
$84.00
D4381
Localized delivery of antimicrobial agents per tooth
$45.00
D4910
Periodontal maintenance (limit 4 per calendar year)
(only covered after active periodontal therapy)
$77.00
Prosthetics (removable tooth replacement – dentures) includes up to
4 adjustments within first 6 months after insertion – Replacement limit 1 every
5 years.
D5110
Full upper denture
$535.00
D5120
Full lower denture
$535.00
D5130
Immediate full upper denture
$575.00
D5140
Immediate full lower denture
$575.00
D5211
Upper partial denture – Resin base (including clasps, rests
and teeth)
$400.00
D5212
Lower partial denture – Resin base (including clasps, rests
and teeth)
$400.00
D5213
Upper partial denture – Cast metal framework (including
clasps, rests and teeth)
$625.00
D5214
Lower partial denture – Cast metal framework (including
clasps, rests and teeth)
$625.00
D5225
Upper partial denture – Flexible base (including clasps, rests
and teeth)
$430.00
D5226
Lower partial denture – Flexible base (including clasps, rests
and teeth)
$430.00
D5410
Adjust complete denture – Upper
-10-
$38.00
cigna dental care®
Patient
Charge
Code
D5411
Adjust complete denture – Lower
$38.00
D5421
Adjust partial denture – Upper
$38.00
D5422
Adjust partial denture – Lower
$38.00
Repairs to prosthetics
D5510
Repair broken complete denture base
$71.00
D5520
Replace missing or broken teeth – Complete denture
(each tooth)
$71.00
D5610
Repair resin denture base
$71.00
D5630
Repair or replace broken clasp
$88.00
D5640
Replace broken teeth – Per tooth
$71.00
D5650
Add tooth to existing partial denture
$71.00
D5660
Add clasp to existing partial denture
$88.00
Denture relining (limit 1 every 36 months)
D5710
Rebase complete upper denture
$210.00
D5711
Rebase complete lower denture
$210.00
D5720
Rebase upper partial denture
$210.00
D5721
Rebase lower partial denture
$210.00
D5730
Reline complete upper denture – Chairside
$120.00
D5731
Reline complete lower denture – Chairside
$120.00
D5740
Reline upper partial denture – Chairside
$120.00
D5741
Reline lower partial denture – Chairside
$120.00
D5750
Reline complete upper denture – Laboratory
$185.00
D5751
Reline complete lower denture – Laboratory
$185.00
D5760
Reline upper partial denture – Laboratory
$185.00
D5761
Reline lower partial denture – Laboratory
$185.00
-11-
cigna dental care®
Code
Patient
Charge
Interim dentures (limit 1 every 5 years)
D5810
Interim complete denture – Upper
$305.00
D5811
Interim complete denture – Lower
$305.00
D5820
Interim partial denture – Upper
$255.00
D5821
Interim partial denture – Lower
$255.00
Implant/abutment supported prosthetics – All charges for crown and bridge
(fixed partial denture) are per unit (each replacement on a supporting implant(s)
equals 1 unit). Coverage for replacement of crowns and bridges and implant
supported dentures is limited to 1 every 5 years.
Per tooth charge for crowns, inlays, onlays, post and cores,
and veneers if your dentist uses same day in-office CAD/CAM
(ceramic) services. Same day in-office CAD/CAM (ceramic)
services refer to dental restorations that are created in
the dental office by the use of a digital impression and an
in-office CAD/CAM milling machine.
$150.00
D6053
Implant/abutment supported removable denture for
completely edentulous arch
$835.00
D6054
Implant/abutment supported removable denture for
partially edentulous arch
$925.00
D6058
Abutment supported porcelain/ceramic crown
$760.00
D6059
Abutment supported porcelain fused to metal crown
(high noble metal)
$720.00
D6060
(predominantly base metal)
$670.00
D6061
(noble metal)
$700.00
D6062
Abutment supported cast metal crown (high noble metal)
$720.00
D6063
Abutment supported cast metal crown (predominantly
base metal)
$670.00
D6064
Abutment supported cast metal crown (noble metal)
$700.00
D6065
Implant supported porcelain/ceramic crown
$760.00
-12-
cigna dental care®
Patient
Charge
Code
D6066
Implant supported porcelain fused to metal crown (titanium,
titanium alloy, high noble metal)
$720.00
D6067
Implant supported metal crown (titanium, titanium alloy,
high noble metal)
$720.00
D6068
Abutment supported retainer for porcelain/ceramic fixed
partial denture
$760.00
D6069
Abutment supported retainer for porcelain fused to metal
fixed partial denture (high noble metal)
$720.00
D6070
fixed partial denture (predominantly base metal)
$670.00
D6071
fixed partial denture (noble metal)
$700.00
D6072
Abutment supported retainer for cast metal fixed partial
denture (high noble metal)
$720.00
D6073
denture (predominantly base metal)
$670.00
D6074
denture (noble metal)
$700.00
D6075
Implant supported retainer for ceramic fixed partial denture
$760.00
D6076
Implant supported retainer for porcelain fused to metal fixed
partial denture (titanium, titanium alloy, high noble metal)
$720.00
D6077
Implant supported retainer for cast metal fixed partial
denture (titanium, titanium alloy, high noble metal)
$720.00
D6078
Implant/abutment supported fixed denture for completely
edentulous arch
$835.00
D6079
Implant/abutment supported fixed denture for partially
edentulous arch
$925.00
D6092
Recement implant/abutment supported crown
$51.00
D6093
Recement implant/abutment supported fixed partial denture
$51.00
D6094
Abutment supported crown (titanium)
-13-
$720.00
cigna dental care®
Patient
Charge
Code
D6194
Abutment supported retainer crown for fixed partial
denture (titanium)
$720.00
Complex rehabilitation on implant/abutment supported
prosthetic procedures – Additional charge per unit for
multiple crown units/complex rehabilitation (6 or more
units of crown and/or bridge in same treatment plan
requires complex rehabilitation for each unit – ask your
dentist for the guidelines)
$135.00
Oral surgery (includes routine postoperative treatment) Surgical removal of
impacted tooth – Not covered for ages below 15 unless pathology (disease) exists.
D7111
Extraction of coronal remnants – Deciduous tooth
$12.00
D7140
Extraction, erupted tooth or exposed root – Elevation and/or
forceps removal
$12.00
D7210
Surgical removal of erupted tooth – Removal of bone and/or
section of tooth
$89.00
D7220
Removal of impacted tooth – Soft tissue
$71.00
D7230
Removal of impacted tooth – Partially bony
$145.00
D7240
Removal of impacted tooth – Completely bony
$185.00
D7241
Removal of impacted tooth – Completely bony, unusual
complications (narrative required)
$200.00
D7250
Surgical removal of residual tooth roots – Cutting procedure
D7251
Coronectomy – Intentional partial tooth removal
$145.00
D7260
Oroantral fistula closure
$200.00
D7261
Primary closure of a sinus perforation
$200.00
D7270
Tooth stabilization of accidentally evulsed or displaced tooth
$14.00
D7280
Surgical access of an unerupted tooth (excluding
wisdom teeth)
$14.00
D7283
Placement of device to facilitate eruption of impacted tooth
D7285
Biopsy of oral tissue – Hard (bone, tooth) (tooth related –
not allowed when in conjunction with another surgical
procedure)
-14-
$89.00
$8.00
$145.00
cigna dental care®
Patient
Charge
Code
D7286
Biopsy of oral tissue – Soft (all others) (tooth related –
not allowed when in conjunction with another surgical
procedure)
D7287
Exfoliative cytological sample collection
$78.00
D7288
Brush biopsy – Transepithelial sample collection
$78.00
D7310
Alveoloplasty in conjunction with extractions – 4 or more
teeth or tooth spaces per quadrant
$89.00
D7311
Alveoloplasty in conjunction with extractions – 1 to 3 teeth
or tooth spaces per quadrant
$45.00
D7320
Alveoloplasty not in conjunction with extractions – 4 or more
teeth or tooth spaces per quadrant
D7321
Alveoloplasty not in conjunction with extractions –
1 to 3 teeth or tooth spaces per quadrant
$64.00
D7450
Removal of benign odontogenic cyst or tumor –
Up to 1.25 cm
$14.00
D7451
Removal of benign odontogenic cyst or tumor –
Greater than 1.25 cm
$14.00
D7471
Removal of lateral exostosis – Maxilla or mandible
$14.00
D7472
Removal of torus palatinus
$14.00
D7473
Removal of torus mandibularis
$14.00
D7485
Surgical reduction of osseous tuberosity
D7510
Incision and drainage of abscess – Intraoral soft tissue
$14.00
D7511
Incision and drainage of abscess – Intraoral soft tissue –
Complicated
$20.00
D7880
Occlusal orthotic device, by report (limit 1 per 24 months;
only covered in conjunction with Temporomandibular Joint
(TMJ) treatment)
$425.00
D7960
Frenulectomy – Also known as frenectomy or frenotomy –
Separate procedure not incidental to another procedure
$14.00
D7963
Frenuloplasty
$20.00
-15-
$110.00
$120.00
$120.00
cigna dental care®
Code
Patient
Charge
Orthodontics (tooth movement)
Orthodontic treatment (maximum benefit of 24 months of interceptive and/or
comprehensive treatment. Atypical cases or cases beyond 24 months require an
additional payment by the patient.)
D8050
Interceptive orthodontic treatment of the primary
dentition – Banding
$480.00
D8060
Interceptive orthodontic treatment of the transitional
dentition – Banding
$480.00
D8070
Comprehensive orthodontic treatment of the transitional
$500.00
D8080
Comprehensive orthodontic treatment of the adolescent
$515.00
D8090
Comprehensive orthodontic treatment of the adult
dentition – Banding
$515.00
D8660
Pre-orthodontic treatment visit
D8670
Periodic orthodontic treatment visit – As part of contract
$67.00
Children – Up to 19th birthday:
24-month treatment fee
Charge per month for 24 months
$2,280.00
$95.00
Adults:
24-month treatment fee
Charge per month for 24 months
$3,000.00
$125.00
D8680
Orthodontic retention – Removal of appliances, construction
and placement of retainer(s)
$345.00
D8999
Unspecified orthodontic procedure – By report (orthodontic
treatment plan and records)
$195.00
-16-
cigna dental care®
Code
Patient
Charge
General anesthesia/IV sedation – General anesthesia is covered when
performed by an oral surgeon when medically necessary for covered procedures
listed on the patient charge schedule. IV sedation is covered when performed by
a periodontist or oral surgeon when medically necessary for covered procedures
listed on the patient charge schedule. Plan limitation for this benefit is 1 hour per
appointment. There is no coverage for general anesthesia or IV sedation when used
for the purpose of anxiety control or patient management.
D9220
General anesthesia – First 30 minutes
D9221
General anesthesia – Each additional 15 minutes
D9241
IV conscious sedation – First 30 minutes
D9242
IV conscious sedation – Each additional 15 minutes
$190.00
$84.00
$190.00
$73.00
Emergency services
D9110
Palliative (emergency) treatment of dental pain –
Minor procedure
D9440
Office visit – After regularly scheduled hours
$0.00
$66.00
Miscellaneous services
D9940
Occlusal guard – By report (limit 1 per 24 months)
$265.00
D9941
Fabrication of athletic mouthguard (limit 1 per 12 months)
$110.00
D9951
Occlusal adjustment – Limited
D9952
Occlusal adjustment – Complete
$255.00
D9975
External bleaching for home application, per arch; includes
materials and fabrication of custom trays (all other methods
of bleaching are not covered)
$165.00
$58.00
This may contain CDT codes and/or portions of, or excerpts from the nomenclature
contained within the Current Dental Terminology, a copyrighted publication provided
by the American Dental Association. The American Dental Association does not
endorse any codes which are not included in its current publication.
-17-
After your enrollment is effective:
Call the dental office identified in your Welcome Kit. If you wish to change dental
offices, a transfer can be arranged at no charge by calling Cigna Dental at the toll
free number listed on your ID card or plan materials. Multiple ways to locate a
*DHMO Network General Dentist:
• Online provider directory at Cigna.com
• Online provider directory on myCigna.com
• Call the number located on your ID card to:
– Use the Dental Office Locator via Speech Recognition
– Speak to a Customer Service Representative
EMERGENCY: If you have a dental emergency as defined in your group’s plan
documents, contact your Network General Dentist as soon as possible. If you are
out of your service area or unable to contact your Network Office, emergency care
can be rendered by any licensed dentist. Definitive treatment (e.g., root canal)
is not considered emergency care and should be performed or referred by your
Network General Dentist. Consult your group’s plan documents for a complete
definition of dental emergency, your emergency benefit and a listing of Exclusions
and Limitations.
-18-
*The term “DHMO” is used to refer to product designs that may differ by state of residence of enrollee, including but not
limited to, prepaid plans, managed care plans, and plans with open access features.
“Cigna,” “Cigna Dental Care” and “GO YOU” are registered service marks, and the “Tree of Life” logo is a service mark,
of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products
and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating
subsidiaries include Connecticut General Life Insurance Company (“CGLIC”), Cigna Health and Life Insurance Company
(“CHLIC”), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. (“CDHI”) and its subsidiaries. The Cigna
Dental Care plan is provided by Cigna Dental Health Plan of Arizona, Inc.; Cigna Dental Health of California, Inc.; Cigna
Dental Health of Colorado, Inc.; Cigna Dental Health of Delaware, Inc.; Cigna Dental Health of Florida, Inc., a Prepaid
Limited Health Services Organization licensed under Chapter 636, Florida Statutes; Cigna Dental Health of
Kansas, Inc. (Kansas and Nebraska); Cigna Dental Health of Kentucky, Inc.; Cigna Dental Health of Maryland, Inc.; Cigna
Dental Health of Missouri, Inc.; Cigna Dental Health of New Jersey, Inc.; Cigna Dental Health of North Carolina, Inc.; Cigna
Dental Health of Ohio, Inc.; Cigna Dental Health of Pennsylvania, Inc.; Cigna Dental Health of Texas, Inc.; and Cigna Dental
Health of Virginia, Inc. In other states, the Cigna Dental Care plan is underwritten by CGLIC, CHLIC, or Cigna HealthCare of
Connecticut, Inc., and administered by CDHI.
856609 02/13 © 2013 Cigna. Some content provided under license.
UNITE HERE HEALTH
CIGNA DENTAL CARE INSURANCE
EFFECTIVE DATE: January 1, 2016
CN006
3331506
This document printed in December, 2015 takes the place of any documents previously issued to you
which described your benefits.
Printed in U.S.A.
Table of Contents
Certification ....................................................................................................................................5
Important Notices ..........................................................................................................................7
Eligibility - Effective Date .............................................................................................................7
Member Insurance .................................................................................................................................................. 7
Waiting Period ........................................................................................................................................................ 7
Dependent Insurance .............................................................................................................................................. 7
Important Information about Your Dental Plan ........................................................................8
Dental Benefits – Cigna Dental Care ...........................................................................................8
Coordination of Benefits..............................................................................................................13
Expenses For Which A Third Party May Be Responsible .......................................................15
Payment of Benefits .....................................................................................................................16
Termination of Insurance............................................................................................................16
Members............................................................................................................................................................... 16
Dependents ........................................................................................................................................................... 17
Dental Benefits Extension............................................................................................................17
Federal Requirements .................................................................................................................17
Notice of Provider Directory/Networks................................................................................................................ 17
Qualified Medical Child Support Order (QMCSO) ............................................................................................. 17
Effect of Section 125 Tax Regulations on This Plan ............................................................................................ 18
Eligibility for Coverage for Adopted Children ..................................................................................................... 19
Group Plan Coverage Instead of Medicaid ........................................................................................................... 19
Requirements of Medical Leave Act of 1993 (as amended) (FMLA) .................................................................. 19
Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA) .................................... 19
Claim Determination Procedures Under ERISA .................................................................................................. 20
COBRA Continuation Rights Under Federal Law ............................................................................................... 21
ERISA Required Information ............................................................................................................................... 24
Dental Conversion Privilege ................................................................................................................................. 26
Notice of an Appeal or a Grievance ..................................................................................................................... 26
When You Have A Complaint or an Appeal .............................................................................26
Definitions .....................................................................................................................................28
Cigna Dental Care – Cigna Dental Health Plan ........................................................................31
The certificate and the state specific riders listed in the next section apply if you are a resident of one
of the following states: AZ, CO, DE, FL, KS/NE, MD, OH, PA, VA ................................................................. 31
State Rider Cigna Dental Health of Colorado, Inc. ..................................................................42
State Rider Cigna Dental Health of Florida, Inc. .....................................................................43
State Rider Cigna Dental Health of Ohio, Inc. ..........................................................................45
State Rider Cigna Dental Health of Pennsylvania, Inc. ...........................................................47
State Rider Cigna Dental Health of Virginia, Inc. ....................................................................48
The certificate(s) listed in the next section apply if you are a resident of one of the following states:
CA, CT, IL, KY, MO, NJ, NC, TX ...................................................................................................................... 55
Cigna Dental Health of California, Inc. .....................................................................................56
Cigna HealthCare of Connecticut, Inc. ......................................................................................77
Cigna Dental Health of Kentucky, Inc. ......................................................................................90
State Amendment Cigna Dental Health of Kentucky, Inc. (Illinois) .......................................99
Cigna Dental Health of North Carolina, Inc. ..........................................................................101
Cigna Dental Health of New Jersey, Inc. .................................................................................114
Cigna Dental Health of Texas, Inc............................................................................................126
Cigna Dental Care – Cigna Dental Health Plan ......................................................................145
The rider(s) listed in the next section are general provisions that apply to the residents of: AZ, CA, CO,
CT, DE, FL, IL, KS/NE, KY, MD, MO, NJ, NC, OH, PA, TX, VA.................................................................. 145
Federal Requirements ...............................................................................................................146
Notice of Provider Directory/Networks.............................................................................................................. 146
Qualified Medical Child Support Order (QMCSO) ........................................................................................... 146
Effect of Section 125 Tax Regulations on This Plan .......................................................................................... 146
Eligibility for Coverage for Adopted Children ................................................................................................... 147
Group Plan Coverage Instead of Medicaid ......................................................................................................... 147
Requirements of Medical Leave Act of 1993 (as amended) (FMLA) ................................................................ 147
Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA) .................................. 148
Claim Determination Procedures Under ERISA ................................................................................................ 148
COBRA Continuation Rights Under Federal Law ............................................................................................. 149
ERISA Required Information ............................................................................................................................. 153
Home Office: Bloomfield, Connecticut
Mailing Address: Hartford, Connecticut 06152
CIGNA HEALTH AND LIFE INSURANCE COMPANY
a Cigna company (hereinafter called Cigna) certifies that it insures certain Members for the benefits
provided by the following policy(s):
POLICYHOLDER: UNITE HERE HEALTH
GROUP POLICY(S) — COVERAGE
3331506 - DHMO1 CIGNA DENTAL CARE INSURANCE
EFFECTIVE DATE: January 1, 2016
This certificate describes the main features of the insurance. It does not waive or alter any of the terms of
the policy(s). If questions arise, the policy(s) will govern.
This certificate takes the place of any other issued to you on a prior date which described the insu rance.
HC-CER17
04-10
V1
Explanation of Terms
You will find terms starting with capital letters throughout your certificate. To help you understand your benefits, most of these terms
are defined in the Definitions section of your certificate.
Waiting Period
Important Notices
As defined by UNITE HERE HEALTH.
Nevada Division of Insurance
Classes of Eligible Members
Each Member as reported to the insurance company by your
Fund.
You can contact the Nevada Division of Insurance at the
following:
The Department of Business Industry, Division of
Insurance
Toll free number: (888) 872-3234
Hours of operation of the division: Mondays through Fridays
from 8:00 a.m. until 5:00 p.m., Pacific Standard Time (PST).
Effective Date of Member Insurance
You will become insured on the date you elect the insurance
by signing an approved payroll deduction or enrollment form,
as applicable, but no earlier than the date you become eligible.
If you are a Late Entrant, you may elect the insurance only
during an Open Enrollment Period. Your insurance will
become effective on the first day of the month after the end of
that Open Enrollment Period in which you elect it.
If you have local telephone access to the Carson City and Las
Vegas offices of the Division of Insurance, you should call the
local numbers.
Local telephone numbers are: Carson City, 702-687-4270 and
Las Vegas, 702-486-4009
HC-IMP108
You will become insured on your first day of eligibility,
following your election, if you are in Active Service on that
date, or if you are not in Active Service on that date due to
your health status.
04-10
Late Entrant – Member
You are a Late Entrant if:
V1
Eligibility - Effective Date
Member Insurance
This plan is offered to you as a Member.
you are in a Class of Eligible Members; and

you are an eligible, full-time Member; and

you normally work a specified number of hours per week as
defined by UNITE HERE HEALTH; and

you pay any required contribution.

the day you acquire your first Dependent.
you again elect it after you cancel your payroll deduction (if
required).
For your Dependents to be insured, you will have to pay the
required contribution, if any, toward the cost of Dependent
Insurance.
Effective Date of Dependent Insurance
Insurance for your Dependents will become effective on the
date you elect it by signing an approved payroll deduction
form (if required), but no earlier than the day you become
eligible for Dependent Insurance. All of your Dependents as
defined will be included.
If you are a Late Entrant for Dependent Insurance, the
insurance for each of your Dependents will not become
effective until Cigna agrees to insure that Dependent.
Eligibility for Dependent Insurance
You will become eligible for Dependent insurance on the later
of:
the day you become eligible for yourself; or

Dependent Insurance
If you were previously insured and your insurance ceased, you
must satisfy the Waiting Period to become insured again. If
your insurance ceased because you were no longer employed
in a Class of Eligible Members, you are not required to satisfy
any waiting period if you again become a member of a Class
of Eligible Members within one year after your insurance
ceased.

you elect the insurance more than 30 days after you become
eligible; or
Open Enrollment Period
Open Enrollment Period means a period in each calendar year
as designated by your Fund.
Eligibility for Member Insurance
You will become eligible for insurance on the day you
complete the waiting period if:


Your Dependents will be insured only if you are insured.
7
myCigna.com
Consult your plan administrator for the rules that govern your
plan.
Late Entrant – Dependent
You are a Late Entrant for Dependent Insurance if:

you elect that insurance more than 30 days after you
become eligible for it; or

you again elect it after you cancel your payroll deduction (if
required).
Effective Date of Change
If you change options during open enrollment, you (and your
Dependents) will become insured on the effective date of the
plan. If you change options other than at open enrollment (as
allowed by your plan), you will become insured on the first
day of the month after the transfer is processed.
Choice of Dental Office for Cigna Dental Care
When you elect Member Insurance, you may select a Dental
Office from the list provided by CDH. If your first choice of a
Dental Office is not available, you will be notified by CDH of
your designated Dental Office, based on your alternate
selection. No Dental Benefits are covered unless the Dental
Service is received from your designated Dental Office,
referred by a Network General Dentist at that facility to a
specialist approved by CDH, or otherwise authorized by CDH,
except for Emergency Dental Treatment. A transfer from one
Dental Office to another Dental Office may be requested by
you through CDH. Any such transfer will take effect on the
first day of the month after it is authorized by CDH. A transfer
will not be authorized if you or your Dependent has an
outstanding balance at the Dental Office.
HC-ELG4
HC-IMP2
Your Cigna Dental Coverage
The information below outlines your coverage and will help
you to better understand your Dental Plan. Included is
information about which services are covered, which are not,
and how much dental services will cost you.
Member Services
If you have any questions or concerns about the Dental Plan,
Member Services Representatives are just a toll-free phone
call away. They can explain your benefits or help with matters
regarding your Dental Office or Dental Plan. For assistance
with transfers, specialty referrals, eligibility, second opinions,
emergencies, Covered Services, plan benefits, ID cards,
location of Dental Offices, conversion coverage or other
matters, call Member Services from any location at 1-800Cigna24. The hearing impaired may contact the state TTY
toll-free relay service number listed in their local telephone
directory.
04-10
Important Information about Your
Dental Plan
When you elected Dental Insurance for yourself and your
Dependents, you elected one of the two options offered:
Cigna Dental Care; or
Other Charges – Patient Charges
Your Patient Charge Schedule lists the dental procedures
covered under your Dental Plan. Some dental procedures are
covered at no charge to you. For other Covered Services, the
Patient Charge Schedule lists the fees you must pay when you
visit your Dental Office. There are no deductibles and no
annual dollar limits for services covered by your Dental Plan.
Cigna Dental Preferred Provider
Details of the benefits under each of the options are described
in separate certificates/booklets.

When electing an option initially or when changing options as
described below, the following rules apply:


V1
Dental Benefits – Cigna Dental Care
V3 M

04-10
HC-IMP74
You and your Dependents may enroll for only one of the
options, not for both options.
Your Network General Dentist should tell you about Patient
Charges for Covered Services, the amount you must pay for
non-Covered Services and the Dental Office's payment
policies. Timely payment is important. It is possible that the
Dental Office may add late charges to overdue balances.
Your Dependents will be insured only if you are insured
and only for the same option.
Change in Option Elected
If your plan is subject to Section 125 (an IRS regulation), you
are allowed to change options only at Open Enrollment or
when you experience a “Life Status Change.”
Your Patient Charge Schedule is subject to annual change.
Cigna Dental will give written notice to your Group of any
change in Patient Charges at least 60 days prior to such
change. You will be responsible for the Patient Charges listed
on the Patient Charge Schedule that is in effect on the date a
procedure is started.
If your plan is not subject to Section 125 you are allowed to
change options at any time.
8
myCigna.com
Choice of Dentist
You and your Dependents should have selected a Dental
Office when you enrolled in the Dental Plan. If you did not,
you must advise Cigna Dental of your Dental Office selection
prior to receiving treatment. The benefits of the Dental Plan
are available only at your Dental Office, except in the case of
an emergency or when Cigna Dental otherwise authorizes
payment for out-of-network benefits.
Emergency Dental Care – Reimbursement
An emergency is a dental condition of recent onset and
severity which would lead a prudent layperson possessing an
average knowledge of dentistry to believe the condition needs
immediate dental procedures necessary to control excessive
bleeding, relieve severe pain, or eliminate acute infection. You
should contact your Network General Dentist if you have an
emergency in your Service Area.
You may select a network Pediatric Dentist as the Network
General Dentist for your dependent child under age 7 by
calling Member Services at 1-800-Cigna24 for a list of
network Pediatric Dentists in your Service Area or, if your
Network General Dentist sends your child under age 7 to a
network Pediatric Dentist, the network Pediatric Dentist’s
office will have primary responsibility for your child’s care.
Your Network General Dentist will provide care for children 7
years and older. If your child continues to visit the Pediatric
Dentist after his/her 7th birthday, you will be fully responsible
for the Pediatric Dentist’s Usual Fees. Exceptions for medical
reasons may be considered on a case-by-case basis.

Emergency Care Away From Home
If you have an emergency while you are out of your Service
Area or unable to contact your Network General Dentist,
you may receive emergency Covered Services as defined
above from any general dentist. Routine restorative
procedures or definitive treatment (e.g. root canal) are not
considered emergency care. You should return to your
Network General Dentist for these procedures. For
emergency Covered Services, you will be responsible for
the Patient Charges listed on your Patient Charge Schedule.
Cigna Dental will reimburse you the difference, if any,
between the dentist’s Usual Fee for emergency Covered
Services and your Patient Charge, up to a total of $50 per
incident. To receive reimbursement, send appropriate
reports and x-rays to Cigna Dental at the address listed for
your state on the front of this booklet.

Emergency Care After Hours
There is a Patient Charge listed on your Patient Charge
Schedule for emergency care rendered after regularly
scheduled office hours. This charge will be in addition to
other applicable Patient Charges.
If for any reason your selected Dental Office cannot provide
your dental care, or if your Network General Dentist
terminates from the network, Cigna Dental will let you know
and will arrange a transfer to another Dental Office. Refer to
the Section titled "Office Transfers" if you wish to change
your Dental Office.
To obtain a list of Dental Offices near you, visit our website at
myCigna.com, or call the Dental Office Locator at 1-800Cigna24. It is available 24 hours a day, 7 days per week. If
you would like to have the list faxed to you, enter your fax
number, including your area code. You may always obtain a
current Dental Office Directory by calling Member Services.
Limitations on Covered Services
Listed below are limitations on services when covered by your
Dental Plan:
Your Payment Responsibility (General Care)
For Covered Services provided by your Dental Office, you
will be charged the fees listed on your Patient Charge
Schedule. For services listed on your Patient Charge Schedule
at any other dental office, you may be charged Usual Fees. For
non-Covered Services, you are responsible for paying Usual
Fees.
If, on a temporary basis, there is no Network General Dentist
in your Service Area, Cigna Dental will let you know and you
may obtain Covered Services from a non-network Dentist.
You will pay the non-network Dentist the applicable Patient
Charge for Covered Services. Cigna Dental will pay the nonnetwork Dentist the difference, if any, between his or her
Usual Fee and the applicable Patient Charge.
See the Specialty Referrals section regarding payment
responsibility for specialty care.
All contracts between Cigna Dental and network Dentists state
that you will not be liable to the network Dentist for any sums
owed to the network Dentist by Cigna Dental.
9

Frequency – The frequency of certain Covered Services,
like cleanings, is limited. Your Patient Charge Schedule
lists any limitations on frequency.

Pediatric Dentistry – Coverage for treatment by a Pediatric
Dentist ends on your child's 7th birthday. Effective on your
child’s 7th birthday, dental services must be obtained from a
Network General Dentist; however, exceptions for medical
reasons may be considered on an individual basis.

Oral Surgery – The surgical removal of an impacted
wisdom tooth may not be covered if the tooth is not
diseased or if the removal is only for orthodontic reasons.
Your Patient Charge Schedule lists any limitations on oral
surgery.

Periodontal (gum tissue and supporting bone) Services Periodontal regenerative procedures are limited to one
regenerative procedure per site (or per tooth, if applicable),
when covered on the Patient Charge Schedule.
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Localized delivery of antimicrobial agents is limited to eight
teeth (or eight sites, if applicable) per 12 consecutive
months, when covered on the Patient Charge Schedule.

Clinical Oral Evaluations – When this limitation is noted
on the Patient Charge Schedule, periodic oral evaluations,
comprehensive oral evaluations, comprehensive periodontal
evaluations, and oral evaluations for patients under 3 years
of age are limited to a combined total of 4 evaluations
during a 12 consecutive month period.

Surgical Placement of Implant Services – When covered
on the Patient Charge Schedule, surgical placement of a
dental implant; repair, maintenance, or removal of a dental
implant; implant abutment(s); or any services related to the
surgical placement of a dental implant are limited to one per
year with replacement of a surgical implant frequency
limitation of one every 10 years.

Prosthesis Over Implant – When covered on the Patient
Charge Schedule, a prosthetic device, supported by an
implant or implant abutment is considered a separate
distinct service(s) from surgical placement of an implant.
Replacement of any type of prosthesis with a prosthesis
supported by an implant or implant abutment is only
covered if the existing prosthesis is at least 5 calendar years
old, is not serviceable and cannot be repaired.
General Limitations - Dental Benefits
No payment will be made for expenses incurred or services
received:

services related to an injury or illness paid under workers'
compensation, occupational disease or similar laws.

services provided or paid by or through a federal or state
governmental agency or authority, political subdivision or a
public program, other than Medicaid.

services required while serving in the armed forces of any
country or international authority or relating to a declared or
undeclared war or acts of war.

cosmetic dentistry or cosmetic dental surgery (dentistry or
dental surgery performed solely to improve appearance)
unless the service is specifically listed on your Patient
Charge Schedule. If bleaching (tooth whitening) is listed on
your Patient Charge Schedule, only the use of take-home
bleaching gel with trays is covered; other types of bleaching
methods are not covered.

general anesthesia, sedation and nitrous oxide, unless
specifically listed on your Patient Charge Schedule. When
listed on your Patient Charge Schedule, general anesthesia
and IV Sedation are covered when medically necessary and
provided in conjunction with Covered Services performed
by an Oral Surgeon or Periodontist. There is no coverage for
general anesthesia or intravenous sedation when used for
the purposes of anxiety control or patient management.

prescription medications.

procedures, appliances or restorations if the main purpose is
to: change vertical dimension (degree of separation of the
jaw when teeth are in contact); restore teeth which have
been damaged by attrition, abrasion, erosion and/or
abfraction; or restore the occlusion.

for or in connection with an Injury arising out of, or in the
course of, any employment for wage or profit;

for charges which would not have been made in any facility,
other than a Hospital or a Correctional Institution owned or
operated by the United States Government or by a state or
municipal government if the person had no insurance;

replacement of fixed and/or removable appliances
(including fixed and removable orthodontic appliances) that
have been lost, stolen, or damaged due to patient abuse,
misuse or neglect.

to the extent that payment is unlawful where the person
resides when the expenses are incurred or the services are
received;


for charges which the person is not legally required to pay;
surgical placement of a dental implant; repair, maintenance or
removal of a dental implant; implant abutment(s); or any
services related to the surgical placement of a dental implant,
unless specifically listed on your Patient Charge Schedule.

for charges which would not have been made if the person
had no insurance;

services considered to be unnecessary or experimental in
nature or do not meet commonly accepted dental standards.

due to injuries which are intentionally self-inflicted.

procedures or appliances for minor tooth guidance or to
control harmful habits.

hospitalization, including any associated incremental
charges for dental services performed in a hospital.
(Benefits are available for network Dentist charges for
covered services performed at a hospital. Other associated
charges are not covered and should be submitted to the
medical carrier for benefit determination.)

the completion of crowns, bridges, dentures or root canal
treatment already in progress on the effective date of your
Cigna Dental coverage.
Services Not Covered Under Your Dental Plan
Listed below are the services or expenses which are NOT
covered under your Dental Plan and which are your
responsibility at the dentist's Usual Fees. There is no coverage
for:

services not listed on the Patient Charge Schedule.

services provided by a non-network Dentist without Cigna
Dental's prior approval (except in emergencies).
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
the completion of implant supported prosthesis (including
crowns, bridges and dentures) already in progress on the
effective date of your Cigna Dental coverage, unless
specifically listed on your Patient Charge Schedule.

consultations and/or evaluations associated with services
that are not covered.

endodontic treatment and/or periodontal (gum tissue and
supporting bone) surgery of teeth exhibiting a poor or
hopeless periodontal prognosis.

bone grafting and/or guided tissue regeneration when
performed at the site of a tooth extraction, unless

Appointments
To make an appointment with your network Dentist, call the
Dental Office that you have selected. When you call, your
Dental Office will ask for your identification number and will
check your eligibility.
Broken Appointments
The time your network Dentist schedules for your
appointment is valuable to you and the dentist. Broken
appointments make it difficult for your Dental Office to
schedule time with other patients.
If you or your enrolled Dependent break an appointment with
less than 24 hours notice to the Dental Office, you may be
charged a broken appointment fee.
performed in conjunction with an apicoectomy or
periradicular surgery.

intentional root canal treatment in the absence of injury or
disease to solely facilitate a restorative procedure.

services performed by a prosthodontist.

localized delivery of antimicrobial agents when performed
alone or in the absence of traditional periodontal therapy.

infection control and/or sterilization. Cigna Dental considers
this to be incidental to and part of the charges for services
provided and not separately chargeable.

the recementation of any inlay, onlay, crown, post and core or
fixed bridge within 180 days of initial placement. Cigna
Dental considers recementation within this timeframe to be
incidental to and part of the charges for the initial restoration.
Office Transfers
If you decide to change Dental Offices, we can arrange a
transfer. You should complete any dental procedure in
progress before transferring to another Dental Office. To
arrange a transfer, call Member Services at 1-800-Cigna24. To
obtain a list of Dental Offices near you, visit our website at
myCigna.com, or call the Dental Office Locator at 1-800Cigna24. Your transfer request will take about 5 days to
process. Transfers will be effective the first day of the month
after the processing of your request. Unless you have an
emergency, you will be unable to schedule an appointment at
the new Dental Office until your transfer becomes effective.
There is no charge to you for the transfer; however, all Patient
Charges which you owe to your current Dental Office must be
paid before the transfer can be processed.

the recementation of any implant supported prosthesis
(including crowns, bridges and dentures) within 180 days of
initial placement. Cigna Dental considers recementation
within this timeframe to be incidental to and part of the
charges for the initial restoration unless specifically listed on
your Patient Charge Schedule.

services to correct congenital malformations, including the
replacement of congenitally missing teeth.

Pediatric Dentists – children's dentistry.

Endodontists – root canal treatment.
the replacement of an occlusal guard (night guard) beyond
one per any 24 consecutive month period when this
limitation is noted on your Patient Charge Schedule.

Periodontists – treatment of gums and bone.

Oral Surgeons – complex extractions and other surgical
procedures.

Orthodontists – tooth movement.


crowns, bridges and/or implant supported prosthesis used
solely for splinting.

resin bonded retainers and associated pontics.
Specialty Care
Your Network General Dentist at your Dental Office has
primary responsibility for your professional dental care.
Because you may need specialty care, the Cigna Dental
network includes the following types of specialty dentists:
When specialty care is needed, your Network General Dentist
must start the referral process. X-rays taken by your Network
General Dentist should be sent to the Network Specialty
Dentist.
Pre-existing conditions are not excluded if the procedures
involved are otherwise covered in your Patient Charge
Schedule.
Specialty Referrals
Should any law require coverage for any particular service(s)
noted above, the exclusion or limitation for that service(s)
shall not apply.
In General
Upon referral from a Network General Dentist, your Network
Specialty Dentist will submit a specialty care treatment plan to
Cigna Dental for payment authorization, except for Pediatric
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Dentistry and Endodontics, for which prior authorization is not
required. You should verify with the Network Specialty
Dentist that your treatment plan has been authorized for
payment by Cigna Dental before treatment begins.

Retention (Post Treatment Stabilization) – the period
following orthodontic treatment during which you may wear
an appliance to maintain and stabilize the new position of
the teeth.
When Cigna Dental authorizes payment to the Network
Specialty Dentist, the fees or no-charge services listed on the
Patient Charge Schedule in effect on the date each procedure
is started will apply, except as set out in the Orthodontics
section. Treatment by the Network Specialty Dentist must
begin within 90 days from the date of Cigna Dental’s
authorization. If you are unable to obtain treatment within the
90-day period, please call Member Services to request an
extension. Your coverage must be in effect when each
procedure begins.
Patient Charges
The Patient Charge for your entire orthodontic case, including
retention, will be based upon the Patient Charge Schedule in
effect on the date of your visit for Treatment Plan and
Records. However, if banding/appliance insertion does not
occur within 90 days of such visit; your treatment plan
changes; or there is an interruption in your coverage or
treatment, a later change in the Patient Charge Schedule may
apply.
The Patient Charge for Orthodontic Treatment is based upon
24 months of interceptive and/or comprehensive treatment. If
you require more than 24 months of treatment in total, you
will be charged an additional amount for each additional
month of treatment, based upon the Orthodontist's Contract
Fee. If you require less than 24 months of treatment, your
Patient Charge will be reduced on a prorated basis.
For non-Covered Services or if Cigna Dental does not
authorize payment to the Network Specialty Dentist for
Covered Services, including Adverse Determinations, you
must pay the Network Specialty Dentist’s Usual Fee. If you
have a question or concern regarding an authorization or a
denial, contact Member Services.
After the Network Specialty Dentist has completed treatment,
you should return to your Network General Dentist for
cleanings, regular checkups and other treatment. If you visit a
Network Specialty Dentist without a referral or if you continue
to see a Network Specialty Dentist after you have completed
specialty care, it will be your responsibility to pay for
treatment at the dentist’s Usual Fees.
Additional Charges
You will be responsible for the Orthodontist's Usual Fees for
the following non-Covered Services:

incremental costs associated with optional/elective
materials, including but not limited to ceramic, clear, lingual
brackets, or other cosmetic appliances;
When your Network General Dentist determines that you need
specialty care and a Network Specialty Dentist is not
available, as determined by Cigna Dental, Cigna Dental will
authorize a referral to a non-Network Specialty Dentist. The
referral procedures applicable to specialty care will apply. In
such cases, you will be responsible for the applicable Patient
Charge for Covered Services. Cigna Dental will reimburse the
non-network Dentist the difference, if any, between his or her
Usual Fee and the applicable Patient Charge. For non-Covered
Services or services not authorized for payment, including
Adverse Determinations, you must pay the dentist’s Usual
Fee.

orthognathic surgery and associated incremental costs;

appliances to guide minor tooth movement;

appliances to correct harmful habits; and

services which are not typically included in orthodontic
treatment. These services will be identified on a case-bycase basis.
Orthodontics in Progress
If orthodontic treatment is in progress for you or your
Dependent at the time you enroll, the fee listed on the Patient
Charge Schedule is not applicable. Please call Member
Services at 1-800-Cigna24 to find out if you are entitled to any
benefit under the Dental Plan.
Orthodontics - (This section is only applicable if Orthodontia
is listed on your Patient Charge Schedule.)
Complex Rehabilitation/Multiple Crown Units
Complex rehabilitation is extensive dental restoration
involving 6 or more "units" of crown, and/or bridge and/or
implant supported prosthesis (including crowns and bridges)
in the same treatment plan. Using full crowns (caps), and/or
fixed bridges and/or implant supported prosthesis (including
crowns and bridges) which are cemented in place, your
Network General Dentist will rebuild natural teeth, fill in
spaces where teeth are missing and establish conditions which
allow each tooth to function in harmony with the occlusion
(bite). The extensive procedures involved in complex
Definitions –
 Orthodontic Treatment Plan and Records – the
preparation of orthodontic records and a treatment plan by
the Orthodontist.

Interceptive Orthodontic Treatment – treatment prior to
full eruption of the permanent teeth, frequently a first phase
preceding comprehensive treatment.

Comprehensive Orthodontic Treatment – treatment after
the eruption of most permanent teeth, generally the final
phase of treatment before retention.
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rehabilitation require an extraordinary amount of time, effort,
skill and laboratory collaboration for a successful outcome.
contracted providers, and that limits or excludes benefits
provided by providers outside of the panel, except in the case
of emergency or if referred by a provider within the panel.
Complex rehabilitation will be covered when performed by
your Network General Dentist after consultation with you
about diagnosis, treatment plan and charges. Each tooth or
tooth replacement included in the treatment plan is referred to
as a "unit" on your Patient Charge Schedule. The crown, and
bridge and/or implant supported prosthesis (including crowns
and bridges) charges on your Patient Charge Schedule are for
each unit of crown or bridge. You pay the per unit charge for
each unit of crown, and/or bridge and/or implant supported
prosthesis (including crowns and bridges) PLUS an additional
charge for each unit when 6 or more units are prescribed in
your Network General Dentist's treatment plan.
Primary Plan
The Plan that determines and provides or pays benefits
without taking into consideration the existence of any other
Plan.
Secondary Plan
A Plan that determines, and may reduce its benefits after
taking into consideration, the benefits provided or paid by the
Primary Plan. A Secondary Plan may also recover from the
Primary Plan the Reasonable Cash Value of any services it
provided to you.
Allowable Expense
A necessary, reasonable and customary service or expense,
including deductibles, coinsurance or copayments, that is
covered in full or in part by any Plan covering you. When a
Plan provides benefits in the form of services, the Reasonable
Cash Value of each service is the Allowable Expense and is a
paid benefit.
Note: Complex rehabilitation only applies for implant
supported prosthesis, when implant supported prosthesis are
HC-DEN109
01-13
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Examples of expenses or services that are not Allowable
Expenses include, but are not limited to the following:
Coordination of Benefits
Under this dental plan Coordination of Benefits rules apply to
specialty care only.
This section applies if you or any one of your Dependents is
covered under more than one Plan and determines how
benefits payable from all such Plans will be coordinated. You
should file all claims with each Plan.
Definitions
For the purposes of this section, the following terms have the
meanings set forth below:
Plan
Any of the following that provides benefits or services for
medical or dental care or treatment:

Group insurance and/or group-type coverage, whether
insured or self-insured which neither can be purchased by
the general public, nor is individually underwritten,
including closed panel coverage.

Governmental benefits as permitted by law, excepting
Medicaid, Medicare and Medicare supplement policies.

Medical benefits coverage of group, group-type, and
individual automobile contracts.

An expense or service or a portion of an expense or service
that is not covered by any of the Plans is not an Allowable
Expense.

If you are covered by two or more Plans that provide
services or supplies on the basis of reasonable and
customary fees, any amount in excess of the highest
reasonable and customary fee is not an Allowable Expense.

If you are covered by one Plan that provides services or
supplies on the basis of reasonable and customary fees and
one Plan that provides services and supplies on the basis of
negotiated fees, the Primary Plan's fee arrangement shall be
the Allowable Expense.

If your benefits are reduced under the Primary Plan (through
the imposition of a higher copayment amount, higher
coinsurance percentage, a deductible and/or a penalty)
because you did not comply with Plan provisions or because
you did not use a preferred provider, the amount of the
reduction is not an Allowable Expense. Such Plan
provisions include second surgical opinions and
precertification of admissions or services.
Each Plan or part of a Plan which has the right to coordinate
benefits will be considered a separate Plan.
Claim Determination Period
A calendar year, but does not include any part of a year during
which you are not covered under this policy or any date before
this section or any similar provision takes effect.
Closed Panel Plan
A Plan that provides medical or dental benefits primarily in
the form of services through a panel of employed or
Reasonable Cash Value
An amount which a duly licensed provider of health care
services usually charges patients and which is within the range
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the Plans do not agree on the order of benefit determination,
the Plan with the gender rules shall determine the order of
benefits.
of fees usually charged for the same service by other health
care providers located within the immediate geographic area
where the health care service is rendered under similar or
comparable circumstances.
If none of the above rules determines the order of benefits, the
Plan that has covered you for the longer period of time shall
be primary.
Order of Benefit Determination Rules
A Plan that does not have a coordination of benefits rule
consistent with this section shall always be the Primary Plan.
If the Plan does have a coordination of benefits rule consistent
with this section, the first of the following rules that applies to
the situation is the one to use:

The Plan that covers you as an enrollee or an Member shall
be the Primary Plan and the Plan that covers you as a
Dependent shall be the Secondary Plan;

If you are a Dependent child whose parents are not divorced
or legally separated, the Primary Plan shall be the Plan
which covers the parent whose birthday falls first in the
calendar year as an enrollee or Member;

If you are the Dependent of divorced or separated parents,
benefits for the Dependent shall be determined in the
following order:




Effect on the Benefits of This Plan
If this Plan is the Secondary Plan, this Plan may reduce
benefits so that the total benefits paid by all Plans during a
Claim Determination Period are not more than 100% of the
total of all Allowable Expenses.
The difference between the amount that this Plan would have
paid if this Plan had been the Primary Plan, and the benefit
payments that this Plan had actually paid as the Secondary
Plan, will be recorded as a benefit reserve for you. Cigna will
use this benefit reserve to pay any Allowable Expense not
otherwise paid during the Claim Determination Period.
As each claim is submitted, Cigna will determine the
following:
first, if a court decree states that one parent is responsible
for the child's healthcare expenses or health coverage and
the Plan for that parent has actual knowledge of the terms
of the order, but only from the time of actual knowledge;

then, the Plan of the parent with custody of the child;

then, the Plan of the spouse of the parent with custody of
the child;

then, the Plan of the parent not having custody of the
child, and

finally, the Plan of the spouse of the parent not having
custody of the child.

Cigna’s obligation to provide services and supplies under
this policy;

whether a benefit reserve has been recorded for you; and

whether there are any unpaid Allowable Expenses during
the Claims Determination Period.
If there is a benefit reserve, Cigna will use the benefit reserve
recorded for you to pay up to 100% of the total of all
Allowable Expenses. At the end of the Claim Determination
Period, your benefit reserve will return to zero and a new
benefit reserve will be calculated for each new Claim
Determination Period.
Recovery of Excess Benefits
If Cigna pays charges for benefits that should have been paid
by the Primary Plan, or if Cigna pays charges in excess of
those for which we are obligated to provide under the Policy,
Cigna will have the right to recover the actual payment made
or the Reasonable Cash Value of any services.
The Plan that covers you as an active Member (or as that
Member's Dependent) shall be the Primary Plan and the
Plan that covers you as laid-off or retired Member (or as
that Member's Dependent) shall be the secondary Plan. If
the other Plan does not have a similar provision and, as a
result, the Plans cannot agree on the order of benefit
determination, this paragraph shall not apply.
Cigna will have sole discretion to seek such recovery from any
person to, or for whom, or with respect to whom, such
services were provided or such payments made by any
insurance company, healthcare plan or other organization. If
we request, you must execute and deliver to us such
instruments and documents as we determine are necessary to
secure the right of recovery.
The Plan that covers you under a right of continuation
which is provided by federal or state law shall be the
Secondary Plan and the Plan that covers you as an active
Member or retiree (or as that Member's Dependent) shall be
the Primary Plan. If the other Plan does not have a similar
provision and, as a result, the Plans cannot agree on the
order of benefit determination, this paragraph shall not
apply.
Right to Receive and Release Information
Cigna, without consent or notice to you, may obtain
information from and release information to any other Plan
with respect to you in order to coordinate your benefits
pursuant to this section. You must provide us with any
information we request in order to coordinate your benefits
If one of the Plans that covers you is issued out of the state
whose laws govern this Policy, and determines the order of
benefits based upon the gender of a parent, and as a result,
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pursuant to this section. This request may occur in connection
with a submitted claim; if so, you will be advised that the
"other coverage" information, (including an Explanation of
Benefits paid under the Primary Plan) is required before the
claim will be processed for payment. If no response is
received within 90 days of the request, the claim will be
denied. If the requested information is subsequently received,
the claim will be processed.
HC-COB58

agrees that this lien shall constitute a charge against the
proceeds of any recovery and the plan shall be entitled to
assert a security interest thereon;

agrees to hold the proceeds of any recovery in trust for the
benefit of the plan to the extent of any payment made by the
plan.
Additional Terms
 No adult Participant hereunder may assign any rights that it
may have to recover medical expenses from any third party
or other person or entity to any minor Dependent of said
adult Participant without the prior express written consent
of the plan. The plan’s right to recover shall apply to
decedents’, minors’, and incompetent or disabled persons’
settlements or recoveries.
04-10
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Expenses For Which A Third Party May
Be Responsible

No Participant shall make any settlement, which specifically
reduces or excludes, or attempts to reduce or exclude, the
benefits provided by the plan.

The plan’s right of recovery shall be a prior lien against any
proceeds recovered by the Participant. This right of
recovery shall not be defeated nor reduced by the
application of any so-called “Made-Whole Doctrine”,
“Rimes Doctrine”, or any other such doctrine purporting to
defeat the plan’s recovery rights by allocating the proceeds
exclusively to non-medical expense damages.

No Participant hereunder shall incur any expenses on behalf
of the plan in pursuit of the plan’s rights hereunder,
specifically; no court costs, attorneys' fees or other
representatives' fees may be deducted from the plan’s
recovery without the prior express written consent of the
plan. This right shall not be defeated by any so-called “Fund
Doctrine”, “Common Fund Doctrine”, or “Attorney’s Fund
Doctrine”.

The plan shall recover the full amount of benefits provided
hereunder without regard to any claim of fault on the part of
any Participant, whether under comparative negligence or
otherwise.

In the event that a Participant shall fail or refuse to honor its
obligations hereunder, then the plan shall be entitled to
recover any costs incurred in enforcing the terms hereof
including, but not limited to, attorney’s fees, litigation, court
costs, and other expenses. The plan shall also be entitled to
offset the reimbursement obligation against any entitlement
to future medical benefits hereunder until the Participant has
fully complied with his reimbursement obligations
hereunder, regardless of how those future medical benefits
are incurred.

Any reference to state law in any other provision of this
plan shall not be applicable to this provision, if the plan is
governed by ERISA. By acceptance of benefits under the
plan, the Participant agrees that a breach hereof would cause
irreparable and substantial harm and that no adequate
This plan does not cover:

Expenses incurred by you or your Dependent (hereinafter
individually and collectively referred to as a "Participant,")
for which another party may be responsible as a result of
having caused or contributed to an Injury or Sickness.

Expenses incurred by a Participant to the extent any
payment is received for them either directly or indirectly
from a third party tortfeasor or as a result of a settlement,
judgment or arbitration award in connection with any
automobile medical, automobile no-fault, uninsured or
underinsured motorist, homeowners, workers'
compensation, government insurance (other than Medicaid),
or similar type of insurance or coverage.
Right Of Reimbursement
If a Participant incurs a Covered Expense for which, in the
opinion of the plan or its claim administrator, another party
may be responsible or for which the Participant may receive
payment as described above, the plan is granted a right of
reimbursement, to the extent of the benefits provided by the
plan, from the proceeds of any recovery whether by
settlement, judgment, or otherwise.
Lien Of The Plan
By accepting benefits under this plan, a Participant:

grants a lien and assigns to the plan an amount equal to the
benefits paid under the plan against any recovery made by
or on behalf of the Participant which is binding on any
attorney or other party who represents the Participant
whether or not an agent of the Participant or of any
insurance company or other financially responsible party
against whom a Participant may have a claim provided said
attorney, insurance carrier or other party has been notified
by the plan or its agents;
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remedy at law would exist. Further, the plan shall be
entitled to invoke such equitable remedies as may be
necessary to enforce the terms of the plan, including, but not
limited to, specific performance, restitution, the imposition
of an equitable lien and/or constructive trust, as well as
injunctive relief.
HC-SUB2
Miscellaneous
Certain Dental Offices may provide discounts on services not
listed on the Patient Charge Schedule, including a 10%
discount on bleaching services. You should contact your
participating Dental Office to determine if such discounts are
offered.
If you are a Cigna Dental plan member you may be eligible
for additional dental benefits during certain episodes of care.
For example, certain frequency limitations for dental services
may be relaxed for pregnant women, diabetics or those with
cardiac disease. Please review your plan enrollment materials
for details.
04-10
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Payment of Benefits
To Whom Payable
Dental Benefits are assignable to the provider. When you
assign benefits to a provider, you have assigned the entire
amount of the benefits due on that claim. If the provider is
overpaid because of accepting a patient’s payment on the
charge, it is the provider’s responsibility to reimburse the
patient. Because of Cigna’s contracts with providers, all
claims from contracted providers should be assigned.
HC-POB27
V1
Termination of Insurance
Members
Cigna may, at its option, make payment to you for the cost of
any Covered Expenses from a Non-Participating Provider
even if benefits have been assigned. When benefits are paid to
you or your Dependent, you or your Dependents are
responsible for reimbursing the provider.
Your insurance will cease on the earliest date below:
If any person to whom benefits are payable is a minor or, in
the opinion of Cigna is not able to give a valid receipt for any
payment due him, such payment will be made to his legal
guardian. If no request for payment has been made by his legal
guardian, Cigna may, at its option, make payment to the
person or institution appearing to have assumed his custody
and support.

the date you cease to be in a Class of Eligible Members or
cease to qualify for the insurance.

the last day for which you have made any required
contribution for the insurance.

the date the policy is canceled.

as defined by UNITE HERE HEALTH except as described
below.
Any continuation of insurance must be based on a plan which
precludes individual selection.
Temporary Layoff or Leave of Absence
If your Active Service ends due to temporary layoff or leave
of absence, your insurance will be continued until the date
your Fund: stops paying premium for you; or otherwise
cancels your insurance. However, your insurance will not be
continued for more than 60 days past the date your Active
Service ends.
When one of our participants passes away, Cigna may receive
notice that an executor of the estate has been established. The
executor has the same rights as our insured and benefit
payments for unassigned claims should be made payable to the
executor.
Payment as described above will release Cigna from all
liability to the extent of any payment made.
Injury or Sickness
If your Active Service ends due to an Injury or Sickness, your
insurance will be continued while you remain totally and
continuously disabled as a result of the Injury or Sickness.
However, the insurance will not continue past the date your
Fund stops paying premium for you or otherwise cancels the
insurance.
Recovery of Overpayment
When an overpayment has been made by Cigna, Cigna will
have the right at any time to: recover that overpayment from
the person to whom or on whose behalf it was made; or offset
the amount of that overpayment from a future claim payment.
HC-POB4
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Note:
When a person’s Dental Insurance ceases, Cigna does not
offer any Converted Policy either on an individual or group
basis. However, upon termination of insurance due to
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termination of employment in an eligible class or ceasing to
qualify as a Dependent, you or any of your Dependents may
apply to Cigna Dental Health, Inc. for coverage under an
individual dental plan.
Federal Requirements
The following pages explain your rights and responsibilities
under federal laws and regulations. Some states may have
similar requirements. If a similar provision appears elsewhere
in this booklet, the provision which provides the better benefit
will apply.
Upon request, Cigna Dental Health Inc. or your Fund will
provide you with further details of the Converted Policy.
Dependents
HC-FED1
Your insurance for all of your Dependents will cease on the
earliest date below:

the date your insurance ceases.

the date you cease to be eligible for Dependent Insurance.

the last day for which you have made any required
contribution for the insurance.

the date Dependent Insurance is canceled.
Notice of Provider Directory/Networks
Notice Regarding Provider Directories and Provider
Networks
If your Plan utilizes a network of Providers, a separate listing
of Participating Providers who participate in the network is
available to you without charge by visiting www.cigna.com;
mycigna.com or by calling the toll-free telephone number on
your ID card.
The insurance for any one of your Dependents will cease on
the date that Dependent no longer qualifies as a Dependent.
HC-TRM72
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Your Participating Provider network consists of a group of
local dental practitioners, of varied specialties as well as
general practice, who are employed by or contracted with
Cigna HealthCare or Cigna Dental Health.
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Dental Benefits Extension
HC-FED2
An expense incurred in connection with a Dental Service that
is completed after a person's benefits cease will be deemed to
be incurred while he is insured if:

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Qualified Medical Child Support Order
(QMCSO)
for fixed bridgework and full or partial dentures, the first
impressions are taken and/or abutment teeth fully prepared
while he is insured and the device installed or delivered to
him within 3 calendar months after his insurance ceases.

for a crown, inlay or onlay, the tooth is prepared while he is
insured and the crown, inlay or onlay installed within 3
calendar months after his insurance ceases.
Eligibility for Coverage Under a QMCSO
If a Qualified Medical Child Support Order (QMCSO) is
issued for your child, that child will be eligible for coverage as
required by the order and you will not be considered a Late
Entrant for Dependent Insurance.

for root canal therapy, the pulp chamber of the tooth is
opened while he is insured and the treatment is completed
within 3 calendar months after his insurance ceases.
You must notify your Fund and elect coverage for that child,
and yourself if you are not already enrolled, within 31 days of
the QMCSO being issued.
There is no extension for any Dental Service not shown above.
This extension of benefits does not apply if insurance ceases
due to nonpayment of premiums.
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Qualified Medical Child Support Order Defined
A Qualified Medical Child Support Order is a judgment,
decree or order (including approval of a settlement agreement)
or administrative notice, which is issued pursuant to a state
domestic relations law (including a community property law),
or to an administrative process, which provides for child
support or provides for health benefit coverage to such child
and relates to benefits under the group health plan, and
satisfies all of the following:


A. Coverage Elections
Per Section 125 regulations, you are generally allowed to
enroll for or change coverage only before each annual benefit
period. However, exceptions are allowed if your Fund agrees
and you enroll for or change coverage within 30 days of the
following:

B. Change of Status
A change in status is defined as:
the order recognizes or creates a child’s right to receive
group health benefits for which a participant or beneficiary
is eligible;
the order specifies your name and last known address, and
the child’s name and last known address, except that the
name and address of an official of a state or political
subdivision may be substituted for the child’s mailing
address;

the order provides a description of the coverage to be
provided, or the manner in which the type of coverage is to
be determined;

the order states the period to which it applies; and

if the order is a National Medical Support Notice completed
in accordance with the Child Support Performance and
Incentive Act of 1998, such Notice meets the requirements
above.
The QMCSO may not require the health insurance policy to
provide coverage for any type or form of benefit or option not
otherwise provided under the policy, except that an order may
require a plan to comply with State laws regarding health care
coverage.

change in legal marital status due to marriage, death of a
spouse, divorce, annulment or legal separation;

change in number of Dependents due to birth, adoption,
placement for adoption, or death of a Dependent;

change in employment status of Member, spouse or
Dependent due to termination or start of employment,
strike, lockout, beginning or end of unpaid leave of absence,
including under the Family and Medical Leave Act
(FMLA), or change in worksite;

changes in employment status of Member, spouse or
Dependent resulting in eligibility or ineligibility for
coverage;

change in residence of Member, spouse or Dependent to a
location outside of the Fund’s network service area; and

changes which cause a Dependent to become eligible or
ineligible for coverage.
C. Court Order
A change in coverage due to and consistent with a court order
of the Member or other person to cover a Dependent.
Payment of Benefits
Any payment of benefits in reimbursement for Covered
Expenses paid by the child, or the child’s custodial parent or
legal guardian, shall be made to the child, the child’s custodial
parent or legal guardian, or a state official whose name and
address have been substituted for the name and address of the
child.
HC-FED4
the date you meet the criteria shown in the following
Sections B through H.
D. Medicare or Medicaid Eligibility/Entitlement
The Member, spouse or Dependent cancels or reduces
coverage due to entitlement to Medicare or Medicaid, or
enrolls or increases coverage due to loss of Medicare or
Medicaid eligibility.
E. Change in Cost of Coverage
If the cost of benefits increases or decreases during a benefit
period, your Fund may, in accordance with plan terms,
automatically change your elective contribution.
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When the change in cost is significant, you may either
increase your contribution or elect less-costly coverage. When
a significant overall reduction is made to the benefit option
you have elected, you may elect another available benefit
option. When a new benefit option is added, you may change
your election to the new benefit option.
Effect of Section 125 Tax Regulations on This
Plan
Your Fund has chosen to administer this Plan in accordance
with Section 125 regulations of the Internal Revenue Code.
Per this regulation, you may agree to a pretax salary reduction
put toward the cost of your benefits. Otherwise, you will
receive your taxable earnings as cash (salary).
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F. Changes in Coverage of Spouse or Dependent Under
Another Fund’s Plan
You may make a coverage election change if the plan of your
spouse or Dependent: incurs a change such as adding or
deleting a benefit option; allows election changes due to
Change in Status, Court Order or Medicare or Medicaid
Eligibility/Entitlement; or this Plan and the other plan have
different periods of coverage or open enrollment periods.
Group Plan Coverage Instead of Medicaid
G. Reduction in work hours
If an Member’s work hours are reduced below 30 hours/week
(even if it does not result in the Member losing eligibility for
the Fund’s coverage); and the Member (and family) intend to
enroll in another plan that provides Minimum Essential
Coverage (MEC). The new coverage must be effective no later
than the 1st day of the 2nd month following the month that
includes the date the original coverage is revoked.
HC-FED13
If your income and liquid resources do not exceed certain
limits established by law, the state may decide to pay
premiums for this coverage instead of for Medicaid, if it is
cost effective. This includes premiums for continuation
coverage required by federal law.
Requirements of Medical Leave Act of 1993 (as
amended) (FMLA)
Any provisions of the policy that provide for: continuation of
insurance during a leave of absence; and reinstatement of
insurance following a return to Active Service; are modified
by the following provisions of the federal Family and Medical
Leave Act of 1993, as amended, where applicable:
H. Enrollment in Qualified Health Plan (QHP)
The Member must be eligible for a Special Enrollment Period
to enroll in a QHP through a Marketplace or the Member
wants to enroll in a QHP through a Marketplace during the
Marketplace’s annual open enrollment period; and the
disenrollment from the group plan corresponds to the intended
enrollment of the Member (and family) in a QHP through a
Marketplace for new coverage effective beginning no later
than the day immediately following the last day of the original
coverage.
HC-FED70
Continuation of Health Insurance During Leave
Your health insurance will be continued during a leave of
absence if:

that leave qualifies as a leave of absence under the Family
and Medical Leave Act of 1993, as amended; and

you are an eligible Member under the terms of that Act.
The cost of your health insurance during such leave must be
paid, whether entirely by your Fund or in part by you and your
Fund.
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Reinstatement of Canceled Insurance Following Leave
Upon your return to Active Service following a leave of
absence that qualifies under the Family and Medical Leave
Act of 1993, as amended, any canceled insurance (health, life
or disability) will be reinstated as of the date of your return.
Eligibility for Coverage for Adopted Children
Any child who is adopted by you, including a child who is
placed with you for adoption, will be eligible for Dependent
Insurance, if otherwise eligible as a Dependent, upon the date
of placement with you. A child will be considered placed for
adoption when you become legally obligated to support that
child, totally or partially, prior to that child’s adoption.
You will not be required to satisfy any eligibility or benefit
waiting period to the extent that they had been satisfied prior
to the start of such leave of absence.
Your Fund will give you detailed information about the
Family and Medical Leave Act of 1993, as amended.
If a child placed for adoption is not adopted, all health
coverage ceases when the placement ends, and will not be
continued.
HC-FED17
The provisions in the “Exception for Newborns” section of
this document that describe requirements for enrollment and
effective date of insurance will also apply to an adopted child
or a child placed with you for adoption.
HC-FED67
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Uniformed Services Employment and ReEmployment Rights Act of 1994 (USERRA)
The Uniformed Services Employment and Re-employment
Rights Act of 1994 (USERRA) sets requirements for
continuation of health coverage and re-employment in regard
to an Member’s military leave of absence. These requirements
apply to medical and dental coverage for you and your
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Dependents. They do not apply to any Life, Short-term or
Long-term Disability or Accidental Death & Dismemberment
coverage you may have.
You or your authorized representative (typically, your health
care provider) must request Medical Necessity determinations
according to the procedures described below, in the
Certificate, and in your provider’s network participation
documents as applicable.
Continuation of Coverage
For leaves of less than 31 days, coverage will continue as
described in the Termination section regarding Leave of
Absence.
When services or benefits are determined to be not Medically
Necessary, you or your representative will receive a written
description of the adverse determination, and may appeal the
determination. Appeal procedures are described in the
Certificate, in your provider’s network participation
documents, and in the determination notices.
For leaves of 31 days or more, you may continue coverage for
yourself and your Dependents as follows:
You may continue benefits by paying the required premium to
your Fund, until the earliest of the following:

24 months from the last day of employment with the Fund;

the day after you fail to return to work; and

the date the policy cancels.
Postservice Medical Necessity Determinations
When you or your representative requests a Medical Necessity
determination after services have been rendered, Cigna will
notify you or your representative of the determination within
30 days after receiving the request. However, if more time is
needed to make a determination due to matters beyond
Cigna’s control Cigna will notify you or your representative
within 30 days after receiving the request. This notice will
include the date a determination can be expected, which will
be no more than 45 days after receipt of the request.
Your Fund may charge you and your Dependents up to 102%
of the total premium.
Following continuation of health coverage per USERRA
requirements, you may convert to a plan of individual
coverage according to any “Conversion Privilege” shown in
your certificate.
If more time is needed because necessary information is
missing from the request, the notice will also specify what
information is needed. The determination period will be
suspended on the date Cigna sends such a notice of missing
information, and the determination period will resume on the
date you or your representative responds to the notice.
Reinstatement of Benefits (applicable to all coverages)
If your coverage ends during the leave of absence because you
do not elect USERRA or an available conversion plan at the
expiration of USERRA and you are reemployed by your
current Fund, coverage for you and your Dependents may be
reinstated if you gave your Fund advance written or verbal
notice of your military service leave, and the duration of all
military leaves while you are employed with your current
Fund does not exceed 5 years.
Postservice Claim Determinations
When you or your representative requests payment for
services which have been rendered, Cigna will notify you of
the claim payment determination within 30 days after
receiving the request. However, if more time is needed to
make a determination due to matters beyond Cigna’s control,
Cigna will notify you or your representative within 30 days
after receiving the request. This notice will include the date a
determination can be expected, which will be no more than 45
days after receipt of the request. If more time is needed
because necessary information is missing from the request, the
notice will also specify what information is needed, and you or
your representative must provide the specified information
within 45 days after receiving the notice. The determination
period will be suspended on the date Cigna sends such a notice
of missing information, and resume on the date you or your
representative responds to the notice.
You and your Dependents will be subject to only the balance
of a waiting period that was not yet satisfied before the leave
began. However, if an Injury or Sickness occurs or is
aggravated during the military leave, full Plan limitations will
apply.
If your coverage under this plan terminates as a result of your
eligibility for military medical and dental coverage and your
order to active duty is canceled before your active duty service
commences, these reinstatement rights will continue to apply.
HC-FED18
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Notice of Adverse Determination
Every notice of an adverse benefit determination will be
provided in writing or electronically, and will include all of
the following that pertain to the determination:
Claim Determination Procedures Under ERISA
Procedures Regarding Medical Necessity Determinations
In general, health services and benefits must be Medically
Necessary to be covered under the plan. The procedures for
determining Medical Necessity vary, according to the type of
service or benefit requested, and the type of health plan.

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the specific reason or reasons for the adverse determination;
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
reference to the specific plan provisions on which the
determination is based;

a description of any additional material or information
necessary to perfect the claim and an explanation of why
such material or information is necessary;

For your Dependents, COBRA continuation coverage is
available for up to 36 months from the date of the following
qualifying events if the event would result in a loss of
coverage under the Plan:
a description of the plan’s review procedures and the time
limits applicable, including a statement of a claimant’s
rights to bring a civil action under section 502(a) of ERISA
following an adverse benefit determination on appeal;

upon request and free of charge, a copy of any internal rule,
guideline, protocol or other similar criterion that was relied
upon in making the adverse determination regarding your
claim, and an explanation of the scientific or clinical
judgment for a determination that is based on a Medical
Necessity, experimental treatment or other similar exclusion
or limit; and

in the case of a claim involving urgent care, a description of
the expedited review process applicable to such claim.
HC-FED20
For You and Your Dependents
What is COBRA Continuation Coverage?
Under federal law, you and/or your Dependents must be given
the opportunity to continue health insurance when there is a
“qualifying event” that would result in loss of coverage under
the Plan. You and/or your Dependents will be permitted to
continue the same coverage under which you or your
Dependents were covered on the day before the qualifying
event occurred, unless you move out of that plan’s coverage
area or the plan is no longer available. You and/or your
Dependents cannot change coverage options until the next
open enrollment period.
your reduction in work hours.
your divorce or legal separation; or

for a Dependent child, failure to continue to qualify as a
Dependent under the Plan.
Secondary Qualifying Events
If, as a result of your termination of employment or reduction
in work hours, your Dependent(s) have elected COBRA
continuation coverage and one or more Dependents experience
another COBRA qualifying event, the affected Dependent(s)
may elect to extend their COBRA continuation coverage for
an additional 18 months (7 months if the secondary event
occurs within the disability extension period) for a maximum
of 36 months from the initial qualifying event. The second
qualifying event must occur before the end of the initial 18
months of COBRA continuation coverage or within the
disability extension period discussed below. Under no
circumstances will COBRA continuation coverage be
available for more than 36 months from the initial qualifying
event. Secondary qualifying events are: your death; your
divorce or legal separation; or, for a Dependent child, failure
to continue to qualify as a Dependent under the Plan.
When is COBRA Continuation Available?
For you and your Dependents, COBRA continuation is


The following individuals are not qualified beneficiaries for
purposes of COBRA continuation: domestic partners,
grandchildren (unless adopted by you), stepchildren (unless
adopted by you). Although these individuals do not have an
independent right to elect COBRA continuation coverage, if
you elect COBRA continuation coverage for yourself, you
may also cover your Dependents even if they are not
considered qualified beneficiaries under COBRA. However,
such individuals’ coverage will terminate when your COBRA
continuation coverage terminates. The sections titled
“Secondary Qualifying Events” and “Medicare Extension For
Your Dependents” are not applicable to these individuals.
COBRA Continuation Rights Under Federal
Law
your termination of employment for any reason, other than
gross misconduct; or
your death;
Who is Entitled to COBRA Continuation?
Only a “qualified beneficiary” (as defined by federal law) may
elect to continue health insurance coverage. A qualified
beneficiary may include the following individuals who were
covered by the Plan on the day the qualifying event occurred:
you, your spouse, and your Dependent children. Each
qualified beneficiary has their own right to elect or decline
COBRA continuation coverage even if you decline or are not
eligible for COBRA continuation.
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

Disability Extension
If, after electing COBRA continuation coverage due to your
termination of employment or reduction in work hours, you or
one of your Dependents is determined by the Social Security
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provision is no longer applicable; or the occurrence of an
event described in one of the first three bullets above;
Administration (SSA) to be totally disabled under Title II or
XVI of the SSA, you and all of your Dependents who have
elected COBRA continuation coverage may extend such
continuation for an additional 11 months, for a maximum of
29 months from the initial qualifying event.

To qualify for the disability extension, all of the following
requirements must be satisfied:


any reason the Plan would terminate coverage of a
participant or beneficiary who is not receiving continuation
coverage (e.g., fraud).
Fund’s Notification Requirements
Your Fund is required to provide you and/or your Dependents
with the following notices:
SSA must determine that the disability occurred prior to or
within 60 days after the disabled individual elected COBRA
continuation coverage; and

An initial notification of COBRA continuation rights must
be provided within 90 days after your (or your spouse’s)
coverage under the Plan begins (or the Plan first becomes
subject to COBRA continuation requirements, if later). If
you and/or your Dependents experience a qualifying event
before the end of that 90-day period, the initial notice must
be provided within the time frame required for the COBRA
continuation coverage election notice as explained below.

A COBRA continuation coverage election notice must be
provided to you and/or your Dependents within the
following timeframes:
A copy of the written SSA determination must be provided
to the Plan Administrator within 60 calendar days after the
date the SSA determination is made AND before the end of
the initial 18-month continuation period.
If the SSA later determines that the individual is no longer
disabled, you must notify the Plan Administrator within 30
days after the date the final determination is made by SSA.
The 11-month disability extension will terminate for all
covered persons on the first day of the month that is more than
30 days after the date the SSA makes a final determination
that the disabled individual is no longer disabled.

if the Plan provides that COBRA continuation coverage
and the period within which an Fund must notify the Plan
Administrator of a qualifying event starts upon the loss of
coverage, 44 days after loss of coverage under the Plan;

if the Plan provides that COBRA continuation coverage
and the period within which an Fund must notify the Plan
Administrator of a qualifying event starts upon the
occurrence of a qualifying event, 44 days after the
qualifying event occurs; or

in the case of a multi- Fund plan, no later than 14 days
after the end of the period in which Funds must provide
notice of a qualifying event to the Plan Administrator.
All causes for “Termination of COBRA Continuation” listed
below will also apply to the period of disability extension.
Medicare Extension for Your Dependents
When the qualifying event is your termination of employment
or reduction in work hours and you became enrolled in
Medicare (Part A, Part B or both) within the 18 months before
the qualifying event, COBRA continuation coverage for your
Dependents will last for up to 36 months after the date you
became enrolled in Medicare. Your COBRA continuation
coverage will last for up to 18 months from the date of your
termination of employment or reduction in work hours.
How to Elect COBRA Continuation Coverage
The COBRA coverage election notice will list the individuals
who are eligible for COBRA continuation coverage and
inform you of the applicable premium. The notice will also
include instructions for electing COBRA continuation
coverage. You must notify the Plan Administrator of your
election no later than the due date stated on the COBRA
election notice. If a written election notice is required, it must
be post-marked no later than the due date stated on the
COBRA election notice. If you do not make proper
notification by the due date shown on the notice, you and your
Dependents will lose the right to elect COBRA continuation
coverage. If you reject COBRA continuation coverage before
the due date, you may change your mind as long as you
furnish a completed election form before the due date.
Termination of COBRA Continuation
COBRA continuation coverage will be terminated upon the
occurrence of any of the following:

the end of the COBRA continuation period of 18, 29 or 36
months, as applicable;

failure to pay the required premium within 30 calendar days
after the due date;

cancellation of the Fund’s policy with Cigna;

after electing COBRA continuation coverage, a qualified
beneficiary enrolls in Medicare (Part A, Part B, or both);

beneficiary becomes covered under another group health
plan, unless the qualified beneficiary has a condition for
which the new plan limits or excludes coverage under a preexisting condition provision. In such case coverage will
continue until the earliest of: the end of the applicable
maximum period; the date the pre-existing condition
Each qualified beneficiary has an independent right to elect
COBRA continuation coverage. Continuation coverage may
be elected for only one, several, or for all Dependents who are
qualified beneficiaries. Parents may elect to continue coverage
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confirm coverage during this time may be informed that
coverage has been suspended. If payment is received before
the end of the grace period, your coverage will be reinstated
back to the beginning of the coverage period. This means that
any claim you submit for benefits while your coverage is
suspended may be denied and may have to be resubmitted
once your coverage is reinstated. If you fail to make a
payment before the end of the grace period for that coverage
period, you will lose all rights to COBRA continuation
coverage under the Plan.
on behalf of their Dependent children. You or your spouse
may elect continuation coverage on behalf of all the qualified
beneficiaries. You are not required to elect COBRA
continuation coverage in order for your Dependents to elect
COBRA continuation.
How Much Does COBRA Continuation Coverage Cost?
Each qualified beneficiary may be required to pay the entire
cost of continuation coverage. The amount may not exceed
102% of the cost to the group health plan (including both Fund
and Member contributions) for coverage of a similarly
situated active Member or family member. The premium
during the 11-month disability extension may not exceed
situated active Member or family member.
You Must Give Notice of Certain Qualifying Events
If you or your Dependent(s) experience one of the following
qualifying events, you must notify the Plan Administrator
within 60 calendar days after the later of the date the
qualifying event occurs or the date coverage would cease as a
result of the qualifying event:
For example: If the Member alone elects COBRA
continuation coverage, the Member will be charged 102% (or
150%) of the active Member premium. If the spouse or one
Dependent child alone elects COBRA continuation coverage,
they will be charged 102% (or 150%) of the active Member
premium. If more than one qualified beneficiary elects
COBRA continuation coverage, they will be charged 102% (or
150%) of the applicable family premium.

Your divorce or legal separation; or

Your child ceases to qualify as a Dependent under the Plan.

The occurrence of a secondary qualifying event as discussed
under “Secondary Qualifying Events” above (this notice
must be received prior to the end of the initial 18- or 29month COBRA period).
(Also refer to the section titled “Disability Extension” for
additional notice requirements.)
When and How to Pay COBRA Premiums
First payment for COBRA continuation
Notice must be made in writing and must include: the name of
the Plan, name and address of the Member covered under the
Plan, name and address(es) of the qualified beneficiaries
affected by the qualifying event; the qualifying event; the date
the qualifying event occurred; and supporting documentation
(e.g., divorce decree, birth certificate, disability determination,
etc.).
If you elect COBRA continuation coverage, you do not have
to send any payment with the election form. However, you
must make your first payment no later than 45 calendar days
after the date of your election. (This is the date the Election
Notice is postmarked, if mailed.) If you do not make your first
payment within that 45 days, you will lose all COBRA
continuation rights under the Plan.
Newly Acquired Dependents
If you acquire a new Dependent through marriage, birth,
adoption or placement for adoption while your coverage is
being continued, you may cover such Dependent under your
COBRA continuation coverage. However, only your newborn
or adopted Dependent child is a qualified beneficiary and may
continue COBRA continuation coverage for the remainder of
the coverage period following your early termination of
COBRA coverage or due to a secondary qualifying event.
COBRA coverage for your Dependent spouse and any
Dependent children who are not your children (e.g.,
stepchildren or grandchildren) will cease on the date your
COBRA coverage ceases and they are not eligible for a
secondary qualifying event.
Subsequent payments
After you make your first payment for COBRA continuation
coverage, you will be required to make subsequent payments
of the required premium for each additional month of
coverage. Payment is due on the first day of each month. If
you make a payment on or before its due date, your coverage
under the Plan will continue for that coverage period without
any break.
Grace periods for subsequent payments
Although subsequent payments are due by the first day of the
month, you will be given a grace period of 30 days after the
first day of the coverage period to make each monthly
payment. Your COBRA continuation coverage will be
provided for each coverage period as long as payment for that
coverage period is made before the end of the grace period for
that payment. However, if your payment is received after the
due date, your coverage under the Plan may be suspended
during this time. Any providers who contact the Plan to
COBRA Continuation for Retirees Following Fund’s
Bankruptcy
If you are covered as a retiree, and a proceeding in bankruptcy
is filed with respect to the Fund under Title 11 of the United
States Code, you may be entitled to COBRA continuation
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coverage. If the bankruptcy results in a loss of coverage for
you, your Dependents or your surviving spouse within one
year before or after such proceeding, you and your covered
Dependents will become COBRA qualified beneficiaries with
respect to the bankruptcy. You will be entitled to COBRA
continuation coverage until your death. Your surviving spouse
and covered Dependent children will be entitled to COBRA
continuation coverage for up to 36 months following your
death. However, COBRA continuation coverage will cease
upon the occurrence of any of the events listed under
“Termination of COBRA Continuation” above.
Plan Trustees
A list of any Trustees of the Plan, which includes name, title
and address, is available upon request to the Plan
Administrator.
Plan Type
The plan is a healthcare benefit plan.
Collective Bargaining Agreements
You may contact the Plan Administrator to determine whether
the Plan is maintained pursuant to one or more collective
bargaining agreements and if a particular Fund is a sponsor. A
copy is available for examination from the Plan Administrator
upon written request.
Interaction With Other Continuation Benefits
You may be eligible for other continuation benefits under state
law. Refer to the Termination section for any other
continuation benefits.
HC-FED66
Discretionary Authority
The Plan Administrator delegates to Cigna the discretionary
authority to interpret and apply plan terms and to make factual
determinations in connection with its review of claims under
the plan. Such discretionary authority is intended to include,
but not limited to, the determination of the eligibility of
persons desiring to enroll in or claim benefits under the plan,
the determination of whether a person is entitled to benefits
under the plan, and the computation of any and all benefit
payments. The Plan Administrator also delegates to Cigna the
discretionary authority to perform a full and fair review, as
required by ERISA, of each claim denial which has been
appealed by the claimant or his duly authorized representative.
07-14 M
ERISA Required Information
The name of the Plan is:
UNITE HERE HEALTH
The name, address, ZIP code and business telephone number
of the sponsor of the Plan is:
UNITE HERE HEALTH
P.O.Box 6020
Aurora, IL 60598
(630) 236-5100
Employer Identification
Number (EIN):
Plan Number:
237385560
501
Plan Modification, Amendment and Termination
The Fund as Plan Sponsor reserves the right to, at any time,
change or terminate benefits under the Plan, to change or
terminate the eligibility of classes of employees to be covered
by the Plan, to amend or eliminate any other plan term or
condition, and to terminate the whole plan or any part of it.
Contact the Fund for the procedure by which benefits may be
changed or terminated, by which the eligibility of classes of
employees may be changed or terminated, or by which part or
all of the Plan may be terminated. No consent of any
participant is required to terminate, modify, amend or change
the Plan.
of the Plan Administrator is:
Fund named above
The name, address and ZIP code of the person designated as
agent for service of legal process is:
Termination of the Plan together with termination of the
insurance policy(s) which funds the Plan benefits will have no
adverse effect on any benefits to be paid under the policy(s)
for any covered medical expenses incurred prior to the date
that policy(s) terminates. Likewise, any extension of benefits
under the policy(s) due to you or your Dependent's total
disability which began prior to and has continued beyond the
date the policy(s) terminates will not be affected by the Plan
termination. Rights to purchase limited amounts of life and
medical insurance to replace part of the benefits lost because
the policy(s) terminated may arise under the terms of the
policy(s). A subsequent Plan termination will not affect the
extension of benefits and rights under the policy(s).
Fund named above
The office designated to consider the appeal of denied claims
is:
The Cigna Claim Office responsible for this Plan
The cost of the Plan is shared by Employee and Fund.
The Plan’s fiscal year ends on 03/31.
The preceding pages set forth the eligibility requirements and
benefits provided for you under this Plan.
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against you in any way to prevent you from obtaining a
welfare benefit or exercising your rights under ERISA. If your
claim for a welfare benefit is denied or ignored you have a
right to know why this was done, to obtain copies of
documents relating to the decision without charge, and to
appeal any denial, all within certain time schedules.
Your coverage under the Plan’s insurance policy(s) will end
on the earliest of the following dates:

the date you leave Active Service (or later as explained in
the Termination Section;)

the date you are no longer in an eligible class;

if the Plan is contributory, the date you cease to contribute;

the date the policy(s) terminates.
Enforce Your Rights
Under ERISA, there are steps you can take to enforce the
above rights. For instance, if you request a copy of documents
governing the plan or the latest annual report from the plan
and do not receive them within 30 days, you may file suit in a
federal court. In such a case, the court may require the plan
administrator to provide the materials and pay you up to $110
a day until you receive the materials, unless the materials were
not sent because of reasons beyond the control of the
administrator. If you have a claim for benefits which is denied
or ignored, in whole or in part, you may file suit in a state or
federal court.
See your Plan Administrator to determine if any extension of
benefits or rights are available to you or your Dependents
under this policy(s). No extension of benefits or rights will be
available solely because the Plan terminates.
Statement of Rights
As a participant in the plan you are entitled to certain rights
and protections under the Employee Retirement Income
Security Act of 1974 (ERISA). ERISA provides that all plan
participants shall be entitled to:
Receive Information About Your Plan and Benefits
 examine, without charge, at the Plan Administrator’s office
and at other specified locations, such as worksites and union
halls, all documents governing the plan, including insurance
contracts and collective bargaining agreements and a copy
of the latest annual report (Form 5500 Series) filed by the
plan with the U.S. Department of Labor and available at the
Public Disclosure room of the Employee Benefits Security
Administration.


In addition, if you disagree with the plan’s decision or lack
thereof concerning the qualified status of a domestic relations
order or a medical child support order, you may file suit in
federal court. If it should happen that plan fiduciaries misuse
the plan’s money, or if you are discriminated against for
asserting your rights, you may seek assistance from the U.S.
Department of Labor, or you may file suit in a federal court.
The court will decide who should pay court costs and legal
fees. If you are successful the court may order the person you
have sued to pay these costs and fees. If you lose, the court
may order you to pay these costs and fees, for example if it
finds your claim is frivolous.
obtain, upon written request to the Plan Administrator,
copies of documents governing the Plan, including
insurance contracts and collective bargaining agreements,
and a copy of the latest annual report (Form 5500 Series)
and updated summary plan description. The administrator
may make a reasonable charge for the copies.
Assistance with Your Questions
If you have any questions about your plan, you should contact
the plan administrator. If you have any questions about this
statement or about your rights under ERISA, or if you need
assistance in obtaining documents from the plan administrator,
you should contact the nearest office of the Employee Benefits
Security Administration, U.S. Department of Labor listed in
your telephone directory or the Division of Technical
Assistance and Inquiries, Employee Benefits Security
Administration, U.S. Department of Labor, 200 Constitution
Avenue N.W., Washington, D.C. 20210. You may also obtain
certain publications about your rights and responsibilities
under ERISA by calling the publications hotline of the
Employee Benefits Security Administration.
receive a summary of the Plan’s annual financial report. The
Plan Administrator is required by law to furnish each person
under the Plan with a copy of this summary financial report.
Continue Group Health Plan Coverage
 continue health care coverage for yourself, your spouse or
Dependents if there is a loss of coverage under the Plan as a
result of a qualifying event. You or your Dependents may
have to pay for such coverage. Review the documents
governing the Plan on the rules governing your federal
continuation coverage rights.
Prudent Actions by Plan Fiduciaries
In addition to creating rights for plan participants, ERISA
imposes duties upon the people responsible for the operation
of the employee benefit plan. The people who operate your
plan, called “fiduciaries” of the Plan, have a duty to do so
prudently and in the interest of you and other plan participants
and beneficiaries. No one, including your Fund, your union, or
any other person may fire you or otherwise discriminate
HC-FED72
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05-15 M
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Dental Conversion Privilege
Start with Member Services
We are here to listen and help. If you have a concern regarding
a person, a service, the quality of care, or contractual benefits,
you can call our toll-free number and explain your concern to
one of our Customer Service representatives. You can also
express that concern in writing. Please call or write to us at the
following:
Dental Conversion Privilege for Cigna Dental Care, Cigna
Dental Preferred Provider and Cigna Traditional Dental
Any Employee or Dependent whose Dental Insurance ceases
for a reason other than failure to pay any required contribution
or cancelation of the policy may be eligible for coverage under
another Group Dental Insurance Policy underwritten by Cigna;
provided that: he applies in writing and pays the first premium
to Cigna within 31 days after his insurance ceases; and he is
not considered to be overinsured.
Customer Services Toll-Free Number or address that
appears on your Benefit Identification card, explanation
of benefits or claim form.
We will do our best to resolve the matter on your initial
contact. If we need more time to review or investigate your
concern, we will get back to you as soon as possible, but in
any case within 30 days.
CDH or Cigna, as the case may be, or the Policyholder will
give the Employee, on request, further details of the Converted
Policy.
HC-CNV2
If you are not satisfied with the results of a coverage decision,
you can start the appeals procedure.
04-10
V1
Appeals Procedure
Cigna has a two step appeals procedure for coverage
decisions. To initiate an appeal, you must submit a request for
an appeal in writing within 365 days of receipt of a denial
notice. You should state the reason why you feel your appeal
should be approved and include any information supporting
your appeal. If you are unable or choose not to write, you may
ask to register your appeal by telephone. Call or write to us at
the toll-free number or address on your Benefit Identification
card, explanation of benefits or claim form.
Notice of an Appeal or a Grievance
The appeal or grievance provision in this certificate may be
superseded by the law of your state. Please see your
explanation of benefits for the applicable appeal or grievance
procedure.
HC-SPP4
04-10
Level One Appeal
Your appeal will be reviewed and the decision made by
someone not involved in the initial decision. Appeals
involving Medical Necessity or clinical appropriateness will
be considered by a health care professional.
V1
The Following Will Apply To Residents of
Nevada
For level one appeals, we will respond in writing with a
decision within 30 calendar days after we receive an appeal
for a postservice coverage determination. If more time or
information is needed to make the determination, we will
notify you in writing to request an extension of up to 15
calendar days and to specify any additional information
needed to complete the review.
When You Have A Complaint or an
Appeal
For the purposes of this section, any reference to "you," "your"
or "Member" also refers to a representative or provider
designated by you to act on your behalf, unless otherwise
noted.
You may request that the appeal resolution be expedited if the
time frames under the above process would seriously
jeopardize your life or health or would jeopardize your ability
to regain the dental functionality that existed prior to the onset
of your current condition.
We want you to be completely satisfied with the care you
receive. That is why we have established a process for
addressing your concerns and solving your problems.
A dental professional, in consultation with the treating Dentist,
will decide if an expedited review is necessary. When a review
is expedited, Cigna Dental will respond orally with a decision
within 72 hours, followed up in writing.
If you are not satisfied with our level-one appeal decision, you
may request a level-two appeal.
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eligibility or benefit coverage limits or exclusions are not
eligible for appeal under this process.
Level Two Appeal
If you are dissatisfied with our level one appeal decision, you
may request a second review. To start a level two appeal,
follow the same process required for a level one appeal.
To request a review, you must notify the Appeals Coordinator
within 180 days of your receipt of Cigna's level two appeal
review denial. Cigna will then forward the file to the
Independent Review Organization.
Most requests for a second review will be conducted by the
Appeals Committee, which consists of at least three people.
Anyone involved in the prior decision may not vote on the
Committee. For appeals involving Medical Necessity or
clinical appropriateness, the Committee will consult with at
least one Dentist reviewer in the same or similar specialty as
the care under consideration, as determined by Cigna's Dentist
reviewer. You may present your situation to the Committee in
person or by conference call.
The Independent Review Organization will render an opinion
within 30 days. When requested and when a delay would be
detrimental to your condition, as determined by Cigna's
Dentist reviewer, the review shall be completed within three
days.
The Independent Review Program is a voluntary program
arranged by Cigna.
For level two appeals we will acknowledge in writing that we
have received your request and schedule a Committee review.
For postservice claims, the Committee review will be
completed within 30 calendar days. If more time or
information is needed to make the determination, we will
notify you in writing to request an extension of up to 15
calendar days and to specify any additional information
needed by the Committee to complete the review. You will be
notified in writing of the Committee's decision within five
working days after the Committee meeting, and within the
Committee review time frames above if the Committee does
not approve the requested coverage.
Appeal to the State of Nevada
You have the right to contact the Consumer Service Section
for assistance at any time. The Consumer Service Section may
be contacted at the following address and telephone number:
For Carson City:
788 Fairview Dr. #300
Carson City, NV 89701
1-888-872-3234
For Las Vegas:
2501 E. Sahara Ave. #302
Las Vegas, NV 89104
1-888-872-3234
You may request that the appeal resolution be expedited if the
time frames under the above process would seriously
jeopardize your life or health or would jeopardize your ability
to regain the dental functionality that existed prior to the onset
of your current condition.
Notice of Benefit Determination on Appeal
Every notice of a determination on appeal will be provided in
writing or electronically and, if an adverse determination, will
include: the specific reason or reasons for the adverse
determination; reference to the specific plan provisions on
which the determination is based; a statement that the claimant
is entitled to receive, upon request and free of charge,
reasonable access to and copies of all documents, records, and
other Relevant Information as defined; a statement describing
any voluntary appeal procedures offered by the plan and the
claimant's right to bring an action under ERISA section
502(a); upon request and free of charge, a copy of any internal
rule, guideline, protocol or other similar criterion that was
relied upon in making the adverse determination regarding
your appeal, and an explanation of the scientific or clinical
judgment for a determination that is based on a Medical
Necessity, experimental treatment or other similar exclusion
or limit.
A dental professional, in consultation with the treating Dentist,
will decide if an expedited review is necessary. When a review
is expedited, the Dental Plan will respond orally with a
decision within 72 hours, followed up in writing.
Independent Review Procedure
If you are not fully satisfied with the decision of Cigna's level
two appeal review regarding your Medical Necessity or
clinical appropriateness issue, you may request that your
appeal be referred to an Independent Review Organization.
The Independent Review Organization is composed of persons
who are not employed by Cigna HealthCare or any of its
affiliates. A decision to use the voluntary level of appeal will
not affect the claimant's rights to any other benefits under the
plan.
You also have the right to bring a civil action under Section
502(a) of ERISA if you are not satisfied with the decision on
review. You or your plan may have other voluntary alternative
dispute resolution options such as Mediation. One way to find
out what may be available is to contact your local U.S.
Department of Labor office and your State insurance
There is no charge for you to initiate this independent review
process. Cigna will abide by the decision of the Independent
Review Organization.
In order to request a referral to an Independent Review
Organization, certain conditions apply. The reason for the
denial must be based on a Medical Necessity or clinical
appropriateness determination by Cigna. Administrative,
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regulatory agency. You may also contact the Plan
Administrator.
specialty care procedures. Any such decision will be based on
the necessity or appropriateness of the care in question. To be
considered clinically necessary, the treatment or service must
be reasonable and appropriate and must meet the following
requirements. It must:
Relevant Information
Relevant Information is any document, record, or other
information which was relied upon in making the benefit
determination; was submitted, considered, or generated in the
course of making the benefit determination, without regard to
whether such document, record, or other information was
relied upon in making the benefit determination; demonstrates
compliance with the administrative processes and safeguards
required by federal law in making the benefit determination;
or constitutes a statement of policy or guidance with respect to
the plan concerning the denied treatment option or benefit or
the claimant's diagnosis, without regard to whether such
advice or statement was relied upon in making the benefit
determination.
be consistent with the symptoms, diagnosis or treatment of
the condition present;

conform to commonly accepted standards of treatment;

not be used primarily for the convenience of the member or
provider of care; and

not exceed the scope, duration or intensity of that level of
care needed to provide safe and appropriate treatment.
Requests for payment authorizations that are declined by
Cigna Dental based upon the above criteria will be the
responsibility of the member at the dentist’s Usual Fees.
Legal Action
If your plan is governed by ERISA, you have the right to bring
a civil action under Section 502(a) of ERISA if you are not
satisfied with the outcome of the Appeals Procedure. In most
instances, you may not initiate a legal action against Cigna
until you have completed the Level One and Level Two
Appeal processes. If your Appeal is expedited, there is no
need to complete the Level Two process prior to bringing
legal action.
HC-APL61

HC-DFS350
04-10
V1
Cigna Dental Health
(herein referred to as CDH)
CDH is a wholly-owned subsidiary of Cigna Corporation that,
on behalf of Cigna, contracts with Participating General
Dentists for the provision of dental care. CDH also provides
management and information services to Policyholders and
Participating Dental Facilities.
04-10
V1
HC-DFS352
04-10
V1
Definitions
Active Service
You will be considered in Active Service:


Contract Fees
Contract Fees are the fees contained in the Network Specialty
Dentist agreement with Cigna Dental which represent a
discount from the provider’s Usual Fees.
on any of your Fund's scheduled work days if you are
performing the regular duties of your work on a full-time
basis on that day either at your Fund's place of business or
at some location to which you are required to travel for your
Fund's business.
HC-DFS353
V1
on a day which is not one of your Fund's scheduled work
days if you were in Active Service on the preceding
scheduled work day.
HC-DFS1
04-10
Covered Services
Covered Services are the dental procedures listed in your
Patient Charge Schedule.
04-10
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HC-DFS354
04-10
V1
Adverse Determination
An Adverse Determination is a decision made by Cigna
Dental that it will not authorize payment for certain limited
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No one may be considered as a Dependent of more than one
Member.
Dental Office
Dental Office means the office of the Network General
Dentist(s) that you select as your provider.
HC-DFS257
HC-DFS355
04-10
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04-10
V1
Fund
The term Fund means the Policyholder and all Affiliated
Funds. The term Employer means an employer participating in
the fund which is established under the agreement of Trust for
the purpose of providing insurance.
Dental Plan
The term Dental Plan means the managed dental care plan
offered through the Group Contract between Cigna Dental and
your Group.
HC-DFS356
HC-DFS8
04-10
04-10
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V2
Group
The term Group means the Fund, labor union or other
organization that has entered into a Group Contract with Cigna
Dental for managed dental services on your behalf.
Dentist
The term Dentist means a person practicing dentistry or oral
surgery within the scope of his license. It will also include a
provider operating within the scope of his license when he
performs any of the Dental Services described in the policy.
HC-DFS357
HC-DFS125
04-10
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04-10
V3
Medicaid
The term Medicaid means a state program of medical aid for
needy persons established under Title XIX of the Social
Security Act of 1965 as amended.
Dependent
Dependents are:

your lawful spouse; and

any child of yours who is

less than 26 years old.

26 or more years old, unmarried, and primarily supported
by you and incapable of self-sustaining employment by
reason of mental or physical disability. Proof of the child's
condition and dependence must be submitted to Cigna
within 31 days after the date the child ceases to qualify
above. From time to time, but not more frequently than
once a year, Cigna may require proof of the continuation
of such condition and dependence.
HC-DFS16
04-10
V1
Medicare
The term Medicare means the program of medical care
benefits provided under Title XVIII of the Social Security Act
of 1965 as amended.
HC-DFS17
The term child means a child born to you or a child from the
earlier of: the date the adoption becomes effective; or the first
day of the child’s placement in the home. A Pre-existing
Condition Limitation will not apply to an adopted or placed
child. It also includes a stepchild or a child for whom you are
the legal guardian.
04-10
V1
Member
The term Member means a member in good standing of the
UNITE HERE HEALTH.
Benefits for a Dependent child will continue until the last day
of the calendar month in which the limiting age is reached.
Anyone who is eligible as an Member will not be considered
as a Dependent.
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services; and who provides such services upon approved
referral to persons insured for these benefits.
Network General Dentist
A Network General Dentist is a licensed dentist who has
signed an agreement with Cigna Dental to provide general
dental care services to plan members.
HC-DFS358
HC-DFS362
04-10
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Subscriber
The subscriber is the enrolled Member or member of the
Group.
04-10
V1
Network Specialty Dentist
A Network Specialty Dentist is a licensed dentist who has
signed an agreement with Cigna Dental to provide specialized
dental care services to plan members.
HC-DFS363
HC-DFS359
Usual Fee
The customary fee that an individual Dentist most frequently
charges for a given dental service.
04-10
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04-10
V1
Participation Date
The term Participation Date means the later of:
HC-DFS138
04-10
V1
• the Effective Date of the policy; or
• the date on which your Employer becomes a participant in
the plan of insurance authorized by the agreement of Trust.
HC-DFS18
04-10
V1
Patient Charge Schedule
The Patient Charge Schedule is a separate list of covered
services and amounts payable by you.
HC-DFS360
04-10
V1
Service Area
The Service Area is the geographical area designated by Cigna
Dental within which it shall provide benefits and arrange for
dental care services.
HC-DFS361
04-10
V1
Specialist
The term Specialist means any person or organization licensed
as necessary: who delivers or furnishes specialized dental care
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Cigna Dental Care – Cigna Dental Health Plan
The certificate and the state specific riders listed in the next section apply if you are a resident of one of the following states:
AZ, CO, DE, FL, KS/NE, MD, OH, PA, VA
CDO21
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Cigna Dental Companies
Cigna Dental Health Plan of Arizona, Inc.
Cigna Dental Health of Colorado, Inc.
Cigna Dental Health of Delaware, Inc.
Cigna Dental Health of Florida, Inc. (a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida
Statutes)
Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska)
Cigna Dental Health of Kentucky, Inc.
Cigna Dental Health of Maryland, Inc.
Cigna Dental Health of Missouri, Inc.
Cigna Dental Health of New Jersey, Inc.
Cigna Dental Health of North Carolina, Inc.
Cigna Dental Health of Ohio, Inc.
Cigna Dental Health of Pennsylvania, Inc.
Cigna Dental Health of Virginia, Inc.
P.O. Box 453099
Sunrise, Florida 33345-3099
This Plan Booklet/Combined Evidence of Coverage and Disclosure Form/Certificate of Coverage is intended for your
information; it constitutes a summary of the Dental Plan and is included as a part of the agreement between Cigna Dental and
your Group (collectively, the “Group Contract”). The Group Contract must be consulted to determine the rates and the exact
terms and conditions of coverage. If rates or coverages are changed under your Group Contract, your rates and coverage will
also change. A prospective customer has the right to view the Combined Evidence of Coverage and Disclosure Form prior to
enrollment. It should be read completely and carefully. Customers with special health care needs should read carefully those
sections that apply to them. Please read the following information so you will know from whom or what group of dentists
dental care may be obtained.
NOTICE: IF YOU OR YOUR FAMILY MEMBERS ARE COVERED BY MORE THAN ONE HEALTH CARE PLAN,
YOU MAY NOT BE ABLE TO COLLECT BENEFITS FROM BOTH PLANS. EACH PLAN MAY REQUIRE YOU TO
FOLLOW ITS RULES OR USE SPECIFIC DOCTORS OR HOSPITALS, AND IT MAY BE IMPOSSIBLE TO COMPLY
WITH BOTH PLANS AT THE SAME TIME. READ ALL OF THE RULES VERY CAREFULLY, INCLUDING THE
DUAL COVERAGE SECTION.
Important Cancellation Information – Please Read the Provision Entitled “Disenrollment from the Dental Plan–Termination
of Benefits.”
READ YOUR PLAN BOOKLET CAREFULLY
Please call Customer Service at 1-800-Cigna24 if you have any questions. The hearing impaired may call
the state TTY toll-free relay service listed in their local telephone directory.
In some instances, state laws will supersede or augment the provisions contained in this booklet. These requirements are listed
at the end of this booklet as a State Rider. In case of a conflict between the provisions of this booklet and your State Rider, the
State Rider will prevail.
PB09
12.01.12
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Coverage for dependents living outside a Cigna Dental service
area is subject to the availability of an approved network
where the dependent resides.
I. Definitions
Capitalized terms, unless otherwise defined, have the
meanings listed below.
Group - Fund, labor union or other organization that has
entered into a Group Contract with Cigna Dental for managed
dental services on your behalf.
Adverse Determination - a decision by Cigna Dental not to
authorize payment for certain limited specialty care
procedures on the basis of necessity or appropriateness of
care. To be considered clinically necessary, the treatment or
service must be reasonable and appropriate and meet the
following requirements:
Network Dentist – a licensed dentist who has signed an
agreement with Cigna Dental to provide general dentistry or
specialty care services to you. The term, when used, includes
both Network General Dentists and Network Specialty
Dentists.
A. be consistent with the symptoms, diagnosis or treatment
of the condition present;
Network General Dentist - a licensed dentist who has signed
an agreement with Cigna Dental under which he or she agrees
to provide dental care services to you.
B. conform to commonly accepted standards throughout the
dental field;
C. not be used primarily for the convenience of the customer
or dentist of care; and
Network Specialty Dentist - a licensed dentist who has
signed an agreement with Cigna Dental under which he or she
agrees to provide specialized dental care services to you.
D. not exceed the scope, duration, or intensity of that level of
Patient Charge - the amount you owe your Network Dentist
for any dental procedure listed on your Patient Charge
Schedule.
responsibility of the customer at the dentist’s Usual Fees. A
licensed dentist will make any such denial.
Patient Charge Schedule - list of services covered under your
Dental Plan and how much they cost you.
Cigna Dental - the Cigna Dental Health organization that
provides dental benefits in your state as listed on the face page
of this booklet.
Premiums - fees that your Group remits to Cigna Dental, on
your behalf, during the term of your Group Contract.
Service Area - the geographical area designated by Cigna
Contract Fees - the fees contained in the Network Dentist
agreement with Cigna Dental.
Covered Services - the dental procedures listed on your
Subscriber/You - the enrolled Member or customer of the
Group.
Dental Office - your selected office of Network General
Dentist(s).
Usual Fee - the customary fee that an individual dentist most
frequently charges for a given dental service.
Dental Plan - managed dental care plan offered through the
Group Contract between Cigna Dental and your Group.
II. Introduction To Your Cigna Dental Plan
Dependent - your lawful spouse;
your child (including newborns, adopted children,
stepchildren, a child for whom you must provide dental
coverage under a court order; or, a dependent child who
resides in your home as a result of court order or
administrative placement) who is:
Welcome to the Cigna Dental Plan. We encourage you to use
your dental benefits. Please note that enrollment in the Dental
Plan allows the release of patient records to Cigna Dental or
its designee for health plan operation purposes.
(a) less than 26 years old; or
III. Eligibility/When Coverage Begins
(b) 26 years or older, unmarried and if he or she is both:
To enroll in the Dental Plan, you and your Dependents must
be able to seek treatment for Covered Services within a Cigna
Dental Service Area. Other eligibility requirements are
determined by your Group.
i.
incapable of self-sustaining employment due to
mental or physical disability, and
ii.
reliant upon you for maintenance and support.
If you enrolled in the Dental Plan before the effective date of
your Group Contract, you will be covered on the first day the
Group Contract is effective. If you enrolled in the Dental Plan
after the effective date of the Group Contract, you will be
covered on the first day of the month following processing of
A Newly Acquired Dependent is a dependent child who is
adopted, born, or otherwise becomes your dependent after you
become covered under the Plan.
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your enrollment (unless effective dates other than the first day
of the month are provided for in your Group Contract).
information regarding any part of this fee to be withheld
from your salary or to be paid by you to the Group.
Dependents may be enrolled in the Dental Plan at the time you
enroll, during an open enrollment, or within 31 days of
becoming eligible due to a life status change such as marriage,
birth, adoption, placement, or court or administrative order.
You may drop coverage for your Dependents only during the
open enrollment periods for your Group, unless there is a
change in status such as divorce. Cigna Dental may require
evidence of good dental health at your expense if you or your
Dependents enroll after the first period of eligibility (except
during open enrollment) or after disenrollment because of
nonpayment of Premiums.
C. Other Charges – Patient Charges
Network General Dentists are typically reimbursed by
Cigna Dental through fixed monthly payments and
supplemental payments for certain procedures. No
bonuses or financial incentives are used as an inducement
to limit services. Network Dentists are also compensated
by the fees which you pay, as set out in your Patient
Charge Schedule.
covered under your Dental Plan. Some dental procedures
are covered at no charge to you. For other Covered
Services, the Patient Charge Schedule lists the fees you
must pay when you visit your Dental Office. There are no
deductibles and no annual dollar limits for services
covered by your Dental Plan.
If you have family coverage, a newborn child is automatically
covered during the first 31 days of life. If you wish to continue
coverage beyond the first 31 days, your baby must be enrolled
in the Dental Plan and you must begin paying Premiums, if
any additional are due, during that period.
Your Network General Dentist should tell you about
Patient Charges for Covered Services, the amount you
must pay for non-Covered Services and the Dental
Office’s payment policies. Timely payment is important.
It is possible that the Dental Office may add late charges
to overdue balances.
Under the Family and Medical Leave Act of 1993, you may be
eligible to continue coverage during certain leaves of absence
from work. During such leaves, you will be responsible for
paying your Group the portion of the Premiums, if any, which
you would have paid if you had not taken the leave.
Additional information is available through your Benefits
Representative.
Your Patient Charge Schedule is subject to annual change
in accordance with your Group Contract. Cigna Dental
will give written notice to your Group of any change in
Patient Charges at least 60 days prior to such change. You
will be responsible for the Patient Charges listed on the
Patient Charge Schedule that is in effect on the date a
IV. Your Cigna Dental Coverage
and how much dental services will cost you. A copy of the
Group Contract will be furnished to you upon your request.
D. Choice of Dentist
Office when you enrolled in the Dental Plan. If you did
not, you must advise Cigna Dental of your Dental Office
selection prior to receiving treatment. The benefits of the
Dental Plan are available only at your Dental Office,
except in the case of an emergency or when Cigna Dental
otherwise authorizes payment for out-of-network benefits.
A. Customer Service
If you have any questions or concerns about the Dental
Plan, Customer Service Representatives are just a toll-free
phone call away. They can explain your benefits or help
with matters regarding your Dental Office or Dental Plan.
For assistance with transfers, specialty referrals,
eligibility, second opinions, emergencies, Covered
Services, plan benefits, ID cards, location of Dental
Offices, conversion coverage or other matters, call
Customer Service from any location at 1-800-Cigna24.
The hearing impaired may contact the state TTY toll-free
relay service number listed in their local telephone
directory.
You may select a network Pediatric Dentist as the
Network General Dentist for your dependent child under
age 7 by calling Customer Service at 1-800-Cigna24 to
get a list of network Pediatric Dentists in your Service
Area or if your Network General Dentist sends your child
under the age of 7 to a network Pediatric Dentist, the
network Pediatric Dentist’s office will have primary
responsibility for your child’s care. For children 7 years
and older, your Network General Dentist will provide
care. If your child continues to visit the Pediatric Dentist
upon the age of 7, you will be fully responsible for the
Pediatric Dentist’s Usual Fees. Exceptions for medical
B. Premiums
Your Group sends a monthly fee to Cigna Dental for
customers participating in the Dental Plan. The amount
and term of this fee is set forth in your Group Contract.
You may contact your Benefits Representative for
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your Network General Dentist for these procedures.
For emergency Covered Services, you will be
responsible for the Patient Charges listed on your
Patient Charge Schedule. Cigna Dental will
reimburse you the difference, if any, between the
dentist’s Usual Fee for emergency Covered Services
and your Patient Charge, up to a total of $50 per
reports and x-rays to Cigna Dental at the address
listed for your state on the front of this booklet.
If for any reason your selected Dental Office cannot
provide your dental care, or if your Network General
Dentist terminates from the network, Cigna Dental will let
you know and will arrange a transfer to another Dental
Office. Refer to the Section titled “Office Transfers” if
you wish to change your Dental Office.
To obtain a list of Dental Offices near you, visit our
website at myCigna.com, or call the Dental Office
Locator at 1-800-Cigna24. It is available 24 hours a day, 7
days per week. If you would like to have the list faxed to
you, enter your fax number, including your area code.
You may always obtain a current Dental Office Directory
by calling Customer Service.
2.
E. Your Payment Responsibility (General Care)
For Covered Services at your Dental Office, you will be
charged the fees listed on your Patient Charge Schedule.
For services listed on your Patient Charge Schedule at any
other dental office, you may be charged Usual Fees. For
non-Covered Services, you are responsible for paying
Usual Fees.
G. Limitations on Covered Services
Listed below are limitations on services when covered by
your Dental Plan:
If, on a temporary basis, there is no Network General
Dentist in your Service Area, Cigna Dental will let you
know and you may obtain Covered Services from a nonNetwork Dentist. You will pay the non-Network Dentist
the applicable Patient Charge for Covered Services. Cigna
Dental will pay the non-Network Dentist the difference, if
any, between his or her Usual Fee and the applicable
Patient Charge.
See Section IX, Specialty Referrals, regarding payment
All contracts between Cigna Dental and Network Dentists
state that you will not be liable to the Network Dentist for
any sums owed to the Network Dentist by Cigna Dental.
F. Emergency Dental Care - Reimbursement
severity which would lead a prudent layperson possessing
an average knowledge of dentistry to believe the
condition needs immediate dental procedures necessary to
control excessive bleeding, relieve severe pain, or
eliminate acute infection. You should contact your
Network General Dentist if you have an emergency in
your Service Area.
1.
There is a Patient Charge listed on your Patient
Charge Schedule for emergency care rendered after
regularly scheduled office hours. This charge will be
in addition to other applicable Patient Charges.

Frequency - The frequency of certain Covered
Services, like cleanings, is limited. Your Patient Charge
Schedule lists any limitations on frequency.

Pediatric Dentistry - Coverage for treatment by a
Pediatric Dentist ends on your child’s 7th birthday.
Effective on your child’s 7th birthday, dental services
must be obtained from a Network General Dentist
however, exceptions for medical reasons may be
considered on an individual basis.

Oral Surgery - The surgical removal of an impacted
diseased or if the removal is only for orthodontic
reasons. Your Patient Charge Schedule lists any
limitations on oral surgery.

Periodontal (gum tissue and supporting bone)
Services – Periodontal regenerative procedures are
limited to one regenerative procedure per site (or per
tooth, if applicable), when covered on the Patient
Charge Schedule.
Localized delivery of antimicrobial agents is limited to
eight teeth (or eight sites, if applicable) per 12
consecutive months, when covered on the Patient
Charge Schedule.
If you have an emergency while you are out of your
Service Area or you are unable to contact your
Network General Dentist, you may receive
emergency Covered Services as defined above from
any general dentist. Routine restorative procedures or
definitive treatment (e.g. root canal) are not
considered emergency care. You should return to
35

Clinical Oral Evaluations – When this limitation is
noted on the Patient Charge Schedule, periodic oral
evaluations, comprehensive oral evaluations,
comprehensive periodontal evaluations, and oral
evaluations for patients under 3 years of age, are
limited to a combined total of 4 evaluations during a 12
consecutive month period.

Surgical Placement of Implant Services – When
covered on the Patient Charge Schedule, surgical
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placement of a dental implant; repair, maintenance, or
removal of a dental implant; implant abutment(s); or
any services related to the surgical placement of a
dental implant are limited to one per year with
replacement of a surgical implant frequency limitation
of one every 10 years.

Prosthesis Over Implant - When covered on the
Patient Charge Schedule, a prosthetic device, supported
by an implant or implant abutment is considered a
separate distinct service(s) from surgical placement of
an implant. Replacement of any type of prosthesis with
a prosthesis supported by an implant or implant
abutment is only covered if the existing prosthesis is at
least 5 calendar years old, is not serviceable and cannot
be repaired.

services required while serving in the armed forces of
any country or international authority or relating to a
declared or undeclared war or acts of war.

cosmetic dentistry or cosmetic dental surgery (dentistry
or dental surgery performed solely to improve
appearance) unless specifically listed on your Patient
Charge Schedule. If bleaching (tooth whitening) is
listed on your Patient Charge Schedule, only the use of
take-home bleaching gel with trays is covered; all other
types of bleaching methods are not covered.

When listed on your Patient Charge Schedule, general
anesthesia and IV sedation are covered when medically
necessary and provided in conjunction with Covered
Services performed by an Oral Surgeon or Periodontist.
(Maryland residents: General anesthesia is covered
when medically necessary and authorized by your
physician.) There is no coverage for general anesthesia
or intravenous sedation when used for the purposes of
anxiety control or patient management.


procedures, appliances or restorations if the main
purpose is to: change vertical dimension (degree of
separation of the jaw when teeth are in contact) or
restore teeth which have been damaged by attrition,
abrasion, erosion and/or abfraction.

(including fixed and removable orthodontic appliances)
that have been lost, stolen, or damaged due to patient
abuse, misuse or neglect.

surgical placement of a dental implant; repair,
maintenance, or removal of a dental implant; implant
abutment(s); or any services related to the surgical
placement of a dental implant, unless specifically listed
on your Patient Charge Schedule.

services considered to be unnecessary or experimental
in nature or do not meet commonly accepted dental
standards.
General Limitations Dental Benefits
No payment will be made for expenses incurred or
services received:

for or in connection with an injury arising out of, or in
the course of, any employment for wage or profit;

for charges which would not have been made in any
facility, other than a Hospital or a Correctional
Institution owned or operated by the United States
Government or by a state or municipal government if
the person had no insurance;

resides when the expenses are incurred or the services
are received;

for the charges which the person is not legally required
to pay;

for charges which would not have been made if the
person had no insurance;

H. Services Not Covered Under Your Dental Plan
responsibility at the dentist’s Usual Fees. There is no
coverage for:



services provided by a non-Network Dentist without
Cigna Dental’s prior approval (except emergencies, as
described in Section IV.F).


services related to an injury or illness paid under
workers’ compensation, occupational disease or similar
laws.

services provided or paid by or through a federal or
state governmental agency or authority, political
subdivision or a public program, other than Medicaid.
(Benefits are available for Network Dentist charges for
Covered Services performed at a hospital. Other
associated charges are not covered and should be
submitted to the medical carrier for benefit
determination.)

services to the extent you or your enrolled Dependent
are compensated under any group medical plan, no-
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recementation within this timeframe to be incidental to
and part of the charges for the initial restoration unless
fault auto insurance policy, or uninsured motorist
policy. (Arizona and Pennsylvania residents: Coverage
for covered services to the extent compensated under
group medical plan, no fault auto insurance policies or
uninsured motorist policies is not excluded. Kentucky
and North Carolina residents: Services compensated
under no-fault auto insurance policies or uninsured
motorist policies are not excluded. Maryland residents:
Services compensated under group medical plans are
not excluded.)


the completion of crowns, bridges, dentures, or root
canal treatment, already in progress on the effective
date of your Cigna Dental coverage?
consultations and/or evaluations associated with
services that are not covered.

endodontic treatment and/or periodontal (gum tissue
and supporting bone) surgery of teeth exhibiting a poor
or hopeless periodontal prognosis.

performed at the site of a tooth extraction unless


intentional root canal treatment in the absence of injury
or disease to solely facilitate a restorative procedure.


localized delivery of antimicrobial agents when
performed alone or in the absence of traditional
periodontal therapy.

any localized delivery of antimicrobial agent
procedures when more than eight (8) of these

infection control and/or sterilization. Cigna Dental
considers this to be incidental to and part of the charges
for services provided and not separately chargeable.

the recementation of any inlay, onlay, crown, post and
core or fixed bridge within 180 days of initial
placement. Cigna Dental considers recementation
charges for the initial restoration.

services to correct congenital malformations, including
the replacement of congenitally missing teeth.

the replacement of an occlusal guard (night guard)
beyond one per any 24 consecutive month period, when
this limitation is noted on the Patient Charge Schedule.

crowns, bridges and/or implant supported prosthesis
used solely for splinting.

involved are otherwise covered under your Patient Charge
Schedule.
the completion of implant supported prosthesis
(including crowns, bridges and dentures) already in
progress on the effective date of your Cigna Dental
coverage, unless specifically listed on your Patient
Charge Schedule.


Should any law require coverage for any particular
service(s) noted above, the exclusion or limitation for that
service(s) shall not apply.
V. Appointments
To make an appointment with your Network Dentist, call the
VI. Broken Appointments
The time your Network Dentist schedules for your
If you or your enrolled Dependent breaks an appointment with
VII. Office Transfers
arrange a transfer, call Customer Service at 1-800-Cigna24.
myCigna.com, or call the Dental Office Locator at 1-800Cigna24.
Your transfer request will take about 5 days to process.
Transfers will be effective the first day of the month after the
processing of your request. Unless you have an emergency,
you will be unable to schedule an appointment at the new
Dental Office until your transfer becomes effective.
(including crowns, bridges and dentures) within 180
days of initial placement. Cigna Dental considers
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you have a question or concern regarding an authorization
or a denial, contact Customer Service.
After the Network Specialty Dentist has completed
treatment, you should return to your Network General
Dentist for cleanings, regular checkups and other
treatment. If you visit a Network Specialty Dentist
without a referral or if you continue to see a Network
Specialty Dentist after you have completed specialty care,
it will be your responsibility to pay for treatment at the
dentist’s Usual Fees.
VIII. Specialty Care
Network includes the following types of specialty dentists:

Pediatric Dentists – children’s dentistry.



procedures.

When your Network General Dentist determines that you
need specialty care and a Network Specialty Dentist is not
available, as determined by Cigna Dental, Cigna Dental
will authorize a referral to a non-Network Specialty
Dentist. The referral procedures applicable to specialty
care will apply. In such cases, you will be responsible for
Dental will reimburse the non-Network Dentist the
difference, if any, between his or her Usual Fee and the
applicable Patient Charge. For non-Covered Services or
services not authorized for payment, including Adverse
Determinations, you must pay the dentist’s Usual Fee.
There is no coverage for referrals to prosthodontists or other
specialty dentists not listed above.
Dentist.
B. Orthodontics (This section is applicable only when
Orthodontics is listed on your Patient Charge Schedule.)
See Section IV.D, Choice of Dentist, regarding treatment by a
Pediatric Dentist.
1.
IX. Specialty Referrals
A. In General
Upon referral from a Network General Dentist, your
Network Specialty Dentist will submit a specialty care
treatment plan to Cigna Dental for payment authorization,
except for Pediatrics, Orthodontics and Endodontics, for
which prior authorization is not required. You should
verify with the Network Specialty Dentist that your
treatment plan has been authorized for payment by Cigna
Dental before treatment begins.
Specialty Dentist, the fees or no-charge services listed on
the Patient Charge Schedule in effect on the date each
procedure is started will apply, except as set out in
Section IX.B., Orthodontics. Treatment by the Network
Specialty Dentist must begin within 90 days from the date
of Cigna Dental’s authorization. If you are unable to
obtain treatment within the 90 day period, please call
Customer Service to request an extension. Your coverage
must be in effect when each procedure begins.
2.
must pay the Network Specialty Dentist’s Usual Fee. If
38
Definitions – If your Patient Charge Schedule
indicates coverage for orthodontic treatment, the
following definitions apply:
a.
Orthodontic Treatment Plan and Records –
the preparation of orthodontic records and a
treatment plan by the Orthodontist.
b.
Interceptive Orthodontic Treatment –
treatment prior to full eruption of the permanent
teeth, frequently a first phase preceding
comprehensive treatment.
c.
Comprehensive Orthodontic Treatment –
treatment after the eruption of most permanent
teeth, generally the final phase of treatment
before retention.
d.
Retention (Post Treatment Stabilization) – the
period following orthodontic treatment during
which you may wear an appliance to maintain
and stabilize the new position of the teeth.
Patient Charges
The Patient Charge for your entire orthodontic case,
including retention, will be based upon the Patient
Charge Schedule in effect on the date of your visit for
Treatment Plan and Records. However, if a.
banding/appliance insertion does not occur within 90
days of such visit, b. your treatment plan changes, or
c. there is an interruption in your coverage or
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treatment, a later change in the Patient Charge
Schedule may apply.
as a “unit” on your Patient Charge Schedule. The crown,
each unit of crown, bridge and/or implant supported prosthesis
(including crowns and bridges) PLUS an additional charge for
each unit when 6 or more units are prescribed in your Network
General Dentist’s treatment plan.
The Patient Charge for Orthodontic Treatment is
based upon 24 months of interceptive and/or
comprehensive treatment. If you require more than
24 months of treatment in total, you will be charged
an additional amount for each additional month of
treatment, based upon the Orthodontist’s Contract
Fee. If you require less than 24 months of treatment,
your Patient Charge will be reduced on a pro-rated
basis.
3.
Additional Charges
You will be responsible for the Orthodontist’s Usual
Fees for the following non-Covered Services:
a.
4.
XI. What To Do If There Is A Problem
incremental costs associated with
optional/elective materials, including but not
limited to ceramic, clear, lingual brackets, or
other cosmetic appliances;
b.
orthognathic surgery and associated incremental
costs;
c.
d.
e.
services which are not typically included in
Orthodontic Treatment. These services will be
identified on a case-by-case basis.
For the purposes of this section, any reference to “you” or
“your” also refers to a representative or dentist designated by
you to act on your behalf. Time frames or requirements may
vary depending on the laws in your State. Consult your
State Rider for further details.
Most problems can be resolved between you and your dentist.
However, we want you to be completely satisfied with the
Dental Plan. That is why we have established a process for
addressing your concerns and complaints. The complaint
procedure is voluntary and will be used only upon your request.
A. Start with Customer Service
We are here to listen and to help. If you have a concern
about your Dental Office or the Dental Plan, you can call
1-800-Cigna24 toll-free and explain your concern to one
of our Customer Service Representatives. You can also
express that concern in writing to Cigna Dental, P.O. Box
188047, Chattanooga, TN 37422-8047. We will do our
best to resolve the matter during your initial contact. If we
need more time to review or investigate your concern, we
will get back to you as soon as possible, usually by the
end of the next business day, but in any case within 30
days.
Orthodontics In Progress
If Orthodontic Treatment is in progress for you or
your Dependent at the time you enroll, the fee listed
on the Patient Charge Schedule is not applicable.
Please call Customer Service at 1-800-Cigna24 to
find out if you are entitled to any benefit under the
Dental Plan.
X. Complex Rehabilitation/Multiple Crown
Units
involving 6 or more “units” of crown, bridge and/or implant
supported prosthesis (including crowns and bridges) in the
same treatment plan. Using full crowns (caps), fixed bridges
and/or implant supported prosthesis (including crowns and
bridges) which are cemented in place, your Network General
Dentist will rebuild natural teeth, fill in spaces where teeth are
missing and establish conditions which allow each tooth to
function in harmony with the occlusion (bite). The extensive
procedures involved in complex rehabilitation require an
extraordinary amount of time, effort, skill and laboratory
collaboration for a successful outcome.
If you are not satisfied with the results of a coverage
decision, you may start the appeals procedure.
B. Appeals Procedure
Cigna Dental has a two-step appeals procedure for
coverage decisions. To initiate an appeal, you must
submit a request in writing to Cigna Dental, P.O. Box
188047, Chattanooga, TN 37422-8047, within 1 year
from the date of the initial Cigna Dental decision. You
should state the reason you feel your appeal should be
approved and include any information to support your
appeal. If you are unable or choose not to write, you may
ask Customer Service to register your appeal by calling 1800-Cigna24.
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1.
current condition. A dental professional, in
consultation with the treating dentist, will decide if an
expedited review is necessary. When a review is
expedited, the Dental Plan will respond orally with a
Level-One Appeals
Your level-one appeal will be reviewed and the
decision made by someone not involved in the initial
review. Appeals involving dental necessity or clinical
appropriateness will be reviewed by a dental
professional.
3.
If your appeal concerns a denied pre-authorization,
we will respond with a decision within 15 calendar
days after we receive your appeal. For appeals
concerning all other coverage issues, we will respond
with a decision within 30 calendar days after we
receive your appeal. If we need more information to
make your level-one appeal decision, we will notify
you in writing to request an extension of up to 15
calendar days and to specify any additional
information needed to complete the review.
4.
Appeals to the State
You have the right to contact your State’s
Department of Insurance and/or Department of
Health for assistance at any time. See your State
Rider for further details.
Cigna Dental will not cancel or refuse to renew your
coverage because you or your Dependent has filed a
complaint or an appeal involving a decision made by
Cigna Dental. You have the right to file suit in a court of
law for any claim involving the professional treatment
performed by a dentist.
You may request that the appeal resolution be
expedited if the time frames under the above process
would seriously jeopardize your life or health or
would jeopardize your ability to regain the dental
functionality that existed prior to the onset of your
expedited, Cigna Dental will respond orally with a
XII. Dual Coverage
You and your Dependents may not be covered twice under
this Dental Plan. If you and your spouse have enrolled each
other or the same Dependents twice, please contact your
Benefit Administrator.
If you are not satisfied with our level-one appeal
decision, you may request a level-two appeal.
2.
The independent review procedure is a voluntary
program arranged by the Dental Plan and is not
available in all areas. Consult your State Rider for
more details if applicable.
Level-Two Appeals
To initiate a level-two appeal, follow the same
process required for a level-one appeal. Your leveltwo appeal will be reviewed and a decision made by
someone not involved in the level-one appeal. For
appeals involving dental necessity or clinical
appropriateness, the decision will be made by a
dentist. If specialty care is in dispute, the appeal will
be conducted by a dentist in the same or similar
specialty as the care under review.
If you or your Dependents have dental coverage through your
spouse’s Fund or other sources such as an HMO or similar
dental plan, applicable coordination of benefit rules will
determine which coverage is primary or secondary. In most
cases, the plan covering you as an Member is primary for you,
and the plan covering your spouse as an Member is primary
for him or her. Your children are generally covered as primary
by the plan of the parent whose birthday occurs earlier in the
year. Dual coverage should result in lowering or eliminating
your out-of-pocket expenses. It should not result in
reimbursement for more than 100% of your expenses.
The review will be completed within 30 calendar
days. If we need more information to complete the
appeal, we will notify you in writing to request an
extension of up to 15 calendar days and to specify
any additional information needed to complete the
review. The decision will include the specific
contractual or clinical reasons for the decision, as
applicable.
Coordination of benefit rules are attached to the Group
Contract and may be reviewed by contacting your Benefit
Administrator. Cigna Dental coordinates benefits only for
specialty care services.
XIII. Disenrollment From the Dental Plan –
Termination of Benefits
A. Time Frames for Disenrollment/Termination
Except as otherwise provided in the sections titled
“Extension/Continuation of Benefits” or in your Group
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Contract, disenrollment from the Dental Plan and
termination of benefits will occur on the last day of the
month:
1.
in which Premiums are not remitted to Cigna Dental.
2.
in which eligibility requirements are no longer met.
3.
after 30 days notice from Cigna Dental due to
permanent breakdown of the dentist-patient
relationship as determined by Cigna Dental, after at
least two opportunities to transfer to another Dental
Office.
4.
5.
6.
conversion plan. You must enroll within three (3) months after
becoming ineligible for your Group’s Dental Plan. Premium
payments and coverage will be retroactive to the date coverage
under your Group’s Dental Plan ended. You and your enrolled
Dependents are eligible for conversion coverage unless
benefits were discontinued due to:
after 30 days notice from Cigna Dental due to fraud
or misuse of dental services and/or Dental Offices.
after 60 days notice by Cigna Dental, due to
continued lack of a Dental Office in your Service
Area.

Permanent breakdown of the dentist-patient
relationship,

Fraud or misuse of dental services and/or Dental
Offices,

Nonpayment of Premiums by the Subscriber,

Selection of alternate dental coverage by your Group,
or

Lack of network/Service Area.
Benefits and rates for Cigna Dental conversion coverage and
any succeeding renewals will be based on the Covered
Services listed in the then-current standard conversion plan
and may not be the same as those for your Group’s Dental
Plan. Please call the Cigna Dental Conversion Department at
1-800-Cigna24 to obtain current rates and make arrangements
for continuing coverage.
after voluntary disenrollment.
B. Effect on Dependents
When one of your Dependents is disenrolled, you and
your other Dependents may continue to be enrolled.
When you are disenrolled, your Dependents will be
disenrolled as well.
XVII. Confidentiality/Privacy
XIV. Extension of Benefits
Cigna Dental is committed to maintaining the confidentiality
of your personal and sensitive information. Information about
Cigna Dental’s confidentiality policies and procedures is made
available to you during the enrollment process and/or as part
of your customer plan materials. You may obtain additional
information about Cigna Dental’s confidentiality policies and
procedures by calling Customer Service at 1-800-Cigna24, or
via the Internet at myCigna.com.
Coverage for completion of a dental procedure (other than
orthodontics) which was started before your disenrollment
from the Dental Plan will be extended for 90 days after
disenrollment unless disenrollment was due to nonpayment of
Premiums.
Coverage for orthodontic treatment which was started before
disenrollment from the Dental Plan will be extended to the end
of the quarter or for 60 days after disenrollment, whichever is
later, unless disenrollment was due to nonpayment of
Premiums.
XVIII. Miscellaneous
As a Cigna Dental plan customer, you may be eligible for
various discounts, benefits, or other consideration for the
purpose of promoting your general health and well being.
Please visit our website at myCigna.com for details.
XV. Continuation of Benefits (COBRA)
For Groups with 20 or more Members, federal law requires
the Fund to offer continuation of benefits coverage for a
specified period of time after termination of employment or
reduction of work hours, for any reason other than gross
misconduct. You will be responsible for sending payment of
the required Premiums to the Group. Additional information is
available through your Benefits Representative.
As a Cigna Dental plan customer, you may also be eligible for
additional dental benefits during certain health conditions. For
example, certain frequency limitations for dental services may
be relaxed for pregnant women and customers participating in
certain disease management programs. Please review your
plan enrollment materials for details.
SEE YOUR STATE RIDER FOR ADDITIONAL
DETAILS.
XVI. Conversion Coverage
If you are no longer eligible for coverage under your Group’s
Dental Plan, you and your enrolled Dependents may continue
your dental coverage by enrolling in the Cigna Dental
PB09
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12.01.12 M
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may have no direct financial interest in either the case
or its outcome.
State Rider
Cigna Dental Health of Colorado, Inc.
The Appeals Committee will schedule and hold a
review within 45 working days of receipt of your
request. You will be notified in writing at least 15
working days prior to the review date of your right
to: be present at the review; present your case to the
Grievance Committee, in person or in writing; submit
supporting documentation; ask questions of the
reviewers prior to or at the review; and be
represented by a person of your choice. If you wish to
be present, the review will be held during regular
business hours at a location reasonably accessible to
you. If a face-to-face meeting is not practical for
geographic reasons, you will have the opportunity to
be present by conference call at Cigna Dental’s
expense. Please notify Cigna Dental within 5
working days prior to the review if you intend to
have an attorney present.
Colorado Residents:
I. Definitions
Dependent – your lawful spouse, partner in a Civil Union;
If you decide to obtain dental services from a nonnetwork Dentist at your own cost, you may return to your
Network Dentist to receive Covered Services without
penalty.
If you have a dental emergency which requires Specialty Care,
your Network Dentist will contact Cigna Dental for an
expedited referral.
The Appeals Committee’s decision will include: the
names, titles and qualifying credentials of the
reviewers; a statement of the reviewer’s
understanding of the nature of the appeal and the
pertinent facts; the rationale for the decision;
reference to any documentation used in making the
decision; instructions for requesting the clinical
rationale, including the review criteria used to make
the determination; additional appeal rights, if any;
and the right to contact the Department of Insurance,
including the address and telephone number of the
Commissioner’s office.
Referrals approved by Cigna Dental cannot be retrospectively
denied except for fraud or abuse; however, your Cigna Dental
coverage must be in effect at the time your Network Specialist
begins each procedure.
XI. What to Do if There is a Problem
The following is applicable only to Adverse Determinations
and is in addition to the Appeals Procedure listed in Sections
XI.B.1 and XI.B.2. of your Plan Booklet:
3.
1. Level One Appeals: The reviewer will consult with a
dentist in the same or similar specialty as the care
under consideration. A resolution to your written
complaint will be provided to you and your Network
Dentist, in writing, within 20 working days of receipt.
The written decision will contain the name, title, and
qualifying credentials of the reviewer and of any
specialist consulted, a statement of the reviewer’s
understanding of the reason for your appeal, clinical
rationale, a reference to the documentation used to
make the determination, clinical criteria used, and
instructions for requesting the clinical review criteria,
and a description of the process for requesting a
second level appeal.
Expedited Appeals: Within 1 working day after your
request, Cigna Dental will provide reasonable access
to the Dentist who will perform the expedited review.
The following process replaces Section XI.B.3. of your Plan
Booklet, entitled “Independent Review Procedure”:
If the Appeals Committee upholds a denial based on clinical
necessity, and you have exhausted Cigna Dental’s Appeals
Process, you may request that your appeal be referred to an
Independent Review Organization (IRO). In order to request a
referral to an IRO, the reason for the denial must be based on a
dental necessity determination by Cigna Dental.
Administrative, eligibility or benefit coverage limits are not
eligible for additional review under this process.
There is no charge for you to initiate this independent review
process; however, you must provide written authorization
permitting Cigna Dental to release the information to the
Independent Reviewer selected. The IRO is composed of
persons who are not employed by Cigna Dental or any of its
affiliates. Cigna Dental will abide by the decision of the IRO.
2. Level Two Appeals: A majority of the Appeals
Committee will consist of licensed Dentists who have
appropriate expertise. The licensed Dentist may not
have been previously involved in the care or decision
under consideration, may not be members of the
board of directors or Members of Cigna Dental, and
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To request a referral to an IRO, you must notify the Appeals
Coordinator within 60 days of your receipt of the Appeals
Committee’s level two appeal review denial. Cigna Dental
will then forward the file to the Colorado Department of
Insurance within 2 working days, or within 1 working day for
expedited reviews. We will send you descriptive information
on the entity that the Department selects to conduct the
review.
State Rider
Cigna Dental Health of Florida, Inc.
Florida Residents: This State Rider is attached to and
made part of your Plan Booklet and contains information
that either replaces, or is in addition to, information
contained in your Plan Booklet.
I. Definitions
The IRO may request additional information to support the
request for an independent review. Upon receipt of copies of
any additional information, Cigna Dental may reconsider its
decision. If Cigna Dental provides coverage, the independent
review process will end.
Dependent - A child born to or adopted by your covered
family member may also be considered a Dependent if the
child is pre-enrolled at the time of birth or adoption.
The IRO will provide written notice of its decision to you,
your provider and Cigna Dental within 30 working days after
Cigna Dental receives your request for an independent review.
When requested and when a delay would be detrimental to
your dental condition as certified by your treating dentist, the
IRO will complete the review within 7 working days after
Cigna Dental receives your request. The IRO may request
another 10 working days, or another 5 working days for
expedited requests, to consider additional information.
There will be at least one open enrollment period of not less
than 30 days every 18 months unless Cigna Dental Health and
your Group mutually agree to a shorter period of time than 18
months.
If you have family coverage, your newly-born child, or a
newly-born child of a covered family member, is
automatically covered during the first 31 days of life if the
child is pre-enrolled in the Dental Plan at the time of birth. If
you wish to continue coverage beyond the first 31 days, you
need to begin to pay Premiums, if any additional are due,
during that period.
If the IRO reverses Cigna Dental’s adverse decision, we will
provide coverage within 1 working day for preauthorizations
and within 5 working days for services already rendered.
In addition to the information contained in this booklet, Cigna
Dental Health maintains a written plan concerning
accessibility of Network Dentists, quality management
programs, procedures for continuity of care in the event of
insolvency, and other administrative matters. Under Colorado
law, these materials are available at Cigna Dental Health
administrative offices and will be provided to interested
parties upon request.
91100.CO.1
B. Premiums/Prepayment Fees
Your Group Contract has a 31-day grace period. This
provision means that if any required premium is not paid
on or before the date is due, it may be paid subsequently
during the grace period. During the grace period, the
Group Contract will remain in force.
You may receive a description of the process used to
analyze the qualifications and credentials of Network
Dentists upon request.
CORIDER01V2
04.01.14
XI. What to Do if There is a Problem
The following is in addition to the Section XI of your Plan
Booklet:
The Appeals Coordinator can be reached at 1-800Cigna24 (244.6224) or by writing to P.O. Box 188047,
Chattanooga, TN 37422.
1.
43
Level One Appeals
Your written complaint will be processed within 60
days of receipt unless the complaint involves the
myCigna.com
C. A spouse or child whose group coverage ended by reason
of ceasing to be an eligible family member under the
Subscriber’s coverage.
collection of information outside the service area, in
which case Cigna Dental Health will have an
additional 30 days to process the complaint. You may
file a complaint up to 1 year from the date of
occurrence.
Coverage and Benefits for conversion coverage will be similar
to those of your Group’s Dental Plan. Rates will be at
prevailing conversion levels.
If a meeting with you is necessary, the location of the
meeting shall be at Cigna Dental Health’s
administrative office at a location within the service
area that is convenient for you.
4.
In addition the following provisions apply to your plan:
Expenses For Which A Third Party May Be
Responsible
You always have the right to file a complaint with or
seek assistance from the Department of Insurance,
200 East Gaines Street, Tallahassee, Florida 32399,
1-800-342-2672.
This plan does not cover:
XIII. Disenrollment from the Dental
Plan/Termination
A. Causes for Disenrollment/Termination
3. Permanent breakdown of the dentist-patient
relationship, as determined by Cigna Dental Health,
is defined as disruptive, unruly, abusive, unlawful, or
uncooperative behavior which seriously impairs
Cigna Dental Health’s ability to provide services to
customers, after reasonable efforts to resolve the
problem and consideration of extenuating
circumstances.
1.
Expenses incurred by you or your Dependent (hereinafter
individually and collectively referred to as a
"Participant,") for which another party may be responsible
as a result of having caused or contributed to an Injury or
Sickness.
2.
Expenses incurred by a Participant to the extent any
payment is received for them either directly or indirectly
from a third party tortfeasor or as a result of a settlement,
judgment or arbitration award in connection with any
automobile medical, automobile no-fault, uninsured or
underinsured motorist, homeowners, workers'
compensation, government insurance (other than
Medicaid), or similar type of insurance or coverage.
Right Of Reimbursement
If a Participant incurs a Covered Expense for which, in the
opinion of the plan or its claim administrator, another party
may be responsible or for which the Participant may receive
payment as described above, the plan is granted a right of
reimbursement, to the extent of the benefits provided by the
plan, from the proceeds of any recovery whether by
settlement, judgment, or otherwise.
CIGNA DENTAL HEALTH OF FLORIDA, INC.
Forty-five days notice will be provided to you if
Cigna Dental Health terminates enrollment in the
dental plan.
Coverage for all dental procedures in progress, including
Orthodontics, is extended for 90 days after disenrollment.
BY:
XVI. Converting From Your Group Coverage
TITLE:
You and your enrolled Dependent(s) are eligible for
conversion coverage unless benefits are discontinued because
you or your Dependent no longer resides in a Cigna Dental
Health Service Area, or because of fraud or material
misrepresentation in applying for benefits.
91100.2.FL
President
FLRIDER01V3
04.04.13
Unless benefits were terminated as previously listed,
conversion coverage is available to your Dependents, only, as
follows:
A. A surviving spouse and children at Subscriber’s death;
B. A former spouse whose coverage would otherwise end
because of annulment or dissolution of marriage; or
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State Rider
Cigna Dental Health of Ohio, Inc.
financially responsible for services rendered by a nonnetwork dentist whether or not Cigna Dental authorizes
payment for a referral.
Ohio Residents:
The following is in addition to the information on the first
page of your Plan Booklet:
If you are undergoing treatment and the Dental Plan
becomes insolvent, Cigna Dental will arrange for the
continuation of services until the expiration of your Group
Contract.
NOTICE: IF YOU OR YOUR FAMILY MEMBERS ARE
COVERED BY MORE THAN ONE HEALTH CARE
PLAN, YOU MAY NOT BE ABLE TO COLLECT
BENEFITS FROM BOTH PLANS. EACH PLAN MAY
REQUIRE YOU TO FOLLOW ITS RULES OR USE
SPECIFIC DOCTORS AND HOSPITALS, AND IT MAY
BE IMPOSSIBLE TO COMPLY WITH BOTH PLANS
AT THE SAME TIME. READ ALL OF THE RULES
VERY CAREFULLY, INCLUDING THE
COORDINATION OF BENEFITS SECTION, AND
COMPARE THEM WITH THE RULES OF ANY
OTHER PLAN THAT COVERS YOU OR YOUR
FAMILY.
The following is in addition to the process described in
Section XI of your Plan Booklet:
A. Start With Member Services
You can reach Member Services by calling 1-800Cigna24 or by writing to Cigna Dental Health of Ohio,
Inc., P.O. Box 453099, Sunrise, Florida 33345-3099,
Attention: Member Services. You may also submit a
complaint in person at any Cigna Dental Office.
1.
You and your Dependents must live or work in the service
area to be eligible for coverage.
Level One Appeals
Cigna Dental will provide a written response to your
written complaint.
Within 30 days of receiving a response from Cigna
Dental, you may appeal a complaint resolution
regarding cancellation, termination or non-renewal of
coverage by Cigna Dental to the Ohio Superintendent
of Insurance.
Under Ohio law, if you divorce, you cannot terminate
coverage for enrolled Dependents until the court determines
that you are no longer responsible for providing coverage.
Cigna Dental does not require, make inquiries into, or rely
upon genetic screening or testing in processing applications
for enrollment or in determining insurability under the Dental
Plan.
The Ohio Department of Insurance is located at 50
W. Town Street, Suite 300, Columbus, Ohio 43215,
Attention Consumer Services Division. The
Department’s toll-free number is 1-800-686-1526 or
(614) 644-2673.
Section IV is renamed:
IV. Your Cigna Dental Plan
XII. Dual Coverage
The following is in addition to the process described in
Section IV. E. of your Plan Booklet:
(This section is not applicable when Cigna Dental does not
make payments toward specialty care as indicated by your
Patient Charge Schedule. For those plans, Cigna Dental is
always the primary plan.)
Patient Charge. There is no additional cost to you.
The following supersedes Section XII of your Plan Booklet.
A. Coordination of Benefits
“Coordination of benefits” is the procedure used to pay
health care expenses when a person is covered by more
than one plan. Cigna Dental follows rules established by
Ohio law to decide which plan pays first and how much
the other plan must pay. The objective is to make sure the
combined payments of all plans are no more than your
actual bills. Coordination of benefits applies only to
Specialty Care.
Cigna Dental is not a member of any Guaranty Fund. In
the event of Cigna Dental’s insolvency, you will not be
liable to the Network Dentist for any sums owed to the
Network Dentist by Cigna Dental. However, you may be
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When you or your family members are covered by
another group plan in addition to this one, we will follow
Ohio coordination of benefit rules to determine which
plan is primary and which is secondary. You must submit
all bills first to the primary plan. The primary plan must
pay its full benefits as if you had no other coverage. If the
primary plan denies the claim or does not pay the full bill,
you may then submit the balance to the secondary plan.
E. Which Plan is Primary?
To decide which plan is primary, we have to consider
both the coordination provisions of the other plan and
which member of your family is involved in a claim. The
Primary Plan will be determined by the first of the
following that applies:
1.
Cigna Dental pays for dental care when you follow our
rules and procedures. If our rules conflict with those of
another plan, it may be impossible to receive benefits
from both plans, and you will be forced to choose which
plan to use.
2.
3.

Group hospital indemnity plans which pay less than
$100 per day

School accident coverage

Some supplemental sickness and accident policies
4.
However, if your spouse’s plan has some other
coordination rule (for example, a “gender rule” which
says the father’s plan is always primary), we will
follow the rules of that plan.
D. How Cigna Dental Pays as Secondary Plan
1. When we are secondary, our payments will be based
on the balance left after the primary plan has paid.
We will pay no more than that balance. In no event
will we pay more than we would have paid had we
been primary.
We will pay only for health care expenses that are
covered by Cigna Dental.
3.
We will pay only if you have followed all of our
procedural requirements, including: care is obtained
from or arranged by your primary care dentist;
preauthorized referrals are made to network
specialists; coverage is in effect when procedures
begin; procedures begin within 90 days of referral.
4.
We will pay no more than the “allowable expenses”
for the health care involved. If our allowable expense
is lower than the primary plan’s, we will use the
primary plan’s allowable expense. That may be less
than the actual bill.
Children & the Birthday Rule
When your children’s health care expenses are
involved, we follow the “birthday rule.” The plan of
the parent with the first birthday in a calendar year is
always primary for the children. If your birthday is in
January and your spouse’s birthday is in March, your
plan will be primary for all of your children.
C. How Cigna Dental Pays As Primary Plan
When we are primary, we will pay the full benefit
allowed by your contract as if you had no other coverage.
2.
Children (Parents Divorced or Separated)
If the court decree makes one parent responsible for
health care expenses, that parent’s plan is primary. If
the court decree gives joint custody and does not
mention health care, we follow the birthday rule. If
neither of those rules applies, the order will be
determined in accordance with the Ohio Insurance
Department rule on Coordination of Benefits.
B. Plans That Do Not Coordinate
Cigna Dental will pay benefits without regard to benefits
paid by the following kinds of coverage:
Medicaid
Member
The plan that covers you as an Member (neither laid
off nor retired) is always primary.
Cigna Dental will not reduce or exclude benefits payable
to you or on your behalf because such benefits have also
been paid under a supplemental, specified disease or
limited plan of coverage for sickness and accident
insurance which is entirely paid for by you, your family
or guardian.

Non-coordinating Plan
If you have another group plan that does not
coordinate benefits, it will always be primary.
5.
Other Situations
For all other situations not described above, the order
of benefits will be determined in accordance with the
Ohio Insurance Department rule on Coordination of
Benefits.
F. Coordination Disputes
If you believe that we have not paid a claim properly, you
should first attempt to resolve the problem by contacting
us. If you are still not satisfied, you may call the Ohio
Department of Insurance for instructions on filing a
consumer complaint. Call (614) 644-2673 or 1-800-6861526.
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B. Availability of Financial Statement
Cigna Dental Health of Ohio, Inc. will make available to you,
upon request, its most recent financial statement.
G. Subrogation
If another source directly reimburses you more than your
Patient Charge for Covered Services, you may be required
to reimburse Cigna Dental. Where allowed by law, this
section will apply to you or your Dependents who:
1.
receive benefit payments under this Dental Plan as
the result of a sickness or injury; and
2.
have a lawful claim against another party or parties
for compensation, damages, or other payment
because of that same sickness or injury.
91100b.OH
OHRIDER01V4
05.07.09
State Rider
Cigna Dental Health of Pennsylvania, Inc.
In those instances where this section applies, the rights of
the Member or Dependent to claim or receive
compensation, damages, or other payment from the other
party or parties will be transferred to Cigna Dental, but
only to the extent of benefit payments made under this
Dental Plan.
Pennsylvania Residents:
I. Definitions
Dependent
 A child born of a Dependent Child of a Subscriber shall also
be considered a Subscriber’s Dependent so long as such
Dependent Child remains eligible for benefits.
XIII. Disenrollment From The Dental
Plan/Termination of Benefits

Any unmarried child of yours who is:

A. Causes For Disenrollment/Termination
3. Under Ohio law, you will not be terminated from the
dental plan due to a permanent breakdown of the
dentist-patient relationship. However, your Network
Dentist has the right to decline services to a patient
because of rude or abusive behavior.
You or your Dependent may appeal any termination
action by Cigna Dental by submitting a written
complaint as set out in Section XI.
You and your enrolled Dependents are eligible for conversion
coverage unless benefits were discontinued due to:
A. Nonpayment of Premiums/Prepayment Fees by the
Subscriber;
19 years but less than 23 years old, enrolled in school as a
full-time student and primarily supported by you. If, while
a full-time registered student, the child was called or
ordered to active duty (other than active duty for training)
for 30 or more consecutive days in the Pennsylvania
National Guard or any reserve component of the armed
forces of the United States, the child is eligible to enroll
as a Dependent while a full-time student for a period
equal to the duration of the military service. Eligibility in
this situation will end when the child is no longer a fulltime student. The child must submit the form provided by
the Department of Military and Veterans Affairs to Cigna
when initially called to duty, when returning from duty,
and when reenrolling as a full-time student.
B. Fraud or misuse of dental services and/or Dental Offices;
A Dependent child may be enrolled within 60 days of a court
order.
C. Selection of alternate dental coverage by your Group.
If you have family coverage, a newly born child of a
Dependent child is automatically covered during the first 31
days of life. If you wish to continue coverage beyond the first
31 days, the newborn needs to be enrolled in the Dental Plan
and you need to begin to pay Premiums/Prepayment Fees
during that period.
A. Governing Law
The Group Contract shall be construed for all purposes as a
legal document and shall be interpreted and enforced in
accordance with pertinent laws and regulations of the State of
Ohio. Any person who, with intent to defraud or knowing that
he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive
statement is guilty of insurance fraud.
D. Emergency Dental Care - Reimbursement
If any emergency arises while you are unable to contact
your Network General Dentist, the Dental Plan covers the
cost of emergency dental services so that you are not
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liable for greater out-of-pocket expense than if you were
attended by your Network General Dentist. You must
submit appropriate reports and x-rays to Cigna Dental
Health.
State Rider
Virginia Residents:
Your Cigna Dental Care coverage is provided by Cigna Dental
Health of Virginia, Inc.
Items 12 and 15 are amended as follows:
12. Services considered to be experimental in nature.
This State Rider contains information that either replaces, or is
in addition to, the information contained in your Plan Booklet.
15. Services compensated under any group medical plan,
no-fault auto insurance policy or insured motorist
policy are not excluded.
I. Definitions:
The following is added to the definition of Dependent:
Any unmarried dependent child who is 19 or older, but less
than the plans limiting age, who is a full-time student and is
unable to continue school as a full-time student because of a
medical condition, coverage shall continue for the child for a
period of 12 months or to the date the child no longer qualifies
as a dependent under policy terms.
The following process is in addition to that described in your
Plan Booklet:
You always have the right to file a complaint with or seek
assistance from the Pennsylvania Department of Health,
Bureau of Managed Care, Room 912 Health & Welfare
Building, 625 Forster Street, Harrisburg, Pennsylvania, 171200701, (717) 787-5193.
The following is added to paragraph 3, immediately after the
first sentence:
XII. Dual Coverage
An adopted child shall be eligible for coverage from the date
of adoptive or parental placement in your home.
All benefits provided under the Dental Plan shall be in excess
of and not in duplication of first party medical benefits
payable under the Pennsylvania Motor Vehicle Financial
Responsibility Law, 75 Pa. C.S.A. § 1711, et. seq.
The following is in addition to the information listed in
your Plan Booklet:
The Group Contract, including the Patient Charge Schedule,
Pre-Contracting Application, and Coordination of Benefits
provisions, and any amendments or additions thereto,
represents the entire agreement between the parties with
respect to the subject matter. The invalidity or
unenforceability of any section or subsection of the contract
will not affect the validity or enforceability of the remaining
sections or subsections.
1.
The Group Contract is construed for all purposes as a legal
document and will be interpreted and enforced in accordance
with the pertinent laws and regulations of the Commonwealth
of Pennsylvania and with pertinent federal laws and
regulations.
91100.PA
Cigna Dental will acknowledge your claim for
emergency services within 15 days and accept, deny,
or request additional information within 15 business
days of receipt. If Cigna Dental accepts your claim,
reimbursement for all appropriate emergency services
will be made within 5 days of acceptance.
The following bullet does not apply to Virginia residents.

PARIDER03V4
09.15.08
48
are compensated under any group medical plan, nofault auto insurance policy, or uninsured motorist
policy.
myCigna.com
appeals will be conducted by an Appeals Committee
consisting of at least 3 people. Anyone involved in
the prior decision may not vote on the Appeals
Committee. For appeals involving dental necessity or
clinical appropriateness, the Appeals Committee will
include at least one dentist. If specialty care is in
dispute, the Appeals Committee will consult with a
dentist in the same or similar specialty as the care
under review.
The following replaces Section XI.B of your Plan Booklet:
submit a request in writing to Cigna Dental, at the address
listed for your state on the cover page of this booklet,
within 1 year from the date of the initial Cigna Dental
decision. You should state the reason you feel your appeal
should be approved and include any information to
support your appeal. If you are unable or choose not to
write, you may ask Customer Service to register your
appeal by calling 1-800-Cigna24.
Cigna Dental will acknowledge your appeal in
writing within 5 business days and schedule an
Appeals Committee review. The acknowledgment
letter will include the name, address, and telephone
number of the Appeals Coordinator. We may request
additional information at that time. If your appeal
concerns a denied pre-authorization, the Appeals
Committee review will be completed within 15
calendar days. For appeals concerning all other
coverage issues, the Appeals Committee review will
be completed within 30 calendar days. If we need
more time or information to complete the review, we
will notify you in writing to request an extension of
up to 15 calendar days and to specify any additional
information needed by the Appeals Committee to
complete the review.
Complaints regarding adverse decisions are referred to as
reconsiderations under Virginia law. Network dentists
may request reconsiderations on your behalf, with your
permission. Resolutions to requests for reconsideration of
adverse decisions will be communicated to you within 10
business days of Cigna Dental receiving the request.
1.
Level One Appeals
Your level one appeal will be reviewed and the
professional.
You may present your appeal to the Appeals
Committee in person or by conference call. You must
advise Cigna Dental 5 days in advance if you or your
representative plan to attend in person. You will be
notified in writing of the Appeals Committee’s
decision within 5 business days after the meeting.
The decision will include the specific contractual or
clinical reasons for the decision, as applicable.
receive your appeal. If we need more time or
information to make the decision, we will notify you
in writing to request an extension of up to 15
3.
If you are not satisfied with our level one appeal
decision, you may request a level two appeal.
2.
You have the right to contact the Virginia Bureau of
Insurance and/or Department of Health for assistance
at any time.
Level Two Appeals
To initiate a level two appeal, follow the same
process required for a level one appeal. Level two
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B. Effect On Dependents
XII. Dual Coverage
The following is in addition to the information listed in your
plan booklet:
Under Virginia law, Cigna Dental may not subrogate your
right to recover excess benefits.
The following is in addition to the information listed in your
Plan Booklet:
Under Coordination of Benefits rules, when we are secondary,
our payments will be based on the balance left after the
primary plan has paid. We will pay no more than that balance.
In no event will we pay more than we would have paid had we
been primary.
A. Assignment - Your Group Contract provides that the
Group may not assign the Contract or its rights under the
Contract, nor delegate its duties under the Contract
without the prior written consent of Cigna Dental.
Coordination of Benefit rules are attached to the Group
Contract and your plan booklet for reference.
B. Entire Agreement - Your Group Contract, including the
Evidence of Coverage, State Rider, Patient Charge
Schedule, Pre-Contract Application, and any amendments
thereto, constitutes the entire contractual agreement
between the parties involved. No portion of the charter,
bylaws or other document of Cigna Dental Health of
Virginia, Inc. shall constitute part of the contract unless it
is set forth in full in the contract.
XIII. Disenrollment From the Dental Plan Termination of Benefits
The following replaces Section XIII of your Plan Booklet:
A. Time Frames For Disenrollment/Termination
Except as otherwise provided in the Sections titled
termination of benefits and coverages will occur on the
last day of the month:
1.
In which Premiums are not remitted to Cigna Dental.
2.
There will be a 31-day grace period for the payment
of any premium falling due after the first premium,
during which coverage shall remain in effect.
Coverage shall remain in effect during the grace
period unless the Group gives Cigna Dental written
notice of termination in accordance with the terms of
the Group Contract and in advance of the date of
termination. The contract holder may be responsible
for payment of a prorated Premium for the time the
coverage was in force during the grace period.
3.
After 31 days notice from Cigna Dental due to failure
to meet eligibility requirements.
4.
After 31 days notice from Cigna Dental due to
Office.
5.
After 31 days notice from Cigna Dental due to fraud
6.
After voluntary disenrollment.
C. Incontestability - In the absence of fraud, all statements
contained in a written application made by a Subscriber
are considered representations and not warranties.
Coverage can be voided: 1. during the first two years for
material misrepresentations contained in a written
enrollment form; and, 2. after the first two years, for
fraudulent misstatement contained in a written enrollment
form.
D. Regulation - Cigna Dental Health of Virginia, Inc. is
subject to regulation by both the State Corporation
Commission Bureau of Insurance pursuant to Title 38.2
and the Virginia Department of Health pursuant to Title
32.1 of the Virginia Insurance laws.
E. Subscriber Input - Subscriber enrollees shall have the
opportunity to provide input into the plan’s procedures
and processes regarding the delivery of dental services.
Input will be solicited in various ways:
50

On-going contacts between Customer Service
representatives and enrollees;

On-going contacts with enrollees during open
enrollment meetings;

Annual survey of enrollees regarding their experiences
in the plan.
myCigna.com
Customer Rights and Responsibilities

Your Rights
 You have the right to considerate, respectful care, with
recognition of your personal dignity, regardless of race,
color, religion, sex, age, physical or mental handicap or
national origin.
You have the right to call Customer Service if you need
help choosing a dentist or need more information to help
you make that choice.

You have the right to know who we are, what services we
provide, which dentists are part of our plan and your
rights and responsibilities under the plan. If you have any
questions or concerns, call Customer Service.

You have the right to participate in decision making
regarding your dental care. With the Cigna Dental Care
plan, you and your dentist make decisions about your
recommended treatment.

You have the right to know your costs in advance for
routine and emergency care. You have the right to an
explanation of the benefits listed in your Patient
Charge Schedule. Your dentist can answer questions or
call Customer Service at 1-800-Cigna24.

You have the right to tell us when something goes
wrong:

Start with your dentist. He/she is your primary contact.

If you have a problem that cannot be resolved with your
dentist, call Customer Service. We have an established
process to resolve issues that cannot be worked out in
other ways.

You have the right to appeal the decision of your
complaint through the Cigna Dental Appeals Process.

You have the right to schedule an appointment with your
network dental office within a reasonable time.

You have the right to receive a recall for an appointment
with your dentist.

You have the right to see a dentist within 24 hours for
emergency care. Emergencies are dental problems that
require immediate treatment, (includes control of
bleeding, acute infection, or relief of pain, including local
anesthesia).



You have the right to receive a Patient Charge
Schedule to determine benefits and covered services. If
you do not receive one before your plan becomes
effective, call Customer Service to request one.

You have the right to privacy and confidential
treatment of information and dental records, as
provided by law.

You have the right to obtain information on types of
provider payment arrangements used to compensate
dentists for dental services rendered.
Cigna Dental wants to hear from you if you believe your rights
have been violated.
Your Responsibilities
 Read the details of your Cigna Dental Care Plan
Booklet and Patient Charge Schedule.
You have the right to know about Cigna Dental, dental
services, network providers, and your rights and
responsibilities:


You have the right to information from your network
dentist regarding appropriate or necessary treatment
options without regard to cost or benefit coverage.
You have the right to select or change dental offices
within the Cigna Dental Care network. It is good dental
practice, however, to complete any treatment in progress
with your current dentist before transferring.
You have the right to receive advance notification if your
network general dentist leaves the Cigna Dental Care
network.
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
Choose a primary care dentist from the Cigna Dental
Care network.

Provide information, to the extent possible, that your
dentist needs to provide appropriate dental care.

Receive care only from the Network General Dentist
office you have chosen, unless a transfer has been
arranged.

Be sure your primary care dentist gives you a referral
for any specialty care and gets any preauthorization
required for that treatment.

Ask Cigna Dental to address any concerns you may
have.

Let your dentist know whether you understand the
treatment plan he/she recommends and follow the
treatment plan and instructions for care.

Pay your Patient Charges as soon as possible for the
dental care received so your dentist can continue to
serve you.

Be considerate of the rights of other patients and the
dental office personnel.

Keep appointments or cancel in time for another
patient to be seen in your place.
myCigna.com
If you have quality of care concerns, you may contact the
Office of Licensure and Certification at any time, at the
following:
Important Information Regarding Your Dental
Plan
In the event you need to contact someone about this Dental
Plan for any reason, please contact your Benefit
Administrator. If you have additional questions you may
contact Cigna Dental at the following address and telephone
number:
P.O. Box 453099
Sunrise, FL 33345-3099
1-800-Cigna24
ADDRESS:
Office of Licensure and Certification
(OLC)
Virginia Department of Health
9960 Mayland Drive, Suite 401
Richmond, VA 23233
TELEPHONE:
Toll-Free: 1-800-955-1819
In-state Calls: 1-804-367-2104
Fax Number: 1-804-527-4503
Note: We recommend that you familiarize yourself with our
grievance procedure, and make use of it before taking any
other action.
Website: www.vdh.virginia.gov/olc
Email: [email protected]
If you have been unable to contact or obtain satisfaction from
Cigna Dental or your Benefit Administrator, you may contact
the Virginia State Corporation Commission Bureau of
Insurance at:
ADDRESS:
Life and Health Division
Bureau of Insurance
P.O. Box 1157
Richmond, VA 23218
TELEPHONE:
In-State Calls: 1-800-552-7945
EXHIBIT B
Coordination of Services and Benefits
Applicability: This Coordination of Benefits (COB) provision
applies when a Covered Person has health care coverage under
more than one Plan. ("Plan" is defined below.)
If a Covered Person is covered by this Contract and another
Plan, the Order of Benefit Determination Rules described
below determine whether this Contract or the other Plan is
Primary. The benefits of this Contract:
Local Calls: 1-804-371-9741
National Toll Free: 1-877-310-6560
Written correspondence is preferable so that a record of your
inquiry is maintained. When contacting your Benefits
Administration, company or the Bureau of Insurance, have
your policy number available.
If you have any questions regarding an appeal or grievance
concerning the health care services that you have been
provided which have not been satisfactorily addressed by
Cigna Dental, you may contact the Office of the Managed
Care Ombudsman for assistance at:
ADDRESS:
Toll-Free: 1-877-310-6560
E-MAIL:
[email protected]
shall not be reduced when, under the Order of Benefit
Determination Rules, this Contract is Primary; but
2.
may be reduced for the Reasonable Cash Value of any
service provided under this Contract that may be
recovered from another Plan when, under the Order of
Benefit Determination Rules, the other Plan is Primary.
(The above reduction is described in the subsection below
entitled "Effect on the Benefits of this Plan.")
Definitions: "Plan" means this Contract or any of the
following which provides benefits or services for, or because
of, dental care or treatment:
Office of The Managed Care
Ombudsman
Bureau of Insurance
P.O. Box 1157
Richmond, VA 23218
TELEPHONE:
1.
1.
Group insurance or group-type coverage, whether insured
or uninsured. This includes prepayment or group practice
coverage.
2.
Coverage under a governmental plan or coverage required
or provided by law. This does not include a state plan
under Medicaid (Title XIX of the United States Social
Security Act, as amended from time to time). It also does
not include any plan when, by law, its benefits are excess
to those of any private insurance program or other nongovernmental program.
3.
Dental benefits coverage of all group and group-type
contracts.
http://www.scc.virginia.gov
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"Plan" does not include coverage under individual policies or
contracts. Each contract or other arrangement for coverage
under subparagraphs 1, 2, or 3 above is a separate Plan. Also,
if an arrangement has two parts and COB rules apply only to
one of the two, each of the parts is a separate Plan.
This Plan determines its Order of Benefits using the first of the
following rules that applies:
"Primary" means that a Plan's benefits are to be provided or
paid without considering any other Plan's benefits. (The Order
of Benefit Determination Rules below determine whether a
Plan is Primary or Secondary to another Plan.)
"Allowable Expense" means a necessary, reasonable, and
customary item of expense for dental care, when the item of
expense is covered at least in part by one or more Plans
covering the person for whom the claim is made.
2.
The Plan under which the Covered Person is an Member
shall be Primary.
2.
If the Covered Person is not an Member under a Plan,
then the Plan which covers the Covered Person's parent
(as an Member) whose birthday occurs earlier in a
calendar year shall be Primary.
NOTE: The word "birthday" as used in this subparagraph
refers only to month and day in a calendar year, not to the year
in which the person was born. To aid in the interpretation of
this paragraph, the following example is given: If a Covered
Person's mother has a birthday on January 1 and the Covered
Person's father has a birthday on January 2, the Plan which
covers the Covered Person's mother would be Primary.
"Secondary" means that a Plan's benefits may be reduced and
it may recover the Reasonable Cash Value of the services it
provided from the Primary Plan. (The Order of Benefit
Determination Rules below determine whether a Plan is
Primary or Secondary to another Plan.)
1.
1.
3.
When a Plan provides benefits in the form of services, the
Reasonable Cash Value of each service rendered is an
Allowable Expense and a benefit paid.
a.
c. Finally, the Plan of the parent not having custody of
the child.
"Claim Determination Period" means a calendar year.
However, it does not include any part of a year during which a
Covered Person has no coverage under this Plan, or any part
of a year before the date this COB provision or a similar
provision takes effect.
"Reasonable Cash Value" means an amount which a duly
licensed provider of dental care services usually charges
patients and which is within the range of fees usually charged
for the same service by other dental care providers located
within the immediate geographic area where the dental care
service is rendered under similar or comparable
circumstances.
4.
Notwithstanding subparagraph 3 above, if the specific
terms of a court decree state that one of the parents is
responsible for the health care expenses of the child, and
the entity obligated to pay or provide the benefits of the
Plan of that parent has actual knowledge of those terms,
the benefits of that Plan shall be Primary. This
subparagraph 4 does not apply with respect to any Claim
Determination Period or Plan year in which benefits are
paid or provided before the entity has that actual
knowledge.
5.
The benefits of a Plan which covers a Covered Person as
an Member (or as that Member's dependent) shall be
determined before those of a Plan which covers that
Covered Person as a laid off or retired Member (or as that
Member's dependent). If the other Plan does not have this
provision and if, as a result, the Plans do not agree on the
order of benefit determination, this paragraph shall not
apply.
6.
If a Covered Person whose coverage is provided under a
right of continuation pursuant to federal or state law is
also covered under another Plan, the benefits of the Plan
covering the Covered Person as an Member (or as that
Member's dependent) shall be determined before those of
a Plan under continuation coverage. If the other Plan does
not have this provision and if, as a result, the Plans do not
Order of Benefit Determination Rules: When a Covered
Person receives services through this Plan or is otherwise
entitled to claim benefits under this Plan, and the services or
benefits are a basis for a claim under another Plan, this Plan
shall be Secondary and the other Plan shall be Primary, unless:
the other Plan has rules coordinating its benefits with
those of this Plan; and
2.
both the other Plan's rules and this Plan's rules, as stated
below, require that this Plan's benefits be determined
before those of the other Plan.
First, the Plan of the parent with custody of the child;
b. Then, the Plan of the spouse of the parent with
custody of the child; and
When benefits are reduced under a Primary Plan because
a Covered Person does not comply with the Plan
provisions, the amount of such reduction will not be
considered an Allowable Expense.
1.
If two or more Plans cover a Covered Person as a
dependent child of divorced or separated parents, benefits
for the Covered Person shall be determined in the
following order:
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agree on the order of benefit determination, this paragraph
shall not apply.
7.
8.
necessary by Cigna Dental Health, the Covered Person (or his
or her legal representative if a minor or legally incompetent),
upon request, shall execute and deliver to Cigna Dental Health
such instruments and papers required and do whatever else is
necessary to secure Cigna Dental Health's rights hereunder.
If one of the Plans which covers a Covered Person is
issued out of the state whose laws govern this Contract
and determines the order of benefits based upon the
gender of a parent, and as result, the Plans do not agree on
the order of benefit determination, the Plan with the
gender rules shall determine the order of benefits.
Medicare Benefits: Except as otherwise provided by
applicable federal law, the services and benefits under this
Plan for Covered Persons aged sixty-five (65) and older, or for
Covered Persons otherwise eligible for Medicare payments,
shall not duplicate any services or benefits to which such
Covered Persons are eligible under Parts A or B of the
Medicare Act. Where Medicare is the responsible payor, all
amounts payable pursuant to the Medicare program for
services and benefits provided hereunder to Covered Persons
are payable to and shall be retained by Cigna Dental Health.
Covered Persons enrolled in Medicare shall cooperate with
and assist Cigna Dental Health in its efforts to obtain
reimbursement from Medicare.
If none of the above rules determines the order of
benefits, the Plan which has covered the Covered Person
for the longer period of time shall be Primary.
Effect on the Benefits of this Plan: This subsection applies
when, in accordance with the Order of Benefit Determination
Rules, this Plan is Secondary to one or more other Plans. In
that event, the benefits of this Plan may be reduced under this
subsection. Such other Plan or Plans are referred to as "the
other Plans' in the subparagraphs below.
This Plan may reduce benefits payable or may recover the
Reasonable Cash Value of services provided when the sum of:
1.
The benefits that would be payable for the Allowable
Expenses under this Plan, in the absence of this COB
provision; and
2.
The benefits that would be payable for the Allowable
Expenses under the other Plans, in the absence of
provisions with a purpose like that of this COB provision,
whether or not claim is made, exceeds those Allowable
Expenses in a Claim Determination Period. In that case,
the benefits of this Plan will be reduced, or the
Reasonable Cash Value of any services provided by this
Plan may be recovered from the other Plan, so that they
and the benefits payable under the other Plans do not total
more than those Allowable Expenses.
Right to Receive and Release Information: Cigna Dental
Health may, without consent of or notice to any Covered
Person, and to the extent permitted by law, release to or obtain
from any person or organization or governmental entity any
information with respect to the administering of this Section.
A Covered Person shall provide to Cigna Dental Health any
information it requests to implement this provision.
0539.GE
91993.r4.VA
12.01.12
VARIDER03V6
When the benefits of this Plan are reduced as described above,
each benefit is reduced in proportion. It is then charged against
any applicable benefit limit of this Plan.
Recovery of Excess Benefits: In the event a service or benefit
is provided by Cigna Dental Health which is not required by
this Contract, or if it has provided a service or benefit which
should have been paid by the Primary Plan, that service or
benefit shall be considered an excess benefit. Cigna Dental
Health shall have the right to recover to the extent of the
excess benefit. If the excess benefit is a service, recovery shall
be based upon the Reasonable Cash Value for that service. If
the excess benefit is a payment, recovery shall be based upon
the actual payment made. Recovery may be sought from
among one or more of the following, as Cigna Dental Health
shall determine: any person to, or for, or with respect to
whom, such services were provided or such payments were
made; any insurance company; health care plan or other
organization. This right of recovery shall be Cigna Dental
Health's alone and at its sole discretion. If determined
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The certificate(s) listed in the next section apply if you are a resident of one of the following states: CA, CT, IL, KY, MO, NJ,
NC, TX
CDO20
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Cigna Dental Health of California, Inc.
400 North Brand Boulevard, Suite 400
Glendale, California 91203
COMBINED EVIDENCE OF COVERAGE AND
DISCLOSURE FORM
This Combined Evidence of Coverage and Disclosure Form is intended for your information; it constitutes a summary of the
Dental Plan and is included as a part of the agreement between Cigna Dental and your Group (collectively, the “Group
Contract”). The Group Contract must be consulted to determine the rates and the exact terms and conditions of coverage. A
specimen copy of the Group Contract will be furnished upon request. If rates or coverages are changed under your Group
Contract, your rates and coverage will also change. A prospective customer has the right to view the Combined Evidence of
Coverage and Disclosure Form prior to enrollment. It should be read completely and carefully. Customers with special health
care needs should read carefully those sections that apply to them. Please read the following information so you will know
from whom or what group of dentists dental care may be obtained.
FOLLOW ITS RULES OR USE SPECIFIC DOCTORS OR DENTAL OFFICES, AND IT MAY BE IMPOSSIBLE TO
COMPLY WITH BOTH PLANS AT THE SAME TIME. READ ALL OF THE RULES VERY CAREFULLY, INCLUDING
THE COORDINATION OF BENEFITS SECTION.
Important Cancellation Information - Please Read the Provision Entitled “Disenrollment from the Dental Plan-Termination of
Benefits.”
The Dental Plan is subject to the requirements of Chapter 2.2 of Division 2 of the Health and Safety Code and of Division 1 of
Title 28 of the California Code of Regulations. Any provision required to be in the Group Contract by either of the above will
bind the Dental Plan, whether or not provided in the Group Contract.
CAPB09
03.01.13
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TABLE OF CONTENTS
I.
Definitions
II.
Introduction to Your Cigna Dental Plan
III.
Eligibility/When Coverage Begins
A. In General
B. New Enrollee Transition of Care
C. Renewal Provisions
IV.
A. Customer Service
B. Prepayment Fees
C. Other Charges – Copayments
D. Facilities - Choice of Dentist
F. Specialty Care
G. Specialty Referrals
V.
Covered Dental Services
A. Categories of Covered Services
B. Emergency Dental Care - Reimbursement
VI.
Exclusions
VII. Limitations
VIII. What To Do If There is a Problem/Grievances
A. Your Rights To File Grievances with Cigna Dental
B. How To File A Grievance
C. You Have Additional Rights Under State Law
D. Voluntary Mediation
IX.
Coordination of Benefits
X.
Disenrollment From the Dental Plan – Termination of Benefits
A. For the Group
B. For You and Your Enrolled Dependents
C. Termination Effective Date
D. Effect on Dependents
E. Right to Review
F. Notice of Termination
XI.
Continuity of Care
XII. Continuation of Benefits (COBRA)
XIII. Individual Continuation of Benefits
XIV. Confidentiality/Privacy
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XV. Miscellaneous
A. Programs Promoting General Health
B. Organ and Tissue Donation
C. 911 Emergency Response System
CAPB09
03.01.13
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Dependent - your lawful spouse; your unmarried child
(including newborns, children of the noncustodial parent,
adopted children, stepchildren, a child for whom you must
provide dental coverage under a court order; or, a dependent
child who resides in your home as a result of court order or
I. Definitions
procedures on the basis of clinical necessity or appropriateness
of care. Requests for payment authorizations that are declined
by Cigna Dental based upon clinical necessity or
appropriateness of care will be the responsibility of the
customer at the dentist’s Usual Fees. A licensed dentist will
make any such denial. Adverse Determinations may be
appealed as described in the Section entitled “What To Do If
There Is A Problem.”
A. less than 26 years old; or
B. less than 26 years old if he or she is both:
1.
a full-time student enrolled at an accredited
educational institution, and
2.
reliant upon you for maintenance and support; or
C. any age if he or she is both:
Cigna Dental - Cigna Dental Health of California, Inc.
1.
Clinical Necessity - to be considered clinically necessary, the
treatment or service must be reasonable and appropriate and
meet the following requirements:
incapable of self-sustaining employment by reason of
a physically or mentally disabling injury, illness or
condition; and
2.
chiefly dependent upon you (the subscriber) for
support and maintenance.
For a dependent child 26 years of age or older who is a fulltime student at an educational institution, coverage will be
provided for an entire academic term during which the child
begins as a full-time student and remains enrolled, regardless
of whether the number of hours of instruction for which the
child is enrolled is reduced to a level that changes the child’s
academic status to less than that of a full-time student.
B. conform to professionally recognized standards of dental
practice;
For a child who falls into category B. above, you will need to
furnish Cigna Dental evidence of his or her reliance upon you,
in the form requested, within 31 days after the Dependent
reaches the age of 26 and once a year thereafter during his or
her term of coverage.
COBRA - Consolidated Omnibus Budget Reconciliation Act
of 1986, as amended. The federal law that gives workers who
lose their health benefits the right to choose, under certain
circumstances, to continue group health benefits provided by
the plan under certain circumstances.
For a child who falls into category C. above, you will need to
furnish Cigna Dental proof of the child’s condition and his or
her reliance upon you, within sixty (60) days from the date
that you are notified by Cigna Dental to provide this
information.
Copayment - the amount you owe your Network Dentist for
any dental procedure listed on your Patient Charge Schedule.
where the dependent resides; provided however, Cigna Dental
will not deny enrollment to your dependent who resides
outside the Cigna Dental service area if you are required to
provide coverage for dental services to your dependent
pursuant to a court order or administrative order.
Dentist(s).
Dental Plan - the plan of managed dental care benefits offered
through the Group Contract between Cigna Dental and your
Group.
This definition of “Dependent” applies unless modified by
your Group Contract.
Network Dentist - a licensed dentist who has signed an
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Dentists.
you will be covered on the first day of the month
following processing of your enrollment (unless effective
dates other than the first day of the month are provided
for in your Group Contract).
Network General Dentist -a licensed dentist who has signed
Dependents may be enrolled in the Dental Plan at the time
you enroll, during an open enrollment, or within 31 days
of becoming eligible due to a life status change such as
marriage, birth, adoption, placement, or court or
administrative order. You may drop coverage for your
Dependents only during the open enrollment periods for
your Group, unless there is a change in status such as
divorce. Cigna Dental may require evidence of good
dental health to be provided at your expense if you or
your Dependents enroll after the first period of eligibility
(except during open enrollment) or after disenrollment
because of nonpayment of Prepayment Fees.
Network Pediatric Dentist - a licensed Network Specialty
Dentist who has completed training in a specific program to
provide dental health care for children.
Network General Dentist and Network Specialty Dentist
include any dental clinic, organization of dentists, or other
person or institution licensed by the State of California to
deliver or furnish dental care services that has signed an
specialty care services to you.
If you have family coverage, a newborn child is
automatically covered during the first 31 days of life. If
you wish to continue coverage beyond the first 31 days,
your baby must be enrolled in the Dental Plan and you
must begin paying Prepayment Fees, if any additional are
due, during that period.
Dental Plan and the associated Copayment.
Prepayment Fees - the premium or fees that your Group pays
to Cigna Dental, on your behalf, during the term of your
Group Contract. These fees may be paid all or in part by you.
Under the Family and Medical Leave Act of 1993, you
may be eligible to continue coverage during certain leaves
of absence from work. During such leaves, you will be
responsible for paying your Group the portion of the
Prepayment Fees, if any, which you would have paid if
you had not taken the leave. Additional information is
Group.
B. New Enrollee Transition of Care
If you or your enrolled Dependents are new enrollees
currently receiving services for any of the conditions
described hereafter from a non-Network Dentist, you may
request Cigna Dental to authorize completion of the
services by the non-Network Dentist. Cigna Dental does
not cover services provided by non-Network Dentists
except for the conditions described hereafter that have
been authorized by Cigna Dental prior to treatment. Rare
instances where prolonged treatment by a non-Network
Dentist might be indicated will be evaluated on a case-bycase basis by the Dental Director in accordance with
professionally recognized standards of dental practice.
Authorization to complete services started by a nonNetwork Dentist before you or your enrolled Dependents
became eligible for Cigna Dental shall be considered only
for the following conditions:
II. Introduction to Your Cigna Dental Plan
its designee for dental plan operation purposes.
A. In General
To enroll in the Dental Plan, you and your Dependents
must live or work in the Service Area and be able to seek
treatment for Covered Services within the Cigna Dental
Service Area. Other eligibility requirements are
(1) an acute condition. An acute condition is a dental
condition that involves a sudden onset of symptoms
due to an illness, injury, or other dental problem that
requires prompt dental attention and that has a
limited duration. Completion of the covered services
If you enrolled in the Dental Plan before the effective date
of your Group Contract, you will be covered on the first
day the Group Contract is effective. If you enrolled in the
Dental Plan after the effective date of the Group Contract,
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shall be provided for the duration of the acute
condition.
B. Prepayment Fees
Your Group sends a monthly Prepayment Fee (premium)
to Cigna Dental for customers participating in the Dental
Plan. The amount and term of this prepayment fee is set
forth in your Group Contract. You may contact your
Benefits Representative for information regarding any
part of this Prepayment Fee to be withheld from your
salary or to be paid by you to the Group.
(2) newborn children between birth and age 36 months.
Cigna Dental shall provide for the completion of
covered services for newborn children between birth
and age 36 months for 12 months from the effective
date of coverage for a newly covered enrollee.
(3) performance of a surgery or other procedure that is
authorized by Cigna Dental and has been
recommended and documented by the non-Network
Dentist to occur within 180 days of the effective date
of your Cigna Dental coverage.
C. Other Charges - Copayments
supplemental payments for certain procedures. Network
Specialty Dentists are compensated based on a contracted
fee arrangement for services rendered. No bonuses or
financial incentives are used as inducements to limit
services. Network Dentists are also compensated by the
Copayments that you pay, as set out in your Patient
Charge Schedule. You may request general information
about these matters from Customer Service or from your
Network Dentist.
C. Renewal Provisions
Your coverage under the Dental Plan will automatically
be renewed, except as provided in the section entitled
“Disenrollment From The Dental Plan – Termination of
Benefits.” All renewals will be in accordance with the
terms and conditions of your Group Contract. Cigna
Dental reserves any and all rights to change the
Prepayment Fees or applicable Copayments during the
term of the Group Contract if Cigna Dental determines
the Group’s information relied upon by Cigna Dental in
setting the Prepayment Fees materially changes or is
determined by Cigna Dental to be inaccurate.
covered under your Dental Plan, subject to plan
exclusions and limitations. Some dental procedures are
covered at no charge to you. For other Covered Services,
the Patient Charge Schedule lists the Copayments you
Cigna Dental maintains its principal place of business at 400
North Brand Boulevard, Suite 400, Glendale, CA 91203, with
a telephone number of 1-800-Cigna24.
Your Network General Dentist is instructed to tell you
about Copayments for Covered Services, the amount you
must pay for optional or non-Covered Services and the
Dental Office’s payment policies. Timely payment is
important. It is possible that the Dental Office may add
late charges to overdue balances. IMPORTANT: If you
opt to receive dental services that are not covered services
under this plan, a participating dentist may charge you his
or her usual and customary rate for those services. Prior to
providing a patient with dental services that are not a
covered benefit, the dentist should provide to the patient a
treatment plan that includes each anticipated service to be
provided and the estimated cost of each service. If you
would like more information about dental coverage
options, you may call Customer Service at 1-800-Cigna24
or your insurance broker. To fully understand your
coverage, you may wish to carefully review this evidence
of coverage document.
This section provides information that will help you to better
understand your Dental Plan. Included is information about
how to access your dental benefits and your payment
responsibilities.
A. Customer Service
eligibility, emergencies, Covered Services, plan benefits,
ID cards, location of Dental Offices, conversion coverage
or other matters, call Customer Service from any location
at 1-800-Cigna24. If you have a question about your
treatment plan, we can arrange a second opinion or
consultation. The hearing impaired may contact the state
TTY toll-free relay service number listed in their local
telephone directory.
Your Patient Charge Schedule is subject to change in
accordance with your Group Contract. Cigna Dental will
give written notice to your Group of any change in
Copayments at least 30 days prior to such change. You
will be responsible for the Copayments listed on the
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1-800-Cigna24. To obtain a list of Dental Offices
near you, visit our website at myCigna.com, or call
the Dental Office Locator at 1-800-Cigna24.
D. Facilities - Choice of Dentist
1.
Your transfer request will take about 5 days to
process. Transfers will be effective the first day of
the month after the processing of your request.
Unless you have an emergency, you will be unable to
schedule an appointment at the new Dental Office
until your transfer becomes effective.
In General
You and your Dependents should have selected a
Dental Office when you enrolled in the Dental Plan.
If you did not, you must advise Cigna Dental of your
Dental Office selection prior to receiving treatment.
The benefits of the Dental Plan are available only at
your Dental Office, except in the case of an
emergency or when Cigna Dental otherwise
authorizes payment for out-of-network benefits.
There is no charge to you for the transfer; however,
all Copayments which you owe to your current
Dental Office must be paid before the transfer can be
processed. Copayments for procedures not completed
at the time of transfer may be required to be prorated
between your current Dental Office and the new
Dental Office, but will not exceed the amount listed
Network General Dentist for your dependent child
under age 7 by calling Customer Service at 1-800Cigna24 to get a list of network Pediatric Dentists in
your Service Area or if your Network General
Dentist sends your child under the age of 7 to a
network Pediatric Dentist, the network Pediatric
Dentist’s office will have primary responsibility for
your child’s care. For children 7 years and older, your
Network General Dentist will provide care. If your
child continues to visit the Pediatric Dentist upon the
age of 7, you will be fully responsible for the
Pediatric Dentist’s Usual Fees. Exceptions for
medical reasons may be considered on a case-by-case
basis.
charged the Copayments listed on your Patient Charge
Schedule, subject to applicable exclusions and limitations.
For services listed on your Patient Charge Schedule
provided at any other dental office, you may be charged
Usual Fees. For non-Covered Services, you are
responsible for paying Usual Fees.
Dentist available in the Service Area to treat you, Cigna
Dental will let you know and you may obtain Covered
Services from a non-Network Dentist. You will pay the
non-Network Dentist the applicable Copayment for
Covered Services. Cigna Dental will pay the non-Network
Dentist the difference between his or her Usual Fee and
the applicable Copayment. If you seek treatment for
Covered Services from a non-Network Dentist without
authorization from Cigna Dental, you will be responsible
for paying the non-Network Dentist his or her Usual Fee.
Dentist terminates from the network, Cigna Dental
will let you know and will arrange a transfer to
another Dental Office. Refer to the section titled
“Office Transfers” if you wish to change your Dental
Office.
Locator at 1-800-Cigna24. It is available 24 hours a
day, 7 days per week. If you would like to have the
list faxed to you, enter your fax number, including
your area code. You may always obtain a current
Dental Office Directory by calling Customer Service.
2.
Appointments
To make an appointment with your Network Dentist,
call the Dental Office that you have selected. When
you call, your Dental Office will ask for your
identification number and will check your eligibility.
3.
Office Transfers
If you decide to change Dental Offices, we encourage
you to complete any dental procedure in progress
first. To arrange a transfer, call Customer Service at
See Section IV.G, Specialty Referrals, regarding payment
F. Specialty Care
Network includes the following types of specialty
dentists:
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
Pediatric Dentists - children’s dentistry.

Endodontists - root canal treatment.

Periodontists - treatment of gums and bone.
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
Oral Surgeons - complex extractions and other surgical
procedures.
concern regarding an authorization or a denial,
contact Customer Service.

Orthodontists - tooth movement.
Specialty referrals will be authorized by Cigna Dental
if the services sought are: Covered Services; rendered
to an eligible customer; within the scope of the
Specialty Dentists skills and expertise; and meet
Clinical Necessity requirements. Cigna Dental may
request medical information regarding your condition
and the information surrounding the dentist’s
determination of the Clinical Necessity for the
request. Cigna Dental shall respond in a timely
fashion appropriate for the nature of your condition,
not to exceed five business days from Cigna Dental’s
receipt of the information reasonably necessary and
requested by Cigna Dental to make the
determination. When you face imminent and serious
threat to your health, including, but not limited to, the
potential loss of life, limb, or other major bodily
function, or the normal timeframe for the decision
making process would be detrimental to your life or
health or could jeopardize your ability to regain
maximum function, the decision to approve, modify,
or deny requests shall be made in a timely fashion
appropriate for the nature of your condition, not to
exceed 72 hours after receipt of the request.
Decisions to approve, modify, or deny requests for
authorization prior to the provision of dental services
shall be communicated to the requesting dentist
within 24 hours of the decision. Decisions resulting
in denial, delay, or modification of all or part of the
requested dental service shall be communicated to the
customer in writing within 2 business days of the
decision. Adverse Determinations may be appealed
as described in the Section entitled “What To Do If
There Is A Problem/Grievances.”
When specialty care is needed, your Network General
Dentist must start the referral process. X-rays taken by
your Network General Dentist should be sent to the
Network Specialty Dentist. Except for Pediatrics,
Orthodontics and Endodontic services, payment
authorization is required for coverage of services by a
Network Specialty Dentist.
See Section IV.D Facilities-Choice of Dentist, regarding
treatment by a Pediatric Dentist.
G. Specialty Referrals
1.
In General
Network Specialty Dentist will submit a specialty
care treatment plan to Cigna Dental for payment
authorization prior to rendering the service. Prior
authorization from Cigna Dental is not required for
specialty referrals for Pediatrics, Orthodontics and
Endodontic services. You should verify with the
Network Specialty Dentist that your treatment plan
has been authorized for payment by Cigna Dental
before treatment begins.
If your Patient Charge Schedule reflects coverage for
Orthodontic services, a referral from a Network
General Dentist is not required to receive care from a
Network Orthodontist. However, your Network
General Dentist may be helpful in assisting you to
choose or locate a Network Orthodontist.
When Cigna Dental authorizes payment to the
Network Specialty Dentist, the fees or no-charge
services listed on the Patient Charge Schedule in
effect on the date each procedure is started will
apply, except as set out in Section V.A.7,
Orthodontics.
treatment, you should return to your Network
General Dentist for cleanings, regular checkups and
other treatment. If you visit a Network Specialty
Dentist without a referral or if you continue to see a
Network Specialty Dentist after you have completed
specialty care, it will be your responsibility to pay for
treatment at the dentist’s Usual Fees.
Treatment by the Network Specialty Dentist must
begin within 90 days from the date of Cigna Dental’s
authorization. If you are unable to obtain treatment
within the 90-day period, please call Customer
Service to request an extension. Your coverage must
be in effect when each procedure begins.
When your Network General Dentist determines that
you need specialty care and a Network Specialty
Dentist is not available, as determined by Cigna
Dental, Cigna Dental will authorize a referral to a
non-Network Specialty Dentist. The referral
procedures applicable to specialty care will apply. In
such cases, you will be responsible for the applicable
Copayment for Covered Services. Cigna Dental will
reimburse the non-Network Dentist the difference
If Cigna Dental makes an Adverse Determination of
the requested referral (i.e. Cigna Dental does not
authorize payment to the Network Specialty Dentist
for Covered Services), or if the dental services sought
are not Covered Services, you will be responsible to
pay the Network Specialty Dentist’s Usual Fee for
the services rendered. If you have a question or
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limitation allows, Cigna Dental will waive the
limitation.
between his or her Usual Fee and the applicable
Copayment. For non-Covered Services or services
not authorized for payment, including Adverse
Determinations, you must pay the dentist’s Usual
Fee. Or, if you seek treatment for Covered Services
from a non-Network Dentist without authorization
from Cigna Dental, you will be responsible for
paying the dentist’s Usual Fee.
You may request from Customer Service a copy of
the process that Cigna Dental uses to authorize,
modify, or deny requests for specialty referrals and
services.
2.
Second Opinions
If you have questions or concerns about your
treatment plan, second opinions are available to you
upon request by calling Customer Service. Second
opinions will generally be scheduled within 5 days.
In the case of an imminent and serious health threat,
as determined by Cigna Dental clinicians, second
opinions will be rendered within 72 hours. Cigna
Dental’s policy statement on second opinions may be
requested from Customer Service.
A. Categories of Covered Services
Dental procedures in the following categories of Covered
Services are covered under your Dental Plan when listed
on your Patient Charge Schedule and performed by your
Network Dentist. Please refer to your Patient Charge
Schedule for the procedures covered under each category
and the associated Copayment.
Diagnostic/Preventive
Diagnostic treatment consists of the evaluation of a
patient’s dental needs based upon observation,
examination, x-rays and other tests. Preventive
dentistry involves the education and treatment
devoted to and concerned with preventing the
development of dental disease. Preventive Services
includes dental cleanings, oral hygiene instructions to
promote good home care and prevent dental disease,
and fluoride application for children to strengthen
teeth.
a.
Restorative (Fillings)
Restorative dentistry involves materials or devices
used to replace lost tooth structure or to replace a lost
tooth or teeth.
3.
Crown and Bridge
An artificial crown is a restoration covering or
replacing the major part, or the whole of the clinical
crown of a tooth. A fixed bridge is a prosthetic
replacement of one or more missing teeth cemented
to the abutment teeth adjacent to the space. The
artificial tooth used in a bridge to replace the missing
tooth is called a pontic.
a.
V. Covered Dental Services
1.
2.
Complex Rehabilitation/Multiple Crown
Units
Complex rehabilitation is extensive dental
restoration involving 6 or more “units” of crown,
bridge, and/or implant supported prosthesis
(including crowns and bridges) in the same
treatment plan. Using full crowns (caps), fixed
bridges, and/or implant supported prosthesis
(including crowns and bridges) which are
cemented in place, your Network General
Dentist will rebuild natural teeth, fill in spaces
where teeth are missing and establish conditions
which allow each tooth to function in harmony
with the occlusion (bite). The extensive
procedures involved in complex rehabilitation
require an extraordinary amount of time, effort,
skill and laboratory collaboration for a successful
outcome.
Complex rehabilitation will be covered when
performed by your Network General Dentist
after consultation with you about diagnosis,
treatment plan and charges. Each tooth or tooth
replacement included in the treatment plan is
referred to as a “unit” on your Patient Charge
Schedule. The crown, bridge and/or implant
supported prosthesis (including crowns and
bridges) charges on your Patient Charge
Schedule are for each unit of crown or bridge.
You pay the per unit copayment for each unit of
crown, bridge and /or implant supported
prosthesis (including crowns and bridges) PLUS
an additional charge for complex rehabilitation
for each unit beginning with the 6th unit when 6
or more units are prescribed in your Network
General Dentist’s treatment plan. The additional
charge for complex rehabilitation will not be
applied to the first 5 units of crown or bridge.
Limitation
The frequency of certain Covered Services, like
cleanings, is limited. Your Patient Charge
Schedule lists any limitations on frequency. If
your Network Dentist certifies to Cigna Dental
that, due to medical necessity you require certain
Covered Services more frequently than the
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b.
c.
Note: Complex rehabilitation only applies for
implant supported prosthesis, when implant
supported prosthesis are specifically listed on
your Patient Charge Schedule.
root of the tooth and filling the root canal with a
rubber-like material. Following endodontic treatment,
a crown is usually needed to strengthen the weakened
tooth.
Limitations
(1) all charges for crown and bridge are per
unit (each replacement or supporting tooth
equals one unit).
Exclusions
1. Coverage is not provided for Endodontic
treatment of teeth exhibiting a poor or hopeless
periodontal prognosis.
(2) limit 1 every 5 years unless Cigna Dental
determines that replacement is necessary
because the existing crown or bridge is
unsatisfactory as a result of poor quality of
care, or because the tooth involved has
experienced extensive loss or changes in
tooth structure or supporting tissues since
the placement of the crown or bridge.
2.
5.
Exclusion
(1) there is no coverage for crowns, bridges
used solely for splinting. This exclusion
will not apply if a crown or bridge is
determined by Cigna Dental to be the
treatment most consistent with
professionally accepted standards of care.
(2) there is no coverage for implant supported
prosthesis used solely for splinting unless
specifically listed on your Patient Charge
Schedule.
(3) there is no coverage for resin bonded
retainers and associated pontics.
(4) there is no coverage for the recementation
of any inlay, onlay, crown, post and core,
fixed bridge within 180 days of initial
placement. Cigna Dental considers
recementation within this timeframe to be
incidental to and part of the charges for the
initial restoration.
Periodontics
Periodontics is treatment of the gums and bone which
support the teeth. Periodontal disease is chronic. It
progresses gradually, sometimes without pain or
other symptoms, destroying the support of the gums
and bone. The disease is a combination of
deterioration plus infection.
a.
Preliminary Consultation
This consultation by your Network General
Dentist is the first step in the care process.
During the visit, you and your Network General
Dentist will discuss the health of your gums and
bone.
b.
Evaluation, Diagnosis and Treatment Plan
If periodontal disease is found, your Network
General Dentist or Network Specialty Dentist
will develop a treatment plan. The treatment plan
consists of mapping the extent of the disease
around the teeth, charting the depth of tissue and
bone damage and listing the procedures
necessary to correct the disease.
Depending on the extent of your condition, your
Network General Dentist or Network Specialty
Dentist may recommend any of the following
procedures:
(5) the recementation of any implant supported
prosthesis (including crowns, bridges and
dentures) within 180 days of initial
placement. Cigna Dental considers
recementation within this timeframe to be
incidental to and part of the charges for the
initial restoration unless specifically listed
4.
Coverage is not provided for intentional root
canal treatment in the absence of injury or
disease to solely facilitate a restorative
procedure.
(1) Non-surgical Program - this is a
conservative approach to periodontal
therapy. Use of this program depends upon
how quickly you heal and how consistently
you follow instructions for home care. This
program may include:
Endodontics
Endodontics is root canal treatment, which may be
required when the nerve of a tooth is damaged due to
trauma, infection, or inflammation. Treatment
consists of removing the damaged nerve from the

scaling and root planing

oral hygiene instruction

full mouth debridement
(2) Scaling and Root Planing - this
periodontal therapy procedure combines
scaling of the crown and root surface with
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exhibiting a poor or hopeless periodontal
prognosis.
root planing to smooth rough areas of the
root. This procedure may be performed by
the dental hygienist or your Network
General Dentist.
(3) Osseous Surgery - bone (osseous) surgery
is a procedure used in advanced cases of
periodontal disease to restructure the
supporting gums and bone. Without this
surgery, tooth or bone loss may occur. Two
checkups by the Periodontist are covered
within the year after osseous surgery.
(4) Occlusal Adjustment - occlusal
adjustment requires the study of the
contours of the teeth, how they bite
(occlude) and their position in the arch. It
consists of a recontouring of biting surfaces
so that direct biting forces are along the
long axis of the tooth. If the biting forces
are not properly distributed, the bone,
which supports the teeth, may deteriorate.
(5) Bone Grafts and other regenerative
procedures - this procedure involves
placing a piece of tissue or synthetic
material in contact with tissue to repair a
defect or supplement a deficiency.
c.
Limitations
1. Periodontal regenerative procedures are
limited to one regenerative procedure per
site (or per tooth, if applicable), when
covered on the Patient Charge Schedule.
2.
d.
6.
Localized delivery of antimicrobial agents is
limited to eight teeth (or eight sites, if
applicable) per 12 consecutive months,
when covered on the Patient Charge
Schedule.
Exclusion
1. General anesthesia, sedation and nitrous
oxide are not covered, unless specifically
listed on your Patient Charge Schedule.
When listed on your Patient Charge
Schedule, IV sedation is covered when
medically necessary and provided in
conjunction with Covered Services
performed by a Periodontist. General
anesthesia is not covered when provided by
a Periodontist. There is no coverage for
general anesthesia or intravenous sedation
when used for the purposes of anxiety
control or patient management.
2.
3.
There is no coverage for the replacement of
an occlusal guard (night guard) beyond one
per any 24 consecutive month period, when
this limitation is noted on the Patient Charge
Schedule.
4.
There is no coverage for bone grafting
and/or guided tissue regeneration when
performed at the site of a tooth extraction,
unless specifically listed on your Patient
Charge Schedule.
5.
There is no coverage for bone grafting
and/or guided tissue regeneration when
performed in conjunction with an
apicoectomy or periradicular surgery.
6.
There is no coverage for localized delivery
of antimicrobial agents when performed
alone or in the absence of traditional
Oral Surgery
Oral surgery involves the surgical removal of teeth or
associated surgical procedures by your Network
General Dentist or Network Specialty Dentist.
a.
Limitation
The surgical removal of a wisdom tooth may not
be covered if the tooth is not diseased or if the
removal is only for orthodontic reasons.
Temporary pain from normal eruption is not
considered disease. Your Patient Charge
Schedule lists any limitations on oral surgery.
b.
Exclusion
General anesthesia, sedation and nitrous oxide
are not covered unless specifically listed on your
Patient Charge Schedule. When listed on your
Patient Charge Schedule, general anesthesia and
IV sedation are covered when medically
necessary and provided in conjunction with
Covered Services performed by an Oral Surgeon.
There is no coverage for general anesthesia or
intravenous sedation when used for the purposes
of anxiety control or patient management.
There is no coverage for Periodontal (gum
tissue and supporting bone) surgery of teeth
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7.
not limited to ceramic, clear, lingual
brackets, or other cosmetic appliances;
Orthodontics (This section is applicable only when
Orthodontics is listed on your Patient Charge
Schedule.)
a.
(2) orthognathic surgery and associated
incremental costs;
Definitions - If your Patient Charge Schedule
(3) appliances to guide minor tooth movement;
(4) appliances to correct harmful habits; and
(1) Orthodontic Treatment Plan and
Records - the preparation of orthodontic
records and a treatment plan by the
Orthodontist.
(5) services which are not typically included in
orthodontic treatment. These services will
be identified on a case-by-case basis.
(2) Interceptive Orthodontic Treatment treatment prior to full eruption of the
permanent teeth, frequently a first phase
preceding comprehensive treatment.
(3) Comprehensive Orthodontic Treatment treatment after the eruption of most
permanent teeth, generally the final phase
of treatment before retention.
(4) Retention (Post Treatment Stabilization)
- the period following orthodontic treatment
during which you may wear an appliance to
maintain and stabilize the new position of
the teeth.
b.
If orthodontic treatment is in progress for you or
your Dependent at the time you enroll, call
Customer Service at 1-800-Cigna24 to find out
the benefit to which you are entitled based upon
your individual case and the remaining months
of treatment.
e.
Exclusion
Replacement of fixed and/or removable
orthodontic appliances (including fixed and
removable orthodontic appliances) that have
been lost, stolen, or damaged due to patient
B. Emergency Dental Care - Reimbursement
eliminate acute infection. Emergency dental care services
may include examination, x-rays, sedative fillings,
dispensing of antibiotics or pain relief medication or other
palliative services prescribed by the treating dentist. You
should contact your Network General Dentist if you have
an emergency in your Service Area.
Copayments
The Copayment for your entire orthodontic case,
including retention, will be based upon the
Patient Charge Schedule in effect on the date of
your visit for Orthodontic Treatment Plan and
Records. However, if (a) banding/appliance
insertion does not occur within 90 days of such
visit, (b) your treatment plan changes, or (c)
there is an interruption in your coverage or
Schedule may apply.
The Copayment for orthodontic treatment is
comprehensive treatment. If you require more
than 24 months of treatment in total, you will be
charged an additional amount for each additional
month of treatment, based upon the
Orthodontist’s Contract Fee. If you require less
than 24 months of treatment, your Copayment
will be reduced on a prorated basis.
c.
d.
1.
Additional Charges
You will be responsible for the Orthodontist’s
Usual Fees for the following non-Covered
Services:
(1) incremental costs associated with
optional/elective materials, including but
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definitive treatment (e.g., root canal) are not
responsible for the Copayments listed on your Patient
Charge Schedule. Cigna Dental will reimburse you
the difference between the dentist’s usual fee for
emergency Covered Services and your Copayment,
up to a total of $50 per incident. To receive
reimbursement, send the dentist’s itemized statement
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of the restoration is: to change the vertical dimension of
occlusion; or for cosmetic purposes.
to Cigna Dental at the address listed for your state on
the front of this booklet.
2.
There is a Copayment listed on your Patient Charge
Schedule for emergency care rendered after regularly
scheduled office hours. This charge will be in
addition to other applicable Copayments.


charges by dental offices for failing to cancel an
appointment or canceling an appointment with less than 24
hours notice (i.e. a broken appointment). You will be
responsible for paying any broken appointment fee unless
your broken appointment was unavoidable due to
emergency or exigent circumstances.

consultations and/or evaluations associated with services
that are not covered.

infection control and/or sterilization. Cigna Dental considers
this to be incidental to and part of the charges for services
provided and not separately chargeable.

services to correct congenital malformations, including the
replacement of congenitally missing teeth.
VI. Exclusions
In addition to the exclusions listed in Section V, listed below
are the services or expenses which are also NOT covered
under your Dental Plan and which are your responsibility at
the dentist’s Usual Fees. There is no coverage for:


services provided by a non-Network Dentist without Cigna
Dental’s prior approval (except emergencies, as described in
Section V.B.).

services to the extent you, or your Dependent, are
compensated for them under any group medical plan.

services considered to be unnecessary or experimental in
nature or do not meet commonly accepted dental standards.

surgical placement of a dental implant; repair, maintenance
or removal of a dental implant; implant abutment(s); or any
services related to the surgical placement of a dental
implant, unless specifically listed on your Patient Charge
Schedule.

cosmetic dentistry or cosmetic dental surgery (dentistry or
dental surgery performed solely to improve appearance)
unless specifically listed on your Patient Charge Schedule.
If bleaching (tooth whitening) is listed on your Patient
Charge Schedule, only the use of take-home bleaching gel
with trays is covered; all other types of bleaching methods
are not covered.


Covered Services performed at a hospital. Other associated
charges are not covered and should be submitted to the
medical carrier for benefit determination. If special
circumstances arise where a Network Dentist is not
available, the Plan will make special arrangements for the
provision of covered benefits as necessary for the dental
health of the customer.)

As noted in Section V, the following exclusions also apply:
procedures, appliances or restorations if the main purpose is
to: change vertical dimension (degree of separation of the
jaw when teeth are in contact); restore asymptomatic teeth
where loss of tooth structure was caused by attrition,
abrasion, erosion and/or abfraction and the primary purpose
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
there is no coverage for crowns, bridges used solely for
splinting. This exclusion will not apply if a crown or bridge
is determined by Cigna Dental to be the treatment most
consistent with professionally accepted standards of care.

there is no coverage for implant supported prosthesis used
solely for splinting unless specifically listed on your Patient
Charge Schedule.

there is no coverage for resin bonded retainers and
associated pontics.

general anesthesia, sedation and nitrous oxide are not
covered, unless specifically listed on your Patient Charge
Schedule. There is no coverage for general anesthesia or
intravenous sedation when used for the purposes of anxiety
control or patient management.

replacement of fixed and/or removable orthodontic
appliances (including fixed and removable orthodontic
appliances) that have been lost, stolen, or damaged due to
patient abuse, misuse or neglect.

endodontic treatment and/or periodontal (gum tissue and
supporting bone) surgery of teeth exhibiting a poor or
hopeless periodontal prognosis.

the recementation of any inlay, onlay, crown, post and core
or fixed bridge within 180 days of initial placement. Cigna
Dental considers recementation within this timeframe to be
incidental to and part of the charges for the initial
restoration.

(including crowns, bridges and dentures) within 180 days of
initial placement. Cigna Dental considers recementation
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implant; implant abutment(s); or any services related to the
surgical placement of a dental implant are limited to one per
year with replacement of a surgical implant frequency
limitation of one every 10 years.
charges for the initial restoration unless specifically listed

the replacement of an occlusal guard (night guard) beyond
one per any 24 consecutive month period, when this
limitation is noted on the Patient Charge Schedule.

intentional root canal treatment in the absence of injury or
disease to solely facilitate a restorative procedure.




Prosthesis Over Implant – When covered on the Patient
Charge Schedule, a prosthetic device, supported by an
implant or implant abutment is considered a separate
distinct service(s) from surgical placement of an implant.
Replacement of any type of prosthesis with a prosthesis
supported by an implant or implant abutment is only
covered if the existing prosthesis is at least 5 calendar years
old, is not serviceable and cannot be repaired.
noted above, the limitation for that service(s) shall not apply.
localized delivery of antimicrobial agents when performed
alone or in the absence of traditional periodontal therapy.
noted above, the exclusion for that service(s) shall not apply.
VIII. What To Do If There Is A
Problem/Grievances
VII. Limitations
you to act on your behalf.
In addition to the limitations listed in Section V, listed below
are the services or expenses which have limited coverage
under your Dental Plans. No payment will be made for
expense incurred or services received:

for or in connection with an injury arising out of, or in the
course of, any employment for wage or profit;

for charges which would not have been made in any facility,
other than a Hospital or a Correctional Institution owned or
operated by the United States Government or by a state or
municipal government if the person had no insurance;

resides when the expenses are incurred or the services are
received;

for the charges which the person is not legally required to
pay;

for charges which would not have been made if the person
had no insurance;

due to injuries which are intentionally self-inflicted;
procedure is voluntary and will be used only upon your
request. No Plan Member shall retaliate or discriminate
against a customer (including seeking disenrollment of the
customer) solely on the basis that the customer filed a
grievance. Instances of such retaliation or discrimination shall
be grounds for disciplinary action, (including termination)
against the Member.
A. Your Rights to File Grievances With Cigna Dental
We want you to be completely satisfied with the care you
receive. That is why we have established an internal
grievance process for addressing your concerns and
resolving your problems.
Grievances include both complaints and appeals.
Complaints may include concerns about people, quality of
service, quality of care, benefit interpretations or
eligibility. Appeals are requests to reverse a prior denial
or modified decision about your care. You may contact us
by telephone or in writing with a grievance.
In addition to the above the following limitations will also
apply:


Clinical Oral Evaluations – When this limitation is noted
on the Patient Charge Schedule, periodic oral evaluations,
comprehensive oral evaluations, comprehensive periodontal
evaluations, and oral evaluations for patients under 3 years
of age, are limited to a combined total of 4 evaluations
during a 12 consecutive month period.
B. How to File a Grievance
To contact us by phone, call us toll-free at 1-800-Cigna24
or the toll-free telephone number on your Cigna
identification card. The hearing impaired may call the
state TTY toll-free service listed in their local telephone
directory.
Surgical Placement of Implant Services – When covered
on the Patient Charge Schedule, surgical placement of a
dental implant; repair, maintenance, or removal of a dental
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additional information about your appeal. We will
make sure your appeal is handled by someone who
has authority to take action and who was not involved
in the original decision. We will investigate your
appeal and notify you of our decision, within 30
calendar days. You may request that the appeal
process be expedited, if there is an imminent and
serious threat to your health, including severe pain,
potential loss of life, limb or major bodily function. A
Dental Director for Cigna Dental, in consultation
with your treating dentist, will decide if an expedited
appeal is necessary. When an appeal is expedited,
Cigna Dental will respond orally and in writing with
a decision within 72 hours.
Send written grievances to:
Cigna Dental Health of California, Inc.
P.O. Box 188047
Chattanooga, TN 37422-8047
We will provide you with a grievance form upon request,
but you are not required to use the form in order to make
a written grievance.
You may also submit a grievance online through the
following Cigna website:
http://myCigna.com/health/consumer/medical/state/ca.ht
ml#dental.
If the customer is a minor, is incompetent or unable to
exercise rational judgment or give consent, the parent,
guardian, conservator, relative, or other legal
representative acting on behalf of the customer, as
appropriate, may submit a grievance to Cigna Dental or
the California Department of Managed Health Care
(DMHC or “Department”), as the agent of the customer.
Also, a participating dentist may join with or assist you or
your agent in submitting a grievance to Cigna Dental or
the DMHC.
1.
Complaints
If you are concerned about the quality of service or
care you have received, a benefit interpretation, or
have an eligibility issue, you should contact us to file
a verbal or written complaint. If you contact us by
telephone to file a complaint, we will attempt to
document and/or resolve your complaint over the
telephone. If we receive your complaint in writing,
we will send you a letter confirming that we received
the complaint within 5 calendar days of receiving
your notice. This notification will tell you whom to
contact should you have questions or would like to
submit additional information about your complaint.
We will investigate your complaint and will notify
you of the outcome within 30 calendar days.
2.
Appeals
If your grievance does not involve a complaint about
the quality of service or care, a benefit interpretation
or an eligibility issue, but instead involves
dissatisfaction with the outcome of a decision that
was made about your care and you want to request
Cigna Dental to reverse the previous decision, you
should contact us within one year of receiving the
denial notice to file a verbal or written appeal. Be
sure to share any new information that may help
justify a reversal of the original decision. Within 5
calendar days from when we receive your appeal, we
will confirm with you, in writing, that we received it.
We will tell you whom to contact at Cigna Dental
should you have questions or would like to submit
C. You Have Additional Rights Under State Law
Cigna Dental is regulated by the California Department of
Managed Health Care (DMHC or the “Department”). If
you are dissatisfied with the resolution of your complaint
or appeal, the law states that you have the right to submit
the grievance to the department for review as follows:
The California Department of Managed Health Care is
responsible for regulating health care service plans. If you
have a grievance against your health plan, you should first
telephone your health plan at 1-800-Cigna24 and use your
health plan’s grievance process before contacting the
department. Utilizing this grievance procedure does not
prohibit any potential legal rights or remedies that may be
available to you. If you need help with a grievance
involving an emergency, a grievance that has not been
satisfactorily resolved by your health plan, or a grievance
that has remained unresolved for more than 30 days, you
may call the department for assistance. You may also be
eligible for an Independent Medical Review (IMR). If you
are eligible for IMR, the IMR process will provide an
impartial review of medical decisions made by a health
plan related to the medical necessity of a proposed service
or treatment, coverage decisions for treatments that are
experimental or investigational in nature and payment
disputes for emergency or urgent medical services. The
department also has a toll-free telephone number (1-888HMO-2219) and a TDD line (1-877-688-9891) for the
hearing and speech impaired. The department’s Internet
Web site http://www.hmohelp.ca.gov has complaint
forms, IMR application forms and instructions online.
You may file a grievance with the DMHC if Cigna Dental
has not completed the complaint or appeal process
described above within 30 days of receiving your
grievance. You may immediately file an appeal with
Cigna Dental and/or the DMHC in a case involving an
imminent and serious threat to the health, including, but
not limited to, severe pain, the potential loss of life, limb,
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C. If a child of divorced or separated parents is covered as a
dependent under at least one of the parents’ (or
stepparents’) coverage, benefits are determined in the
following order:
or major bodily function, or in any other case where the
DMHC determines that an earlier review is warranted.
D. Voluntary Mediation
If you have received an appeal decision from Cigna
Dental with which you are not satisfied, you may also
request voluntary mediation with us before exercising the
right to submit a grievance to the DMHC. In order for
mediation to take place, you and Cigna Dental each have
to voluntarily agree to the mediation. Cigna Dental will
consider each request for mediation on a case by case
basis. Each side will equally share the expenses of the
mediation. To initiate mediation, please submit a written
request to the Cigna Dental address listed above. If you
request voluntary mediation, you may elect to submit
your grievance directly to the DMHC after participating
in the voluntary mediation process for at least 30 days.
1.
According to a court decree that designates the
person financially responsible for the dental care
coverage; or without such decree,
2.
The plan of the parent who has custody of the child;
3.
If the parent with custody of the child is remarried;
then the stepparent’s plan; and finally,
4.
The plan of the parent without custody of the child.
D. The benefits of a plan that covers an active Member (and
any dependents) are determined before those of a program
which covers an inactive Member (laid-off or retired).
However, if one of the plans does not have a provision
regarding retired or laid-off Members, this section may
not apply. Please contact the Plan at the number below for
further instruction.
For more specific information regarding these grievance
procedures, please contact our Customer Service
Department.
E. If a customer is covered under a continuation plan (e.g.
COBRA) AND has coverage under another plan, the
following determines the order of benefits:
IX. Coordination of Benefits
Coordination of benefit rules explain the payment process
when you are covered by more than one dental plan. You and
your Dependents may not be covered twice under this Dental
Plan. If you and your spouse have enrolled each other or the
same Dependents twice, please contact your Benefit
Administrator.
1.
The plan that covers the customer as an Member (or
dependent of Member) will be primary;
2.
The continuation plan will be secondary.
However, if the plan that covers the person as an Member
does not follow these guidelines and the plans disagree
about the order of determining benefits, then this rule may
be ignored. Please contact Cigna Dental at the number
below for further instructions.
spouse’s Fund or other sources, applicable coordination of
benefit rules will determine which coverage is primary or
secondary. In most cases, the plan covering you as an Member
is primary for you, and the plan covering your spouse as an
Member is primary for him or her. Your children are generally
covered as primary by the plan of the parent whose birthday
occurs earlier in the year. Coordination of Benefits should
result in lowering or eliminating your out-of-pocket expenses.
It should not result in reimbursement for more than 100% of
your expenses.
F.
If none of the above rules determines the order of
benefits, the plan that has been in effect longer is the
primary plan. To determine which plan has been in effect
longer, we will take into consideration the coverage you
had previously with the same Fund, even if it was a
different plan, as along as there was no drop in eligibility
during the transition between plans.
G. Workers’ Compensation – Should any benefit or service
rendered result from a Workers’ Compensation Injury
Claim, the customer shall assign his/her right to
reimbursement from other sources to Cigna Dental or to
the Participating Provider who rendered the service.
The following is a more detailed explanation of the rules used
to determine which plan must pay first (your “primary” plan)
and which plan must pay second (your “secondary” plan):
A. A customer may be covered as an Member by his/her
Fund and as a dependent by his/her spouse’s Fund. The
plan that covers the customer as an Member (the
policyholder) is the primary plan.
H. When Cigna Dental is primary, we will provide or pay
dental benefits without considering any other plan’s
benefits. When Cigna Dental is secondary, we shall pay
the lesser of either the amount that we would have paid in
the absence of any other dental coverage, or your total out
of pocket cost payable under the primary dental plan for
benefits covered by Cigna Dental.
B. Under most circumstances, if a child is covered as a
dependent under both parents’ coverage (and parents are
not separated or divorced), the plan of the parent with the
earliest birthday in the year is the primary plan.
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I.
Please call Cigna Dental at 1-800-Cigna24 if you have
questions about which plan will act as your primary plan
or if you have other questions about coordination of
benefits.
opportunities to transfer to another Dental Office
prior to such termination. In the event of such
termination, Cigna Dental will cooperate as needed to
help you establish a relationship with a nonparticipating dental office.
Additional coordination of benefit rules are attached to the
Group Contract and may be reviewed by contacting your
Benefit Administrator. Cigna Dental coordinates benefits only
for specialty care services.
X.
4. you threaten the life or well-being of any Dental Plan
Member, Network Dentist, Dental Office Member or
another customer and the Dental Office is materially
impaired in its ability to provide services to you.
Cigna Dental will provide reasonable opportunities to
transfer to another Dental Office prior to such
termination.
Disenrollment From the Dental Plan –
C. Termination Effective Date
The effective date of the termination shall be as follows:
Except for extensions of coverage as otherwise provided in the
sections titled “Extension/Continuation of Benefits” or in your
Group Contract, disenrollment from the Dental
Plan/termination of benefits and coverages will be as follows:
1. in the case of nonpayment of Prepayment Fees,
enrollment will be canceled as of the last day of the
month in which payment was received, subject to
compliance with notice requirements.
A. For the Group
The Dental Plan is renewable with respect to the Group
except as follows:
2. in the case of failure to meet eligibility requirements
or for disruptive or threatening behavior described
above, enrollment will be canceled as of the date of
termination specified in the written notice, provided
that at least 15 days have expired since the date of
notification.
1. for nonpayment of the required Prepayment Fees;
2. for fraud or other intentional misrepresentation of
material fact by the Group;
3. low participation (i.e. less than ten enrollees);
4. if the Dental Plan ceases to provide or arrange for the
provision of dental services for new Dental Plans in
the state; provided, however, that notice of the
decision to cease new or existing dental plans shall be
provided as required by law at least 180 days prior to
discontinuation of coverage; or
3. on the last day of the month after voluntary
disenrollment.
4. termination of Benefits due to fraud or deception
shall be effective immediately upon receipt of notice
of cancellation.
D. Effect on Dependents
When one of your Dependents disenrolls, you and your
other Dependents may continue to be enrolled. When you
are disenrolled, your Dependents will be disenrolled as
well.
5. if the Dental Plan withdraws a Group Dental Plan
from the market; provided, however, that notice of
withdrawal shall be provided as required by law at
least 90 days prior to the discontinuation and that any
other Dental Plan offered is made available to the
Group.
For you and your Dependents, disenrollment will be
effective the last day of the month in which Prepayment
Fees are not paid to Cigna Dental. Cigna Dental will
provide at least 15 days notice to your Group as to the
date your coverage will be discontinued.
B. For You and Your Enrolled Dependents
The Dental Plan may not be canceled or not renewed
except as follows:
1. failure to pay the charge for coverage if you have
been notified and billed for the charge and at least 15
days have elapsed since the date of notification.
E. Right to Review
If you believe that your termination from the Dental Plan
is due to your dental health status or requirements for
dental care services, you may request review of the
termination by the Director of the Department of
Managed Health Care.
2. fraud or deception in the use of services or Dental
Offices or knowingly permitting such fraud or
deception by another.
3. your behavior is disruptive, unruly, abusive or
uncooperative to such an extent that the Dental Plan
or the Network Dental Office is materially impaired
in its ability to provide services to you or another
customer. Cigna Dental will provide reasonable
F. Notice of Termination
If the Group Contract is terminated for any reason
described in this section, the notice of termination of the
Group Contract or your coverage under the Group
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Cigna Dental is not obligated to arrange for continuation of
care with a terminated dentist who has been terminated for
medical disciplinary reasons or who has committed fraud or
other criminal activities.
Contract shall be mailed by the Dental Plan to your Group
or to you, as applicable. Such notice shall be dated and
shall state:
1. the cause for termination, with specific reference to
the applicable provision of the Group Contract or
Plan Booklet;
In order for the terminated Participating Provider to continue
to care for you, the terminated dentist must comply with the
Cigna Dental’s contractual and credentialing requirements and
must meet the Cigna Dental’s standards for utilization review
and quality assurance. The terminated dentist must also agree
with Cigna Dental to a mutually acceptable rate of payment. If
these conditions are not met, Cigna Dental is not required to
arrange for continuity of care.
2. the cause for termination was not the Subscriber’s or
a customer’s health status or requirements for health
care services;
3. the time the termination is effective;
4. the fact that a Subscriber or customer alleging that the
termination was based on health status or
requirements for health care services may request a
review of the termination by the Director of the
California Department of Managed HealthCare;
If you meet the necessary requirements for continuity of care
as described above, and would like to continue your care with
the terminated Dentist, you should call Customer Service.
If you do not meet the requirements for continuity of care or if
the terminated dentist refuses to render care or has been
determined unacceptable for quality or contractual reasons,
Cigna Dental will work with you to accomplish a timely
transition to another qualified Network Dentist.
5. in instances of termination of the Group Contract for
non-payment of fees, that receipt by the Dental Plan
of any such past due fees within 15 days following
receipt of notice of termination will reinstate the
Group Contract as though it had never been
terminated; if payment is not made within such 15
day period a new application will be required and the
Dental Plan shall refund such payment within 20
business days;
XII. Continuation of Benefits (COBRA)
the required Prepayment Fees to the Group. Additional
information is available through your Benefits Representative.
6. any applicable rights you may have under the
“Continuation of Benefits” Section.
XI. Continuity of Care
If you are receiving care from a Network Dentist who has
been terminated from the Cigna Dental network, Cigna Dental
will arrange for you to continue to receive care from that
dentist if the dental services you are receiving are for one of
the following conditions:
XIII. Individual Continuation of Benefits
conversion plan. You must enroll within 3 months after
(1) an acute condition. An acute condition is a dental
condition that involves a sudden onset of symptoms due
to an illness, injury, or other dental problem that requires
prompt dental attention and that has a limited duration.
Completion of the covered services shall be provided for
the duration of the acute condition.
(2) newborn children between birth and age 36 months.
Cigna Dental shall provide for the completion of covered
services for newborn children between birth and age 36
months for 12 months from the termination date of the
Network Dentist’s contract.
(3) performance of a surgery or other procedure that is
authorized by Cigna Dental and has been recommended
and documented by the terminated dentist to occur within
180 days of the effective date of termination of the
dentist’s contract.

permanent breakdown of the dentist-patient relationship,

fraud or misuse of dental services and/or Dental Offices,

nonpayment of Prepayment Fees by the Subscriber,

selection of alternate dental coverage by your Group, or

lack of network/service area.
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One easy way individuals can make themselves eligible
for organ donation is through the Department of Motor
Vehicles (DMV). Every time a license is renewed or a
new one is issued to replace one that was lost, the DMV
will automatically send an organ donor card. Individuals
may complete the card to indicate that they are willing to
have their organs donated upon their death. They will then
be given a small dot to stick on their driver’s license,
indicating they have an organ donor card on file. For
more information, contact your local DMV office and
request an organ donor card.
XIV. Confidentiality/Privacy
C. 911 Emergency Response System
You are encouraged to use appropriately the ‘911’
emergency response system, in areas where the system is
established and operating, when you have an emergency
medical condition that requires an emergency response.
A STATEMENT DESCRIBING CIGNA DENTAL’S
POLICIES AND PROCEDURES FOR PRESERVING
THE CONFIDENTIALITY OF MEDICAL RECORDS IS
AVAILABLE AND WILL BE FURNISHED TO YOU
UPON REQUEST.
CAPB09
CALIFORNIA LANGUAGE ASSISTANCE
PROGRAM NOTICE
XV. Miscellaneous
IMPORTANT INFORMATION ABOUT FREE
LANGUAGE ASSISTANCE
If you have a limited ability to speak or read English you have
the right to the following services at no cost to you:
A. Programs Promoting General Health
various benefits, or other consideration for the purpose of
promoting your general health and well being. Please visit
our website at my.cigna.com for details.
As a Cigna Dental plan customer, you may also be
eligible for additional dental benefits during certain
episodes of care. For example, certain frequency
limitations for dental services may be relaxed for pregnant
women. Please review your plan enrollment materials for
details.
B. Organ and Tissue Donation
Donating organ and tissue provides many societal
benefits. Organ and tissue donation allows recipients of
transplants to go on to lead fuller and more meaningful
lives. Currently, the need for organ transplants far exceeds
availability. The California Health and Safety Code states
that an anatomical gift may be made by one of the
following ways:

a document of gift signed by the donor.

a document of gift signed by another individual and by
two witnesses, all of whom have signed at the direction
and in the presence of the donor and of each other and
state that it has been so signed.

a document of gift orally made by a donor by means of
a tape recording in his or her own voice.
03.01.13

Access to an interpreter when you call Cigna's Member
Services Department.

Access to an interpreter when you talk to your doctor or
health care provider.

If you read Spanish or Traditional Chinese, you also have
the right to request that we read certain documents that
Cigna has mailed to you, in your preferred language. You
may also request written translation of these documents.
To inform Cigna of your preferred written and spoken
languages, your race and/or ethnicity, or to request assistance
from someone who speaks your language, please call us at the
telephone number on your Identification (ID) card or your
customer service phone number.
We are pleased to assist you in the language you prefer and
understand.
INFORMACIÓN IMPORTANTE SOBRE LA
ASISTENCIA GRATUITA CON EL IDIOMA
Si su dominio para hablar o leer en inglés es limitado, usted
tiene derecho a acceder a los siguientes servicios, sin ningún
costo para usted:

74
Acceso a un intérprete cuando se comunica con el
Departamento de Servicios a los miembros de Cigna.
myCigna.com

Acceso a un intérprete cuando habla con su médico o con el
proveedor de atención médica.

Si usted lee español o chino tradicional, también tiene
derecho a solicitar que le leamos ciertos documentos que
Cigna le ha enviado a usted por correo, en el idioma que
usted prefiera. También puede solicitar la traducción por
escrito de estos documentos.
Para informarle a Cigna el idioma escrito u oral que usted
prefiere, su raza y/o origen étnico, o para solicitar ayuda de
alguien que hable su idioma, por favor, llámenos al teléfono
que figura en su Tarjeta de identificación (ID) o al teléfono del
servicio de atención al cliente.
Nos complace ayudarle en el idioma que usted prefiere y
entiende.
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NOT199
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Cigna HealthCare of Connecticut, Inc.
Cigna HealthCare of Connecticut, Inc.
900 Cottage Grove Road
Hartford, CT 06152-1118
Cigna Dental Health, Inc.
1571 Sawgrass Corporate Parkway, Suite 140
Sunrise, FL 33323
Phone: 1-800-Cigna24
This Plan Booklet is intended for your information; it constitutes a summary of the Dental Plan and is included as a part of the
agreement between Cigna HealthCare of Connecticut, Inc. and your Group (collectively, the “Group Contract”). The Group
Contract must be consulted to determine the rates and the exact terms and conditions of coverage. If rates or coverages are
changed under your Group Contract, your rates and coverage will also change.
Consumer Notice: Your out-of-pocket expense for certain complex procedures may exceed 50% of a dentist’s usual charge for
those procedures. Please read your plan documents carefully and discuss your treatment options and financial obligations with
your dentist. If you have any questions about your plan, please call Customer Service or visit http://myCigna.com for
additional information.
PB09CT
12.01.121
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TABLE OF CONTENTS
I.
Definitions
II.
III.
IV.
A. Customer Service
C. Other Charges - Patient Charges
V.
Appointments
VI.
Broken Appointments
VII.
Office Transfers
VIII.
Specialty Care
IX.
Specialty Referrals
A. In General
B. Orthodontics
X.
XI.
What To Do If There Is A Problem
A. Start With Customer Service
XII.
Dual Coverage
XIII.
Disenrollment From the Dental Plan - Termination of Benefits
XIV.
Extension of Benefits
XV.
Continuation of Benefits (COBRA)
XVI.
Conversion Coverage
XVII.
Confidentiality/Privacy
XVIII.
Miscellaneous
PB09CT
12.01.12
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2. reliant upon you for maintenance and support; or
I. Definitions
1. incapable of self-sustaining employment due to
mental or physical disability; and
2. reliant upon you for maintenance and support.
For a Dependent child 19 years of age or older who is a fulltime student at an educational institution, coverage will be
dental field;
For a child who falls into category (b) or (c) above, you will
need to furnish Cigna Dental evidence of his or her reliance
upon you, in the form requested, within 31 days after the
Dependent reaches the age of 19 and once a year thereafter
during his or her term of coverage.
Coverage for Dependents living outside a Cigna Dental
service area is subject to the availability of an approved
network where the Dependent resides.
your State Rider or Group Contract.
Cigna Dental - Cigna Dental Health, Inc., on behalf of
Cigna HealthCare of Connecticut, Inc. (said corporations are
affiliates and are herein after referred to as “Cigna Dental”),
contracts with participating general dentists for the provision
of dental care. Cigna Dental Health, Inc. also provides
management and information services to customers and
participating dental offices.
entered into a Group Contract with Cigna HealthCare of
Connecticut, Inc. for managed dental services on your
behalf.
Medically necessary or medical necessity - means health
care services that a physician/dentist, exercising prudent
clinical judgment, would provide to a patient for the purpose
of preventing, evaluating, diagnosing or treating an illness,
injury, disease or its symptoms, and that are:
(1) In accordance with generally accepted standards of
medical/dental practice;
Dentist(s).
(2) Clinically appropriate, in terms of type, frequency, extent,
site and duration and considered effective for the patient's
illness, injury or disease; and
Group Contract between Cigna HealthCare of Connecticut,
Inc. and your Group.
(3)Not primarily for the convenience of the patient,
physician/dentist or other health care provider and not more
costly than an alternative service or sequence of services at
least as likely to produce equivalent therapeutic or diagnostic
results as to the diagnosis or treatment of that patient's illness,
injury or disease.
(including newborns, adopted children, stepchildren, a child
for whom you must provide dental coverage under a court
order; or, a Dependent child who resides in your home as a
result of court order or administrative placement) who is:
For the purposes of this definition, "generally accepted
standards of medical/dental practice" means standards that are
based on credible scientific evidence published in peerreviewed medical/dental literature generally recognized by the
relevant medical/dental community or otherwise consistent
1. a full-time student enrolled at an accredited
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with the standards set forth in policy issues involving clinical
judgment.
Dependents may be enrolled in the Dental Plan at the time
you enroll, during an open enrollment, or within 31 days of
becoming eligible due to a life status change such as
marriage, birth, adoption, placement, or court or
administrative order. You may drop coverage for your
Dependents only during the open enrollment periods for your
Group, unless there is a change in status such as divorce.
Cigna Dental may require evidence of good dental health at
your expense if you or your Dependents enroll after the first
period of eligibility, (except during open enrollment), or
after disenrollment because of nonpayment of Premiums.
Dentists.
Network General Dentist - a licensed dentist who has
signed an agreement with Cigna Dental under which he or
she agrees to provide dental care services to you.
she agrees to provide specialized dental care services to you.
If you have family coverage, a newborn child is
automatically covered during the first 61 days of life. If you
wish to continue coverage beyond the first 61 days, your
baby must be enrolled in the Dental Plan and you must begin
paying Premiums, if any additional are due, during that
period.
Schedule.
Patient Charge Schedule - list of services covered under
your Dental Plan and how much they cost you.
Under the Family and Medical Leave Act of 1993, you may
be eligible to continue coverage during certain leaves of
absence from work. During such leaves, you will be
responsible for paying your Group the portion of the
Premiums, if any, which you would have paid if you had not
taken the leave. Additional information is available through
your Benefits Representative.
Premiums - fees that your Group remits directly or
indirectly to Cigna HealthCare of Connecticut, Inc., on your
behalf, during the term of your Group Contract.
Group.
information about which services are covered, which are not
A. Customer Service
directory.
your dental benefits. Please note that enrollment in the
Dental Plan allows the release of patient records to Cigna
Dental or its designee for health plan operation purposes.
be able to seek treatment for Covered Services within a
Cigna Dental Service Area. Other eligibility requirements
are determined by your Group.
Group Contract is effective. If you enrolled in the Dental
Plan after the effective date of the Group Contract, you will
be covered on the first day of the month following
processing of your enrollment (unless effective dates other
than the first day of the month are provided for in your
Group Contract).
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Charge Schedule.
website at myCigna.com or call the Dental Office Locator
at 1-800-Cigna24. It is available 24 hours a day, 7 days
per week. If you would like to have the list faxed to you,
enter your fax number, including your area code. You
may always obtain a current Dental Office Directory by
calling Customer Service.
Usual Fees.
Patient Charge.
your Service Area.
1.
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and your Patient Charges. To receive reimbursement,
send appropriate reports and x-rays to Cigna Dental
at the address listed on the front of this booklet.
2.

services received:
your Dental Plan:


Pediatric Dentistry – Coverage for treatment by a
must be obtained from a Network General Dentist;


Charge Schedule.




are received;

to pay;


coverage for:
Charge Schedule.

Prosthesis Over Implant – When covered on the
be repaired.
evaluations for patients under 3 years of age are limited
to a combined total of 4 evaluations during a 12
82


described in Section IV.F.)

laws.

myCigna.com


canal treatment already in progress on the effective date


Charge Schedule.


or hopeless periodontal prognosis, unless dentally
necessary.




service performed by a prosthodontist.






services to correct congenital malformation, including


crowns and bridges used solely for splinting.

intravenous sedation when used for the purposes of


separation of the jaw when teeth are in contact); restore
teeth which have been damaged by attrition, abrasion,
erosion, and/or abfraction or restore the occlusion.


that have been lost; stolen; or damaged due to patient

standards.


determination.)

policy.
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
When specialty care is needed, your Network General
Dentist must start the referral process. X-rays taken by your
Network General Dentist should be sent to the Network
Specialty Dentist.
V. Appointments
Dental Office will ask for your identification number and
will check your eligibility.
See Section IV.D., Choice of Dentist, regarding treatment by
a Pediatric Dentist.
A. In General
except for Pediatrics and Endodontics, for which prior
authorization is not required. You should verify with the
Network Specialty Dentist that your treatment plan has
been authorized for payment by Cigna Dental before
treatment begins.
If you or your enrolled Dependent breaks an appointment
with less than 24 hours notice to the Dental Office, you may
be charged a broken appointment fee.
obtain treatment within the 90-day period, please call
To obtain a list of Dental Offices near you, visit our website
at myCigna.com or call the Dental Office Locator at 1-800Cigna24.
There is no charge to you for the transfer; however, all
Patient Charges which you owe to your current Dental Office
must be paid before the transfer can be processed.




procedures.

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3.
Orthodontics is listed on your Patient Charge
Schedule.)
1.
2.
Definitions
If your Patient Charge Schedule indicates coverage
for orthodontic treatment, the following definitions
apply:
a.
Orthodontic Treatment Plan and Records the preparation of orthodontic records and a
b.
Interceptive Orthodontic Treatment treatment prior to full eruption of the permanent
c.
Comprehensive Orthodontic Treatment treatment after the eruption of most permanent
before retention.
d.
Retention (Post Treatment Stabilization) - the
4.
Additional Charges
a.
b.
costs;
c.
d.
e.
Dental Plan.
Units
involving 6 or more “units” of crown, bridge, and/or implant
Patient Charges
Schedule may apply.
basis.
tooth replacement included in the treatment plan is referred
to as a “unit” on your Patient Charge Schedule. The crown,
bridge and/or implant supported prosthesis (including
crowns and bridges) charges on your Patient Charge
Schedule are for each unit of crown or bridge. You pay the
per unit charge for each unit of crown, bridge and/or implant
supported prosthesis (including crowns and bridges) PLUS
an additional charge for each unit when 6 or more units are
prescribed in your Network General Dentist’s treatment plan.
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receive your appeal. If we need more time or
information to make the decision, we will notify you
in writing to request an extension of up to 15
expedited if the timeframes under the above process
decision within the lesser of 72 hours after the appeal
is received, or 2 business days after the required
information is received, followed up in writing.
Most problems can be resolved between you and your
dentist. However, we want you to be completely satisfied
with the Dental Plan. That is why we have established a
process for addressing your concerns and complaints. The
complaint procedure is voluntary and will be used only upon
your request.
express that concern in writing to Cigna Dental at P.O.
Box 188047, Chattanooga, TN 37422-8047. We’ll do our
need more time to review or investigate your concern,
we’ll get back to you as soon as possible, usually by the
days.
If you are not satisfied with our level one appeal
decision, you may request a level two appeal.
2.
from the date of receipt of the initial Cigna Dental
decision. You should state the reason you feel your appeal
should be approved and include any information to
support your appeal. If you are unable or choose not to
write, you may ask Customer Service to register your
appeal by calling 1-800-Cigna24.
1.
Level Two Appeals
To initiate a level two appeal, follow the same
process required for a level one appeal. For
postservice claim or administrative appeals, your
request must be received before the 14th calendar day
following our mailing of the level one determination.
Level two appeals will be conducted by an Appeals
Committee consisting of at least 3 people. Anyone
involved in the prior decision may not vote on the
Appeals Committee. For appeals involving dental
necessity or clinical appropriateness, the Appeals
Committee will include at least one dentist. If
specialty care is in dispute, the Appeals Committee
will consult with a dentist in the same or similar
writing and schedule an Appeals Committee review.
The acknowledgment letter will include the name,
address, and telephone number of the Appeals
Coordinator. We may request additional information
at that time. If your appeal concerns a denied
preauthorization, the Appeals Committee review will
be completed within 15 calendar days. For appeals
concerning all other coverage issues, the Appeals
Committee review will be completed within 60
calendar days after receipt of your original level one
request for appeal, unless you request an extension. If
we receive a request for a Level Two appeal post
service claim appeal on or after the 14th calendar day
following our mailing of the level one determination:
Level One Appeals
Your level one appeal will be reviewed and the
professional in the field related to the care under
consideration, under the authority of a Connecticut
licensed dentist.
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a. it will be deemed as a request by you for an
extension; and b. the 60 day review period will be
suspended on the 14th day we receive no Level Two
appeal, then resume on the day we receive your Level
Two appeal.
month:
You may present your appeal to the Appeals
Committee in person or by conference call. You must
advise Cigna Dental 5 days in advance if you or your
representative plan to attend in person. You will be
notified in writing of the Appeals Committee’s
decision within 5 business days after the meeting.
The decision will include the specific contractual or
clinical reasons for the decision, as applicable.
expedited if the timeframes under the above process
decision within the lesser of 72 hours or 2 business
days after the required information is received,
followed up in writing.
1.
in which Premiums/Prepayment Fees are not remitted
to Cigna Dental.
2.
3.
Office.
4.
5.
Area.
6.
In the event of termination of your Group Contract by
either Cigna Dental or the Group, the Group shall within
15 days provide a notice of termination to each Covered
Person.
XII. Dual Coverage
If you and your spouse are employed by the same Fund and
by reason of that employment are participating in this Dental
Plan, you may be covered as an Member under this plan in
addition to being covered as a Dependent.
If you or your Dependents have dental coverage through
your spouse’s Fund or other sources, applicable coordination
of benefit rules will determine which coverage is primary or
secondary. In most cases, the plan covering you as an
Member is primary for you, and the plan covering your
spouse as an Member is primary for him or her. Your
children are generally covered as primary by the plan of the
parent whose birthday occurs earlier in the year. Dual
coverage should result in lowering or eliminating your outof-pocket expenses. It should not result in reimbursement for
more than 100% of your expenses.
disenrollment unless disenrollment was due to nonpayment
of Premiums/Prepayment Fees.
disenrollment from the Dental Plan will be extended to the
end of the quarter or for 60 days after disenrollment,
whichever is later, unless disenrollment was due to
nonpayment of Premiums/Prepayment Fees.
Administrator. Benefits are coordinated only for specialty
care services.
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misconduct. This provision also applies to any group subject
to continuation of benefit coverage under Connecticut state
law. You will be responsible for sending payment of the
required Premiums to the Group. Additional information is
dental services may be relaxed for pregnant women and
customers participating in certain disease management
programs. Please review your plan enrollment materials for
details.
PB09CT
12.01.12 M
If you are no longer eligible for coverage under your
Group’s Dental Plan, you and your enrolled Dependents may
continue your dental coverage by enrolling in the Cigna
Dental conversion plan. You must enroll within three months
after becoming ineligible for your Group’s Dental Plan.
Premium payments and coverage will be retroactive to the
date coverage under your Group’s Dental Plan ended. You
and your enrolled Dependents are eligible for conversion
coverage unless benefits were discontinued due to:

permanent breakdown of the dentist-patient relationship;

fraud or misuse of dental services and/or Dental Offices;

nonpayment of Premium/Prepayment Fees by the
Subscriber;

selection of alternate dental coverage by your Group; or

lack of network/Service Area.
1-800-Cigna24 to obtain current rates and make
arrangements for continuing coverage.
Cigna HealthCare is committed to maintaining the
confidentiality of your personal and sensitive information.
You may obtain additional information about Cigna
HealthCare’s privacy policies and procedures by calling
Customer Service at 1-800-Cigna24, or via the Internet at
myCigna.com.
As a Cigna HealthCare plan customer, you may be eligible
for various discounts, benefits, or other consideration for the
As a Cigna HealthCare plan customer, you may also be
eligible for additional dental benefits during certain health
conditions. For example, certain frequency limitations for
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If you are an Illinois and/or Kentucky resident the following Plan Booklet applies to you. Additionally, if you are an Illinois resident
the Illinois rider that follows the Plan Booklet also applies to you.
CDO23
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P.O. Box 453099
This Plan Booklet is intended for your information; it constitutes a summary of the Dental Plan and is included as a part of the
agreement between Cigna Dental and your Group (collectively, the “Group Contract”). The Group Contract must be
consulted to determine the rates and the exact terms and conditions of coverage. If rates or coverages are changed under your
Group Contract, your rates and coverage will also change. A prospective customer has the right to view the Combined
Evidence of Coverage and Disclosure Form prior to enrollment. It should be read completely and carefully. Customers with
special health care needs should read carefully those sections that apply to them. Please read the following information so you
will know from whom or what group of dentists dental care may be obtained.
of Benefits.”
PBKY09
12.01.12
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ii.
I. Definitions
dental field;
Dentists.
of this booklet.
Dentist(s).
Schedule.
your unmarried child (including newborns, adopted children,
Group.
(b) less than 26 years old if he or she is both:
i.
ii.
(c) any age if he or she is both:
i.
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its designee for health plan operation purposes for up to 24
months.
directory.
B. Premiums
Charge Schedule.
Representative.
A. Customer Service
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your Service Area.
1.
2.
Usual Fees.
your Dental Plan:
Patient Charge.



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
Charge Schedule.



coverage for:
Charge Schedule.





laws.








be repaired.
services received:

the course of, any employment for wage or profit; if
eligible for benefits under any workers’ compensation
act or similar law;


are received;

to pay;
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

standards.


core, or fixed bridge within 180 days of initial

determination.)




crowns and bridges used solely for splinting.


policy. Kentucky residents: Services compensated
under no-fault auto insurance policies or uninsured
motorist policies are not excluded.


Charge Schedule.



Schedule.
V. Appointments





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



procedures.

Dentist.
Pediatric Dentist.
1.
A. In General
96
a.
b.
c.
before retention.
d.
myCigna.com
2.
Patient Charges
Schedule may apply.
basis.
3.
a.
4.
Additional Charges
b.
costs;
c.
d.
e.
vary depending on the laws in your State.
days.
Dental Plan.
Units
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Cigna Dental has a one-step appeals procedure for
The independent review procedure is a voluntary
program arranged by the Dental Plan and is not
available in all areas.
3.
You have a right to contact the Kentucky Department
of Insurance by sending to P.O. Box 517, Frankfort,
KY 40602-0517 or toll free 1.800.648.6056.
A customer is entitled to an internal appeal and can be
attained with respect to the denial, reduction, or
termination of a plan or the denial of a claim for a health
care service in accordance with KRS 304.17C030(2)(g)(2). A customer, authorized person, or dentist
acting on behalf of the customer may request an internal
appeal within at least 1 year of receipt of a notice of the
initial decision made by Cigna Dental. Cigna Dental will
provide a written internal appeal determination within
thirty (30) days following receipt of a request for an
internal appeal.
1.
2.
XII. Dual Coverage
Level-One Appeals
professional.
month:
98
1.
2.
3.
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Office.
4.
5.
Area.
6.

Fraud or misuse of dental services and/or Dental Offices,


Selection of alternate dental coverage by your Group, or

Premiums.
Premiums.
If you are a Cigna Dental Care customer, you may also be
details.
PBKY09
12.01.12 M

State Amendment
(Illinois)
P.O. Box 453099
Illinois Residents:
This State Amendment contains information that either
replaces, or is in addition to, information contained in your
Plan Booklet.
Permanent breakdown of the dentist-patient relationship,
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The following information is added (by means of this insert)
to your Plan Booklet:
I. Definitions:

The Religious Freedom Protection and Civil Union
Act, 750 ILCS 75, allows both same-sex and differentsex couples to enter into a civil union with all the
obligations, protections, and legal rights, that Illinois
provides to married heterosexual couples. The
definition of “Dependent” is amended to include civil
union partners and a child acquired through a civil
union who meets the eligibility requirements outlined
in your Plan Booklet.
Your unmarried child (including newborns, adopted children,
i.
ii.
i.
ii.
Illinois Residents: This exclusion does not apply to your
Plan.

92274
policy.
09/08/2015
ILRIDER01V1
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Cigna Dental Companies
Cigna Dental Health of North Carolina, Inc.
P.O. Box 453099
also change. A prospective customer has the right to view the Combined Evidence of Coverage and Disclosure Form prior to
enrollment. It should be read completely and carefully. Customers with special health care needs should read carefully those
sections that apply to them. Please read the following information so you will know from whom or what group of dentists
of Benefits.”
PB09NC
12.01.12
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ii.
I. Definitions
dental field;
Dentists.
of this booklet.
Dentist(s).
Schedule.
your unmarried child (including newborns, adopted children,
foster children, stepchildren, a child for whom you must
provide dental coverage under a court order; or, a dependent
child who resides in your home as a result of court order or
Group.
i.
ii.
i.
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Evidence of good dental health is not required for late enrollees.
Representative.
Dependent children for whom you are required by a court or
administrative order to provide dental coverage may be
enrolled at any time. You may drop coverage for your
Dependents only during the open enrollment periods for your
Group, unless there is a change in status such as divorce. If
your child is enrolled in the Dental Plan because of a court or
administrative order, the child may not be disenrolled unless
the order is no longer valid or the child is enrolled in another
dental plan with comparable coverage.
A. Customer Service
directory.
If you have family coverage and have a new baby or if you are
appointed as guardian or custodian of a foster child who is
placed in your home, or an adopted child, the newborn, foster
or adopted child will be automatically covered for the first 30
days following birth or placement. Waiting periods do not
apply to these categories of Dependents. If you wish to
continue coverage beyond the first 30 days, you should enroll
the child in the Dental Plan and you need to begin to pay
Premiums/Prepayment Fees during the period, if any
additional are due, during that period. If additional premium is
required you must submit an enrollment form within 30 days
of acquiring the new Dependent child. If no additional
premium is required, the child will be covered even if not
formally enrolled in the plan. However, for ease of
administration, you are encouraged to enroll the new
Dependent child when coverage begins.
B. Premiums
No schedule of premiums, or any amendment to the
schedule, shall be used until it has been filed with and
approved by the Commissioner. Premiums are guaranteed
for the group for a period of twelve (12) months.
However, Premiums may be adjusted by Cigna Dental
upon approval by the North Carolina Department of
Insurance but no more often than once every 6 months
based on at least 12 months of experience and 45 days'
notice to the Group if, in Cigna Dental's sole opinion, its
liability is altered by any state or federal law.
When a child, covered from the moment of birth or placement
in the adoptive or foster home, requires dental care associated
with congenital defects and anomalies, the dental only plan
shall cover such defects to the same extent an otherwise
covered dental service is provided by the plan.
UNDER NORTH CAROLINA GENERAL STATUTE
SECTION 58-50-40, NO PERSON, FUND, PRINCIPAL,
AGENT, TRUSTEE, OR THIRD PARTY
ADMINISTRATOR, WHO IS RESPONSIBLE FOR
THE PAYMENT OF GROUP HEALTH OR LIFE
A life status change may also include placement for adoption.
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INSURANCE OR GROUP HEALTH PLAN
PREMIUMS, SHALL: (1) CAUSE THE
CANCELLATION OR NONRENEWAL OF GROUP
HEALTH OR LIFE INSURANCE, HOSPITAL,
MEDICAL, OR DENTAL SERVICE CORPORATION
PLAN, MULTIPLE FUND WELFARE
ARRANGEMENT, OR GROUP HEALTH PLAN
COVERAGES AND THE CONSEQUENTIAL LOSS
OF THE COVERAGES OF THE PERSONS INSURED,
BY WILLFULLY FAILING TO PAY THOSE
PREMIUMS IN ACCORDANCE WITH THE TERMS
OF THE INSURANCE OR PLAN CONTRACT, AND
(2) WILLFULLY FAIL TO DELIVER, AT LEAST 45
DAYS BEFORE THE TERMINATION OF THOSE
COVERAGES, TO ALL PERSONS COVERED BY
THE GROUP POLICY A WRITTEN NOTICE OF THE
PERSON'S INTENTION TO STOP PAYMENT OF
PREMIUMS. THIS WRITTEN NOTICE MUST ALSO
CONTAIN A NOTICE TO ALL PERSONS COVERED
BY THE GROUP POLICY OF THEIR RIGHTS TO
HEALTH INSURANCE CONVERSION POLICIES
UNDER ARTICLE 53 OF CHAPTER 58 OF THE
GENERAL STATUTES AND THEIR RIGHTS TO
PURCHASE INDIVIDUAL POLICIES UNDER THE
FEDERAL HEALTH INSURANCE PORTABILITY
AND ACCOUNTABILITY ACT AND UNDER
ARTICLE 68 OF CHAPTER 58 OF THE GENERAL
STATUTES. VIOLATION OF THIS LAW IS A
FELONY. ANY PERSON VIOLATING THIS LAW IS
ALSO SUBJECT TO A COURT ORDER REQUIRING
THE PERSON TO COMPENSATE PERSONS
INSURED FOR EXPENSES OR LOSSES INCURRED
AS A RESULT OF THE TERMINATION OF THE
INSURANCE.
Charge Schedule.
Usual Fees.
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Patient Charge.
your Dental Plan:




Charge Schedule.
your Service Area.
1.
2.
Charge Schedule.
105



be repaired.
myCigna.com
services received:



are received;

to pay;


Exclusions and limitations do not apply to services
performed to correct congenital defects, including
cosmetic surgery.
coverage for:








standards.

services or supplies for the treatment of an occupational
injury or sickness which are paid under the North
Carolina Workers’ Compensation Act only to the extent
such services or supplies are the liability of the
Member, Fund or workers’ compensation insurance
carrier according to a final adjudication under the North
Carolina Workers’ Compensation Act or an order of the
North Carolina Industrial Commission approving a
settlement agreement under the North Carolina
Workers’ Compensation Act.


determination.)

are compensated under any group medical plan when
Coordination of Benefits rules are applied.





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Charge Schedule.












V. Appointments


Exclusions and limitations do not apply to services
performed to correct congenital defects, including
cosmetic surgery.
Schedule.
107




procedures.
myCigna.com

Dentist.
Pediatric Dentist.
1.
A. In General
2.
a.
b.
c.
before retention.
d.
Patient Charges
Schedule may apply.
basis.
3.
Additional Charges
a.
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4.
b.
costs;
c.
d.
e.
vary depending on the laws in your State. Consult your
State Rider for further details.
Dental Plan.
days.
Units
1.
Level-One Appeals
professional.
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XII. Dual Coverage
2.
Level-Two Appeals
To initiate a level-two appeal, follow the same
process required for a level-one appeal. Your leveltwo appeal will be reviewed and a decision made by
someone not involved in the level-one appeal. For
appeals involving dental necessity or clinical
appropriateness, the decision will be made by a
dentist. If specialty care is in dispute, the appeal will
be conducted by a dentist in the same or similar
The review will be completed within 30 calendar
days. If we need more information to complete the
appeal, we will notify you in writing to request an
extension of up to 15 calendar days and to specify
any additional information needed to complete the
review. You will be notified in writing of the
decision no later than 30 days after the date the
appeal is made. The decision will include the specific
contractual or clinical reasons for the decision, as
applicable.
month:
3.
You have the right to contact your State’s
Department of Insurance and/or Department of
Health for assistance at any time.
1.
2.
3.
Office.
4.
5.
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Premiums.
Premiums.
A. Healthy Rewards
From time to time, Cigna Dental Health may offer or
provide certain persons who enroll in the Cigna Dental
plan access to certain discounts, benefits or other
consideration for the purpose of promoting general health
and well being. Discounts arranged by our Cigna
HealthCare affiliates may be offered in areas such as
acupuncture, cosmetic dentistry, fitness club
memberships, hearing care and hearing instruments, laser
vision correction, vitamins and herbal supplements, and
non-prescription health and wellness products. In
addition, our Cigna HealthCare affiliates may arrange for
third party service providers, such as chiropractors,
massage therapists and optometrists, to provide
discounted goods and services to those persons who enroll
in the Cigna Dental plan. While Cigna HealthCare has
arranged these goods, services and/or third party provider
discounts, the third party service providers are liable to
enrollees for the provision of such goods and/or services.
Cigna HealthCare and Cigna Dental Health are not
responsible for the provision of such goods and/or
services, nor are we liable for the failure of the provision
of the same. Further, Cigna HealthCare and Cigna Dental
Health are not liable to enrollees for the negligent
provision of such goods and/or services by third party
service providers.

Permanent breakdown of the dentist-patient relationship,

Fraud or misuse of dental services and/or Dental Offices,


Selection of alternate dental coverage by your Group, or

As a Cigna Dental plan customer, you may also be
programs. Please review your plan enrollment materials
for details.
B. Incontestability
Under North Carolina law, no misstatements made by a
Subscriber in the application for benefits can be used to
void coverage after a period of two years from the date of
issue.
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a member insurer becomes financially unable to meet its
obligations. If this should happen, the guaranty
association will assess its other member insurance
companies for the money to pay the claims of the insured
persons who live in this state and, in some cases, to keep
coverage in force. The valuable extra protection provided
by these insurers through the guaranty association is not
unlimited, however. And, as noted below, this protection
is not a substitute for consumers’ care in selecting
companies that are well-managed and financially stable.
C. Willful Failure To Pay Group Insurance Premiums
UNDER NORTH CAROLINA GENERAL STATUTE
SECTION 58-50-40, NO PERSON, FUND, PRINCIPAL,
AGENT, TRUSTEE, OR THIRD PARTY
ADMINISTRATOR, WHO IS RESPONSIBLE FOR
THE PAYMENT OF GROUP HEALTH OR LIFE
INSURANCE OR GROUP HEALTH PLAN
PREMIUMS, SHALL: (1) CAUSE THE
CANCELLATION OR NONRENEWAL OF GROUP
HEALTH OR LIFE INSURANCE, HOSPITAL,
MEDICAL, OR DENTAL SERVICE CORPORATION
PLAN, MULTIPLE FUND WELFARE
ARRANGEMENT, OR GROUP HEALTH PLAN
COVERAGES AND THE CONSEQUENTIAL LOSS
OF THE COVERAGES OF THE PERSONS INSURED,
BY WILLFULLY FAILING TO PAY THOSE
PREMIUMS IN ACCORDANCE WITH THE TERMS
OF THE INSURANCE OR PLAN CONTRACT, AND
(2) WILLFULLY FAIL TO DELIVER, AT LEAST 45
DAYS BEFORE THE TERMINATION OF THOSE
COVERAGES, TO ALL PERSONS COVERED BY
THE GROUP POLICY A WRITTEN NOTICE OF THE
PERSON'S INTENTION TO STOP PAYMENT OF
PREMIUMS. THIS WRITTEN NOTICE MUST ALSO
CONTAIN A NOTICE TO ALL PERSONS COVERED
BY THE GROUP POLICY OF THEIR RIGHTS TO
HEALTH INSURANCE CONVERSION POLICIES
UNDER ARTICLE 53 OF CHAPTER 58 OF THE
GENERAL STATUTES AND THEIR RIGHTS TO
PURCHASE INDIVIDUAL POLICIES UNDER THE
FEDERAL HEALTH INSURANCE PORTABILITY
AND ACCOUNTABILITY ACT AND UNDER
ARTICLE 68 OF CHAPTER 58 OF THE GENERAL
STATUTES. VIOLATION OF THIS LAW IS A
FELONY. ANY PERSON VIOLATING THIS LAW IS
ALSO SUBJECT TO A COURT ORDER REQUIRING
THE PERSON TO COMPENSATE PERSONS
INSURED FOR EXPENSES OR LOSSES INCURRED
AS A RESULT OF THE TERMINATION OF THE
INSURANCE.
The North Carolina Life and Health Insurance Guaranty
association may not provide coverage for this policy. If
coverage is provided, it may be subject to substantial
limitations or exclusions, and require continued residency
in North Carolina. You should not rely on coverage by the
North Carolina Life and Health Insurance Guaranty
Association in selecting an insurance company or in
selecting an insurance policy.
Coverage is NOT provided for your policy or any portion
of it that is not guaranteed by the insurer or for which you
have assumed the risk, such as a variable contract sold by
prospectus.
Insurance companies or their agents are required by law
to give or send you this notice. However, insurance
companies and their agents are prohibited by law from
using the existence of the guaranty association to induce
you to purchase any kind of insurance policy.
The North Carolina Life and Health Insurance Guaranty
Association
Post Office Box 10218
Raleigh, North Carolina, 27605
North Carolina Department of Insurance, Consumer
Services Division
1201 Mail Service Center
Raleigh, NC 27699-1201
The state law that provides for this safety-net coverage is
called the North Carolina Life and Health Insurance
Guaranty Association Act. On the back of this page is a
brief summary of this law’s coverages, exclusions and
limits. This summary does not cover all provisions of the
law; nor does it in any way change anyone’s rights or
obligations under the act or the rights or obligations of the
guaranty association.
D. NC Life & Health Guaranty Association Notice
Notice Concerning Coverage
Limitations And Exclusions Under The North
Carolina
Life And Health Insurance Guaranty Association Act
Residents of this state who purchase life insurance,
annuities or health insurance should know that the
insurance companies licensed in this state to write these
types of insurance are members of the North Carolina
Life and Health Insurance Guaranty Association. The
purpose of this association is to assure that policyholders
will be protected, within limits, in the unlikely event that
Coverage
Generally, individuals will be protected by the life and
health insurance guaranty association if they live in this
state and hold a life or health insurance contract, or an
annuity, or if they are insured under a group insurance
contract, issued by a member insurer. The beneficiaries,
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(2a) With respect to health insurance benefits for any one
individual, regardless of the number of policies:
payees or assignees of insured persons are protected as
well, even if they live in another state.
a. Three hundred thousand dollars ($300,000) for
coverages not defined as basic hospital, medical, and
surgical insurance or major medical insurance as
defined in this Chapter and regulations adopted
pursuant to this Chapter, including disability insurance
and long-term care insurance; or
Exclusions From Coverage
However, persons holding such policies are not protected
by this association if:

they are eligible for protection under the laws of
another state (this may occur when the insolvent insurer
was incorporated in another state whose guaranty
association protects insureds who live outside that
state);

the insurer was not authorized to do business in this
state;

their policy was issued by an HMO, a fraternal benefit
society, a mandatory state pooling plan, a mutual
assessment company or similar plan in which the
policyholder is subject to future assessments, or by an
insurance exchange.
b. Five hundred thousand dollars ($500,000) for basic
hospital, medical, and surgical insurance or major
medical insurance as defined in this Chapter and
regulations adopted pursuant to this Chapter;
(3) With respect to each individual participating in a
governmental retirement plan established under section
401, 403(b), or 457 of the Internal Revenue Code covered
by an unallocated annuity contract, or the beneficiaries of
each individual if deceased, in the aggregate, three
hundred thousand dollars ($300,000) in present value
annuity benefits, including net cash surrender and net
cash withdrawal values; or
The association also does not provide coverage for:

any policy or portion of a policy which is not
guaranteed by the insurer or for which the individual
has assumed the risk, such as a variable contract sold
by prospectus;

any policy of reinsurance (unless an assumption
certificate was issued);

interest rate yields that exceed the average rate
specified in the law;

dividends;

experience or other credits given in connection with the
administration of a policy by a group contractholder;

Funds’ plans to the extent they are self-funded (that is,
not insured by an insurance company, even if an
insurance company administers them);

unallocated annuity contracts (which give rights to
group contractholders, not individuals), unless they
fund a government lottery or a benefit plan of an Fund,
association or union, except that unallocated annuities
issued to Member benefit plans protected by the
Federal Pension Benefit Guaranty Corporation are not
covered.
(4) With respect to any one contract holder covered by
any unallocated annuity contract not included in
subdivision (3) of this subsection, five million dollars
($5,000,000) in benefits, regardless of the number of such
contracts held by that contract holder; or
(5) With respect to any one payee (or beneficiaries of
one payee if the payee is deceased) of a structured
settlement annuity, one million dollars ($1,000,000) for
all benefits, including cash values.
(6) However, in no event shall the Association be
obligated to cover more than an aggregate of three
hundred thousand dollars ($300,000) in benefits with
respect to any one individual under subdivisions (2) and
(3) and sub subdivision (2a)a. except with respect to
benefits for basic hospital, medical, and surgical and
major medical insurance under sub subdivision (2a)b. of
this subsection, in which case the aggregate liability of the
Association shall not exceed five hundred thousand
dollars ($500,000) with respect to any one individual.
PB09NC
12.01.12 M
Limits On Amount Of Coverage
The benefits for which the Association is liable do not, in
any event, exceed the lesser of:
(1) The contractual obligations for which the insurer is
liable or would have been liable if it were not a delinquent
insurer; or
(2) With respect to any one individual, regardless of the
number of policies, three hundred thousand dollars
($300,000) for all benefits, including cash values; or
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Cigna Dental Health of New Jersey, Inc.
P.O. Box 453099
also change. Please read the following information so you will know from whom or what group of dentists dental care may be
obtained. This certificate is subject to the laws of the state of New Jersey.
Important Cancellation Information - Please Read the Provision Entitled “Disenrollment from the Dental Plan - Termination
of Benefits.”
PB09NJ
12.01.12
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TABLE OF CONTENTS
I.
Definitions
II.
III.
IV.
A. Customer Service
B. Premiums
V.
Appointments
VI.
Broken Appointments
VII.
Office Transfers
VIII.
Specialty Care
IX.
Specialty Referrals
A. In General
B. Orthodontics
X.
XI.
XII.
Dual Coverage
A. In General
B. How Cigna Dental Pays As Primary Plan
C. How Cigna Dental Pays As Secondary Plan
XIII.
XIV.
XV.
XVI.
Conversion Coverage
XVII.
Confidentiality/Privacy
XVIII.
Miscellaneous
PB09NJ
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I. Definitions
1.
2.
For a Dependent child 19 years of age or older who is a fulltime student at an educational institution, coverage will be
dental field;
Coverage for Dependents living outside a Cigna Dental
Service Area is subject to the availability of an approved
network where the Dependent resides.
your Group Contract.
entered into a Group Contract with Cigna Dental for
managed dental services on your behalf.
of this booklet.
Dentists.
Network General Dentist - a licensed dentist who has
she agrees to provide dental care services to you.
Dentist(s).
she agrees to provide specialized dental care services to you.
Dependent - your lawful spouse, civil union (if established in
New Jersey prior to February 19, 2007 or if established
outside the state of New Jersey prior to or after February 19,
2007); your unmarried or unpartnered child (including
newborns, adopted children, stepchildren, a child for whom
you must provide dental coverage under a court order; or, a
Dependent child who resides in your home as a result of court
order or administrative placement; or a Dependent child
acquired through a civil union) who is:
Schedule.
Patient Charge Schedule - list of services covered under
your Dental Plan and how much they cost you.
1.
2.
Group.
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A. Customer Service
directory.
III. Eligibility When Coverage Begins
B. Premiums
Network General Dentists are reimbursed by Cigna
Dental through fixed monthly payments and supplemental
payments for certain procedures. No bonuses or financial
incentives are used as an inducement to limit services.
Network Dentists are also compensated by the fees which
you pay, as set out in your Patient Charge Schedule.
Patient Charges for Covered Services the amount you
Representative.
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your Service Area.
Emergency Care Away From Home - If you have an
emergency while you are out of your Service Area or you
are unable to contact your Network General Dentist, you
may receive emergency Covered Services as defined
above from any general dentist. Routine restorative
procedures or definitive treatment (e.g. root canal) are not
considered emergency care. You should return to your
Network General Dentist for these procedures. For
emergency Covered Services, you will be responsible for
the Patient Charges listed on your Patient Charge
Schedule. Cigna Dental will reimburse you the difference,
if any, between the dentist’s Usual Fee for emergency
Covered Services and your Patient Charge, up to a total of
$50 per incident. To receive reimbursement, send
appropriate reports and x-rays to Cigna Dental at the
address listed on the front of this booklet.
Emergency Care After Hours - There is a Patient
Charge listed on your Patient Charge Schedule for
emergency care rendered after regularly scheduled office
hours. This charge will be in addition to other applicable
Patient Charges.
your Dental Plan:
Usual Fees.


Pediatric Dentist ends on your child’s 7th birthday;
considered on an individual basis. Effective on your
child’s 7th birthday, dental services must be obtained
from a Network General Dentist.


Charge Schedule. Localized delivery of antimicrobial
agents is limited to eight teeth (or eight sites, if
applicable) per 12 consecutive months, when covered
on the Patient Charge Schedule.

F. Emergency Dental Care – Reimbursement
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

be repaired.

laws.




anesthesia and IV Sedation are covered when medically

services received:




are received;


to pay;


standards.




coverage for:


described in Section IV. F.).
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

determination.)

the completion of crowns, bridges, dentures or root

Schedule.
Charge Schedule.

V. Appointments












There is no charge to you for the transfer, however, all Patient
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



procedures.
Definitions - If your Patient Charge Schedule indicates
coverage for orthodontic treatment, the following
definitions apply:


Orthodontic Treatment Plan and Records - the
preparation of orthodontic records and a treatment plan
by the Orthodontist.

Interceptive Orthodontic Treatment - treatment prior
to full eruption of the permanent teeth, frequently a first
phase preceding comprehensive treatment.

Comprehensive Orthodontic Treatment - treatment
after the eruption of most permanent teeth, generally
the final phase of treatment before retention.

Retention (Post Treatment Stabilization) - the period
following orthodontic treatment during which you may
wear an appliance to maintain and stabilize the new
position of the teeth.
There is no coverage for referrals to Prosthodontists or other
Dentist.
See Section IV.D., Choice of Dentist, regarding treatment by a
Pediatric Dentist.
A. In General
verify with the Network Specialist that your treatment
plan has been authorized for payment by Cigna Dental
before treatment begins.
Patient Charges
including retention, will be based upon the Patient Charge
Schedule in effect on the date of your visit for Treatment
Plan and Records. However, if a. banding/appliance
insertion does not occur within 90 days of such visit, b.
your treatment plan changes, or c. there is an interruption
in your coverage or treatment, a later change in the
Patient Charge Schedule may apply.
Specialty Dentist, the fees for no-charge services listed on
Section IX. B. Orthodontics. Treatment by the Network
Specialist must begin within 90 days from the date of
Cigna Dental’s authorization. If you are unable to obtain
treatment within the 90-day period, please call Customer
Service to request an extension. Your coverage must be in
effect when each procedure begins.
The Patient Charge for Orthodontic Treatment is based
upon 24 months of interceptive and/or comprehensive
treatment. If you require more than 24 months of
treatment in total, you will be charged an additional
amount for each additional month of treatment, based
upon the Orthodontist’s Contract Fee. If you require less
than 24 months of treatment, your Patient Charge will be
reduced on a pro-rated basis.
Additional Charges
You will be responsible for the Orthodontist’s Usual Fees
for the following non-Covered Services:
must pay the Network Specialty Dentist’s Usual Fee.
If you have a question or concern regarding an
authorization or a denial, contact Customer Service.
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
incremental costs associated with optional/elective
materials, including but not limited to ceramic, clear,
lingual brackets, or other cosmetic appliances;

orthognathic surgery and associated incremental costs;

myCigna.com


services which are not typically included in orthodontic
treatment. These services will be identified on a caseby-case basis.
request.
working days.
Dependent at the time you enroll, the fee listed on the
Patient Charge Schedule is not applicable. Please call
Customer Service at 1-800-Cigna24 to find out if you are
entitled to any benefit under the Dental Plan.
Units
Level-One Appeals
Your level-one appeal will be reviewed and the decision
made by someone not involved in the initial review.
Appeals involving dental necessity or clinical
appropriateness will be reviewed by a dental professional.
We will respond with a decision within 15 working days
after we receive your appeal. If we need more time or
information to make the decision, we will notify you in
writing to request an extension of up to 15 calendar days
and to specify any additional information needed to
complete the review.
You may request that the appeal resolution be expedited if
the time frames under the above process would seriously
jeopardize your life or health or would jeopardize your
ability to regain the dental functionality that existed prior
to the onset of your current condition.
A dental professional, in consultation with the treating
Dentist, will decide if an expedited review is necessary.
When a review is expedited, Cigna Dental will respond
orally with a decision within 72 hours, followed up in
writing.
If you are not satisfied with our level-one appeal decision,
you may request a level-two appeal.
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must pay its full benefits as if you had no other coverage.
If the primary plan denies the claim or does not pay the
full bill, you may then submit the balance to the
secondary plan.
Level-Two Appeals
To initiate a level-two appeal, follow the same process
required for a level-one appeal. Your level- two appeal
will be reviewed and a decision made by someone not
involved in the level-one appeal. For appeals involving
dental necessity or clinical appropriateness, the decision
will be made by a dentist. If specialty care is in dispute,
the appeal will be conducted by a dentist in the same or
similar specialty as the care under review.
Cigna Dental pays for dental care when you follow our
rules and procedures. If our rules conflict with those of
another plan, it may be impossible to receive benefits
from both plans, and you will be forced to choose which
plan to use.
The review will be completed within 15 working days. If
we need more time or information to complete the review,
we will notify you in writing to request an extension of up
to 15 calendar days and to specify any additional
information needed to complete the review. The decision
will include the specific contractual or clinical reasons for
the decision, as applicable.
B. How Cigna Dental Pays As Primary Plan
When you receive care from a Network Specialty Dentist,
Cigna Dental pays the Network Specialty Dentist a
contracted fee amount less your copayment for the
Covered Service. When we are primary, we will pay the
full benefit allowed as if you had no other coverage.
C. How Cigna Dental Pays As Secondary Plan
 If your primary plan pays on the basis of UCR, Cigna
Dental will pay the difference between the provider’s
billed charges and the benefits paid by the primary plan
up to the amount Cigna Dental would have paid if
primary. Cigna Dental’s payment will first be applied
toward satisfaction of your copayment of your primary
plan. You will not be liable for any billed charges in
excess of the sum of the benefits paid by your primary
plan, Cigna Dental as your secondary plan and the
copayment you paid under either the primary or
secondary plan. When Cigna Dental pays as secondary,
you will never be responsible for paying more than
your copayment for the Covered Service.
You may request that the appeal resolution be expedited if
the time frames under the above process would seriously
jeopardize your life or health or would jeopardize your
ability to regain the dental functionality that existed prior
to the onset of your current condition. A dental
professional, in consultation with the treating Dentist, will
decide if an expedited review is necessary. When a review
is expedited, the Dental Plan will respond orally with a
You have the right to contact the New Jersey Department
of Insurance and/or Department of Health for assistance at
any time.

When both your primary plan and Cigna Dental pay
network providers on the basis of a contractual fee
schedule and the provider is a network provider of both
plans, the allowable expense will be considered to be
the contractual fee of your primary plan. Your primary
plan will pay the benefit it would have paid regardless
of any other coverage you may have. Cigna Dental will
pay the copayment for the Covered Service for which
you are liable up to the amount Cigna Dental would
have paid if primary and provided that the total amount
received by the provider from the primary plan, Cigna
Dental and you does not exceed the contractual fee of
the primary plan. You will not be responsible for an
amount more than your copayment.

When your primary plan pays network providers on a
basis of capitation or a contractual fee schedule or pays
a benefit on the basis of UCR, and Cigna Dental pays
network providers on the basis of capitation and a
service or supply is provided by a network provider of
Cigna Dental, we will not be obligated to pay to the
network provider any amount other than the capitation
payment required under the contract between Cigna
XII. Dual Coverage
A. In General
“Coordination of benefits” is the procedure used to pay
health care expenses when a person is covered by more
than one plan. Cigna Dental follows rules established by
New Jersey law to decide which plan pays first and how
much the other plan must pay. The objective is to make
sure the combined payments of all plans are no more than
your actual bills.
When you or your family members are covered by
another group plan in addition to this one, we will follow
New Jersey coordination of benefit rules to determine
which plan is primary and which is secondary. You must
submit all bills first to the primary plan. The primary plan
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Dental and the network provider and we shall not be
liable for any deductible, coinsurance or copayment
imposed by your primary plan. You will not be
responsible for the payment of any amount for eligible
services.

We will pay only for health care expenses that are
covered by Cigna Dental.

We will pay only if you have followed all of our
procedural requirements, including: care is obtained
from or arranged by your primary care dentist;
coverage in effect when procedures begin; procedures
begin within 90 days of referral.
conversion plan. You must enroll within three months after
month:

permanent breakdown of the dentist-patient relationship;

fraud or misuse of dental services and/or Dental Offices;

in which Premiums are not remitted to Cigna Dental;

nonpayment of Premiums by the Subscriber;

in which eligibility requirements are no longer met;

selection of alternate dental coverage by your Group; or

permanent breakdown of the dentist-patient relationship
as determined by Cigna Dental, after at least two
opportunities to transfer to another Dental Office;

lack of network/Service Area.

after 30 days notice from Cigna Dental due to fraud or
misuse of dental services and/or Dental Offices;

after 60 days notice by Cigna Dental, due to continued
lack of a Dental Office in your Service Area;

Coverage for completion of a dental procedure which was
started before your disenrollment from the Dental Plan will be
extended for 90 days after disenrollment unless disenrollment
was due to nonpayment of Premiums.
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If you are a Cigna Dental Care customer you may also be
details.
PB09NJ
12.01.12
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Cigna Dental Health of Texas, Inc.
1640 Dallas Parkway
Plano, TX 75093
This Certificate of Coverage is intended for your information; and is included as a part of the agreement between Cigna
Dental and your Group (collectively, the “Group Contract”). The Group Contract must be consulted to determine the rates
and the exact terms and conditions of coverage. If rates or coverages are changed under your Group Contract, your rates and
coverage will also be changed. Please read the following information so you will know from whom or what group of dentists
Important Cancellation Information - Please Read the Provision Entitled “Disenrollment from the Dental Plan - Termination
of Benefits.”
Please call Customer Service at 1-800-Cigna24 if you have any questions.
If you have a hearing or speech disability, please use your state Telecommunications Relay Service to call us. This service
makes it easier for people who have hearing or speech disabilities to communicate with people who do not. Check your local
telephone directory for your Relay Service’s phone number.
If you have a visual disability, you may call Customer Service and request this booklet in a larger print type or Braille.
PB09TX
12.01.12
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IMPORTANT NOTICE
To obtain information to make a complaint;
You may call Cigna Dental Health’s toll-free telephone number for information or to make a complaint at:
1-800-Cigna24
You may also write to:
1640 Dallas Parkway
Plano, TX 75093
You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at:
1-800-252-3439
You may write the Texas Department of Insurance, P.O. Box 149104, Austin, TX 78714-9104, Fax No. (512) 475-1771.
Claim Disputes:
Should you have a dispute about a claim, you should contact Cigna Dental Health first. If the dispute is not resolved, you may contact
the Texas Department of Insurance.
Attach This Notice to Your Policy:
This notice is for information only and does not become a part or condition of the attached document.
PB09TX
12.01.12
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AVISO IMPORTANTE
Para obtener información o para someter una queja;
Usted pueda llamar al número de teléfono gratis de Cigna Dental Health para información o para someter una queja al:
1-800-Cigna24
Usted también puede escribir a:
1640 Dallas Parkway
Plano, TX 75093
Puede communicarse con el Departamento de Seguros de Texas para obtener información acerca de companías, coberturas, de-rechos
o quejas al:
1-800-252-3439
Puede escribir al Departamento de Seguros de Texas, P.O. Box 149104, Austin, TX 78714-9104, Fax No. (512) 475-1771.
Disputas sobre reclamos:
Si tiene una disputa concerniente a un reclamo, debe comunicarse primero con Cigna Dental Health. Si no se resuelve la disputa,
puede entonces comunicarse con el Departamento de Seguros de Texas.
Adjunte este aviso a su póliza:
Este aviso es sólo para propósito de información y no se convierte en parte o condición del documento adjunto.
PB09TX
12.01.12
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TABLE OF CONTENTS
I.
Definitions
II.
III.
IV.
A. Customer Service
B. Premiums
F. General Care - Reimbursement
G. Emergency Dental Care - Reimbursement
H. Limitations on Covered Services
I. Services Not Covered Under Your Dental Plan
V.
Appointments
VI.
Broken Appointments
VII.
Office Transfers
VIII.
Specialty Care
IX.
Specialty Referrals
A. In General
B. Orthodontics
X.
XI.
XII.
Treatment In Progress
A. Treatment In Progress For Procedures Other Than Orthodontics
B. Treatment In Progress For Orthodontics
XIII.
A. Termination of Your Group
B. Termination of Benefits For You and/or Your Dependents
XIV.
XV.
XVI.
Conversion Coverage
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
I. Definitions
any age if he or she is both:

incapable of self sustaining employment due to mental or
physical disability; and
Adverse Determination - a determination by a utilization
review agent that the dental care services provided or
proposed to be furnished to you or your Dependents are not
medically necessary or are experimental or investigational. To
be considered medically necessary, the specialty referral
procedure must be reasonable and appropriate and meet the

A Dependent includes your grandchild if the child is your
dependent for federal income tax purposes at the time of
application, or a child for whom you must provide medical
support under a court order.
Coverage for dependents living outside a Cigna Dental
Service Area is subject to the availability of an approved
network where the dependent resides.
your Group contract.
dental field;
Dentists.
of this booklet.
Schedule.
Dentist(s).
(including newborns, adopted children (includes a child who
has become the subject of a suit for adoption), stepchildren, a
child for whom you must provide dental coverage under a
court order; or, a dependent child who resides in your home as
a result of court order or administrative placement) who is:

less than 25 years old; or

less than 25 years old if he or she is both:

a full-time student enrolled at an accredited educational
institution, and

dental care services, as set out in the attached list of service
areas.
Spouse - the individual of the opposite sex with whom you
have entered into a marriage relationship which would be
considered valid under the Texas Family Code.
Group.
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Representative.
live, work or reside within the Cigna Dental Service Area.
Other eligibility requirements are determined by your Group.
If the legal residence of an enrolled Dependent is different
from that of the Subscriber, the Dependent must:
A. reside in the Service Area with a person who has
temporary or permanent guardianship, including adoptees
or children subject to adoption, and the Subscriber must
have legal responsibility for that Dependent’s health care;
or
A. Customer Service
The hearing impaired may contact Customer Service
through the State Relay Service located in your local
telephone directory.
B. reside in the Service Area, and the Subscriber must have
legal responsibility for that Dependent’s health care; or
C. reside in the Service Area with the Subscriber’s spouse;
or
D. reside anywhere in the United States when the
Dependent’s coverage is required by a medical support
order.
If you or your Dependent becomes eligible for Medicare, you
may continue coverage so long as you or your Medicareeligible Dependent meet all other group eligibility
requirements.
B. Premiums
from your salary or to be paid by you to the Group. Your
Premium is subject to annual change in accordance with
your Group Contract. Cigna Dental will give written
notice to your Group of any change in Premiums at least
60 days before any change.
In addition to any other premiums for which the Group is
liable, the Group shall also be liable for a customer’s
premiums from the time the customer is no longer eligible
for coverage under the contract until the end of the month
in which the Group notifies Cigna Dental that the
customer is no longer part of the group eligible for
coverage.
Cigna Dental typically pays Network General Dentists
fixed monthly payments for each covered customer and
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by the fees that you pay, as set out in your Patient Charge
Schedule.
Usual Fees.
Patient Charges for Covered Services the amount you
The Dental Office may add late charges to overdue
balances.
If on a temporary basis there is no Network General
Patient Charge.
must pay the Patient Charge listed on the Patient Charge
Schedule that is in effect on the date a procedure is
started.
F. General Care - Reimbursement
Cigna Dental Health will acknowledge your claim for
covered services within 15 days and accept, deny, or
request additional information within 15 business days of
receipt. If Cigna Dental Health accepts your claim,
reimbursement for all appropriate covered services will be
made within 5 days of acceptance.
Network General Dentist for your dependent children
under age 7 by calling Customer Service at 1-800Cigna24 to get a list of network Pediatric Dentists in your
Service Area or if your Network General Dentist sends
your child under the age of 7 to a network Pediatric
Dentist, the network Pediatric Dentist’s office will have
primary responsibility for your child’s care. For children
7 years and older, your Network General Dentist will
provide care. If your child continues to visit the Pediatric
Dentist upon the age of 7, you will be fully responsible
for the Pediatric Dentist’s Usual Fees. Exceptions for
medical reasons may be considered on a case-by-case
basis.
G. Emergency Dental Care - Reimbursement
Emergency dental services are limited to procedures
administered in a dental office, dental clinic or other
comparable facility to evaluate and stabilize emergency
dental conditions of recent onset and severity
accompanied by excessive bleeding, severe pain, or acute
infection that would lead a prudent layperson with
average knowledge of dentistry to believe that immediate
care is needed.
1.
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Emergency Care Away From Home - If you have
an emergency while you are out of your Service Area
or unable to contact your Network General Dentist,
you may receive emergency Covered Services as
defined above without restrictions as to where the
myCigna.com
services are rendered. Routine restorative procedures
or definitive treatment (e.g. root canal) are not
and your Patient Charge.
To receive reimbursement, send appropriate reports
and x-rays to Cigna Dental at the address listed on
the front of this booklet. Cigna Dental Health will
acknowledge your claim for emergency services
within 15 days and accept, deny, or request additional
information within 15 business days of receipt. If
Cigna Dental Health accepts your claim,
reimbursement for all appropriate emergency services
will be made within 5 days of acceptance. Claims for
non-emergency services will be processed within the
same timeframes as claims for emergency services.

evaluations, comprehensive oral evaluations ,


be repaired.
H. Limitations on Covered Services
your Dental Plan:




services received:
Schedule lists any limitations on frequency. If your
Network General Dentist certifies to Cigna Dental that,
due to medical necessity, you require certain Covered
Services more frequently than the limitation allows,
Cigna Dental may waive the applicable limitation.
Charge Schedule.
I.
Charge Schedule.



are received;

to pay;


Services Not Covered Under Your Dental Plan
coverage for:

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
described in Section IV. F.).

laws.




anesthesia and IV Sedation are covered when medically

determination.)

policy.




or hopeless prognosis.






separation of the jaw when the teeth are in contact);
abrasion, erosion and/or abfraction; or restore the
occlusion.





surgical placement of a dental implant, repair,

within the timeframe to be incidental to and part of the

standards.


recementation within the timeframe to be incidental to
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

this limitation is noted on your Patient Charge
Schedule.
Schedule.




procedures.

V. Appointments
Dentist.
schedule time with other patients. If you must change your
appointment, please contact your dentist at least 24 hours
before the scheduled time.
Contact your Benefit Administrator for more information.
Pediatric Dentist
A. In General
transfer at no charge. You should complete any dental
procedure in progress before transferring to another Dental
Office. To arrange a transfer, call Customer Service at 1-800Cigna24. To obtain a list of Dental Offices near you, visit our
website at myCigna.com, or call the Dental Office Locator at
1-800-Cigna24.
Your transfer will take about 5 days to process. Unless you
have an emergency, you will be unable to schedule an
appointment at the new Dental Office until your transfer
becomes effective.
Section IX. B, Orthodontics. Treatment by the Network
obtain treatment within the 90-day period, please call
Network Dentists are Independent Contractors. Cigna Dental
cannot require that you pay your Patient Charges before
processing of your transfer request; however, it is suggested
that all Patient Charges owed to your current Dental Office be
paid prior to transfer.
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treatment a later change in the Patient Charge
Schedule may apply.
basis.
you must pay for treatment at the dentist’s Usual Fees.
Patient Charge. For non-Covered Services or services not
authorized for payment, including Adverse
3.
1.
Definitions - If your Patient Charge Schedule
a.
Orthodontic Treatment Plan and Records the preparation of orthodontic records and a
b.
Interceptive Orthodontic Treatment treatment prior to full eruption of the permanent
c.
Comprehensive Orthodontic Treatment treatment after the eruption of most permanent
before retention.
d.
2.
4.
Additional Charges - You will be responsible for
the Orthodontist’s Usual Fees for the following nonCovered Services:
a.
b.
costs;
c.
d.
e.
orthodontic treatment. These services will be
Orthodontics in Progress - If orthodontic treatment
is in progress for you or your Dependent at the time
you enroll, the fee listed on the Patient Charge
Schedule is not applicable. Please call Customer
Service at 1-800-Cigna24 to find out if you are
entitled to any benefit under the Dental Plan.
Units
Retention (Post Treatment Stabilization) - the
Patient Charges
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resolved promptly by supplying the appropriate
information or clearing up a misunderstanding to
your satisfaction; nor (2) you or your dentist’s
dissatisfaction or disagreement with an Adverse
Determination.
To initiate a complaint, submit a request in
writing to the Dental Plan stating the reason why
you feel your request should be approved and
include any information supporting your request.
If you are unable or choose not to write, you may
ask Customer Service to register your request by
calling the toll-free number.
Within 5 business days of receiving your
complaint, we will send you a letter
acknowledging the date the complaint was
received, a description of the complaint
procedure and timeframes for resolving your
complaint. For oral complaints, you will be
asked to complete a one-page complaint form to
confirm the nature of your problem or to provide
additional information.
request.
Upon receipt of your written complaint or onepage complaint form, Customer Service will
review and/or investigate your problem. Your
complaint will be considered and the resolution
made by someone not involved in the initial
decision or occurrence. Issues involving clinical
appropriateness will be considered by a dental
professional. A written resolution will be
provided to you within 30 calendar days. If
applicable, the written resolution will include a
statement of the specific dental or contractual
reasons for the resolution, the specialization of
any dentist consulted, and a description of the
appeals process, including the time frames for
the appeals process and final decision of the
appeal. If you are not satisfied with our decision,
you may request an appeal.
We are here to listen and to help. If you have a question
the toll-free number to reach one of our Customer Service
Representatives. We will do our best to respond upon
your initial contact or get back to you as soon as possible,
usually by the end of the next business day. You can call
Customer Service at 1-800-Cigna24 or you may write
P.O. Box 188047, Chattanooga, TN 37422-8047.
If you are unable to undergo dental treatment in an office
setting or under local anesthesia due to a documented
physical, mental, or medical reason as determined by the
dentist providing you dental care, please contact Cigna at
1-800-Cigna24 and we will assist you in getting the care
you need.
b. Level Two Review (“Appeal”)
writing within 5 business days. The
acknowledgment will include the name, address,
and telephone number of the Appeals
Coordinator. The review will be held at Cigna
Dental Health’s administrative offices or at
another location within the Service Area,
including the location where you normally
receive services, unless you agree to another site.
1.
Problems Concerning Plan Benefits, Quality of
Care, or Plan Administration
The Dental Plan has a two-step procedure for
complaints and appeals.
a.
Level One Review (“Complaint”)
For the purposes of this section, a complaint
means a written or oral expression of
dissatisfaction with any aspect of the Dental
Plan’s operation. A complaint is not (1) a
misunderstanding or misinformation that is
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appeal an Adverse Determination orally or in
writing. We will acknowledge the appeal in
writing within 5 working days of receipt,
confirming the date we received the appeal,
outlining the appeals procedure, and requesting
any documents you should send us. For oral
appeals, we will include a one-page appeal form.
Additional information may be requested at that
time. Second level reviews will be conducted by
an Appeals Committee, which will include:
(1) An Member of Cigna Dental Health;
(2) A dentist who will preside over the Appeals
Panel; and
(3) An enrollee who is not an Member of Cigna
Dental Health.
Appeal decisions will be made by a licensed
dentist; provided that, if the appeal is denied and
your dentist sends us a letter showing good
cause, the denial will be reviewed by a specialty
dentist in the same or similar specialty as the
care under review. The specialty review will be
completed within 15 working days of receipt.
Anyone involved in the prior decision may not
vote on the Appeals Committee. If specialty care
is in dispute, the Committee will include a
dentist in the same or similar specialty as the
care under consideration, as determined by Cigna
Dental. The review will be held and you will be
notified in writing of the Committee’s decision
within 30 calendar days.
We will send you and your dentist a letter
explaining the resolution of your appeal as soon
as practical but in no case later than 30 calendar
days after we receive the request. If the appeal is
denied, the letter will include:
Cigna Dental will identify the committee
members to you and provide copies of any
documentation to be used during the review no
later than 5 business days before the review,
unless you agree otherwise. You, or your
designated representative if you are a minor or
disabled, may appear in person or by conference
call before the Appeals Committee; present
expert testimony; and, request the presence of
and question any person responsible for making
the prior determination that resulted in your
appeal.
(1) the clinical basis and principal reasons for
the denial;
(2) the specialty of the dentist making the
denial;
(3) a description of the source of the screening
criteria used as guidelines in making the
adverse determination; and
(4) notice of the rights to seek review of the
denial by an independent review
organization and the procedure for obtaining
that review.
Please advise Cigna Dental 5 days in advance if
you or your representative plans to be present.
Cigna Dental will pay the expenses of the
Appeals Committee; however, you must pay
your own expenses, if any, relating to the
Appeals process including any expenses of your
designated representative.
b. Independent Review Organization
If the appeal of an Adverse Determination is
denied, you, your representative, or your dentist
have the right to request a review of that decision
by an Independent Review Organization
(“IRO”.) The written denial outlined above will
include information on how to appeal the denial
to an IRO, and the forms that must be completed
and returned to us to begin the independent
review process.
The appeal will be heard and you will be notified
in writing of the committee’s decision within 30
calendar days from the date of your request.
Notice of the Appeals Committee’s decision will
include a statement of the specific clinical
determination, the clinical basis and contractual
criteria used, and the toll-free telephone number
and address of the Texas Department of
Insurance.
2.
In life-threatening situations, you are entitled to
an immediate review by an IRO without having
to comply with our procedures for internal
appeals of Adverse Determinations. Call
Customer Service to request the review by the
IRO if you have a life-threatening condition and
we will provide the required information.
Problems Concerning Adverse Determinations
a.
Appeals
For the purpose of this section, a complaint
concerning an Adverse Determination constitutes
an appeal of that determination. You, your
designated representative, or your dentist may
In order to request a referral to an IRO, the
reason for the denial must be based on a medical
necessity determination by Cigna Dental.
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Administrative, eligibility or benefit coverage
limits are not eligible for additional review under
this process.
c.
filing a complaint or appealing a decision on
your behalf. Cigna Dental will not cancel or
refuse to renew coverage because you or your
Dependent has filed a complaint or appealed a
decision made by Cigna Dental. You have the
right to file suit in a court of law for any claim
involving the professional treatment performed
by a Dentist.
Expedited Appeals
You may request that the above complaint and
appeal process be expedited if the timeframes
under the above process would seriously
jeopardize your life or health or would
jeopardize your ability to regain the dental
functionality that existed prior to the onset of
your current condition. A dental professional, in
consultation with the treating Dentist, will decide
if an expedited review is necessary.
XII. Treatment In Progress
A. Treatment In Progress For Procedures Other Than
Orthodontics
If your dental treatment is in progress when you enroll in
the Cigna Dental Plan, you should check to make sure
your dentist is in the Cigna Dental Plan Network by
contacting Customer Service at 1-800-Cigna24. You can
elect a new dentist at this time. If you do not, your
treatment expenses will not be covered by the Cigna
Dental Plan.
Investigation and resolution of expedited
complaints and appeals will be concluded in
accordance with the clinical immediacy of the
case but will not exceed 1 business day from
receipt of the complaint. If an expedited appeal
involves an ongoing emergency, you may
request that the appeal be reviewed by a dental
professional in the same or similar specialty as
the care under consideration.
B. Treatment in Progress For Orthodontics
Dependent at the time you enroll in this Dental plan, the
copays listed on your Patient Charge Schedule do not
apply to treatment that is already in progress. This is
because your enrollment in this Dental plan does not
override any obligation you or your Dependent may have
under any agreement with an Orthodontist prior to your
enrollment. Cigna may make a quarterly contribution
toward the completion of your treatment, even if your
Orthodontist does not participate in the Cigna Dental
Health network. Cigna’s contribution is based on the
Patient Charge Schedule selected by your Fund and the
number of months remaining to complete your
interceptive or comprehensive treatment, excluding
retention. Please call Customer Service at 1-800-Cigna24
to obtain an Orthodontics in Progress Information Form.
You and your Orthodontist should complete this form and
return it to Cigna to receive confirmation of Cigna’s
contribution.
d. Filing Complaints with the Texas
Department of Insurance
Any person, including persons who have
attempted to resolve complaints through our
complaint system process and who are
dissatisfied with the resolution, may file a
complaint in writing with the Texas Department
of Insurance at P.O. Box 149091, Austin, Texas
78714-9091, or you may call their toll-free
number, 1-800-252-3439.
The Department will investigate a complaint
against Cigna Dental to determine compliance
with insurance laws within 30 days after the
Department receives your complaint and all
information necessary for the Department to
determine compliance. The Department may
extend the time necessary to complete an
investigation in the event any of the following
circumstances occur:
XIII. Disenrollment From the Dental Plan
(1) additional information is needed;
(2) an on-site review is necessary;
Except as otherwise provided in the Sections titled
Contract, disenrollment from the Dental Plan/termination of
benefits and coverages will be as follows:
(3) we, the physician or dentist, or you do not
provide all documentation necessary to
complete the investigation; or
(4) other circumstances occur that are beyond
the control of the Department.
A. Termination of Your Group
1. due to nonpayment of Premiums, coverage shall
remain in effect for 30 days after the due date of the
Cigna Dental cannot retaliate against a Network
General Dentist or Network Specialty Dentist for
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2.
Premium. If the late payment is received within the
30-day grace period, a 20% penalty will be added to
the Premium. If payment is not received within the
30 days, coverage will be canceled on the 31st day
and the terminated customers will be liable for the
cost of services received during the grace period.
Premiums.
either the Group or Cigna Dental Health may
terminate the Group Contract, effective as of any
renewal date of the Group Contract, by providing at
least 60 days prior written notice to the other party.
B. Termination of Benefits For You and/or Your
Dependents
1. the last day of the month in which Premiums are not
paid to Cigna Dental.
2.
the last day of the month in which eligibility
requirements are no longer met.
3.
the last day of the month in which your Group
notifies Cigna Dental of your termination from the
Dental Plan.
4.
the last day of the month after voluntary
disenrollment.
5.
upon 15 days written notice from Cigna Dental due to
fraud or intentional material misrepresentation or
fraud in the use of services or dental offices.
6.
immediately for misconduct detrimental to safe plan
operations and delivery of services.
7.
for failure to establish a satisfactory patient-dentist
relationship, Cigna Dental will give 30 days written
notification that it considers the relationship
unsatisfactory and will specify necessary changes. If
you fail to make such changes, coverage may be
cancelled at the end of the 30-day period.
8.
Under Texas law you may also choose continuation coverage
for you and your Dependents if coverage is terminated for any
reason except your involuntary termination for cause and if
you or your Dependent has been continuously covered for 3
consecutive months prior to the termination. You must request
continuation coverage from your Group in writing and pay the
monthly Premiums, in advance, within 60 days of the date
your termination ends or the date your Group notifies you of
your rights to continuation. If you elect continuation coverage,
it will not end until the earliest of:
A. 9 months after the date you choose continuation coverage
if you or your dependents are not eligible for COBRA.
B. 6 months after the date you choose continuation coverage
if you or your dependents are eligible for COBRA;
C. the date you and/or your Dependent becomes covered
under another dental plan;
D. the last day of the month in which you fail to pay
Premiums; or
E. the date the Group Contract ends.
upon 30 days notice, due to neither residing, living
nor working in the Service Area. Coverage for a
dependent child who is the subject of a medical
support order cannot be cancelled solely because the
child does not reside, live or work in the Service
Area.
You must pay your Group the amount of Premiums plus 2% in
advance on a monthly basis. You must make the first premium
payment no later than the 45th day following your election for
continued coverage. Subsequent premium payments will be
considered timely if you make such payments by the 30 th day
after the date that payment is due.
When coverage for one of your Dependents ends, you and
your other Dependents may continue to be enrolled. When
your coverage ends, your Dependents coverage will also end.
conversion plan. You must enroll within three months after
payments and coverage will be retroactive to the date your
Group coverage ended. You and your enrolled Dependents are
Premiums.
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eligible for conversion coverage unless benefits were
discontinued due to:
This Certificate of Coverage may only be contested
because of fraud or intentional misrepresentation of
material fact on the enrollment application.
A. permanent breakdown of the dentist-patient relationship;
D. Entire Agreement: The Contract, Pre-Contract
Application, amendments and attachments thereto
represent the entire agreement between Cigna Dental
Health and your Group. Any change in the Group
Contract must be approved by an officer of Cigna Dental
Health and attached thereto; no agent has the authority to
change the Group Contract or waive any of its provisions.
In the event this Certificate contains any provision not in
conformity with the Texas Health Maintenance
Organization Act (the Act) or other applicable laws, this
Certificate shall not be rendered invalid but shall be
construed and implied as if it were in full compliance with
the Act or other applicable laws.
B. fraud or misuse of dental services and/or Dental Offices;
C. nonpayment of Premiums by the Subscriber; or
D. selection of alternate dental coverage by your Group.
Benefits for conversion coverage will be based on the thencurrent standard conversion plan and may not be the same as
those for your Group’s Dental Plan. Premiums will be the
Cigna Dental conversion premiums in effect at the time of
conversion. Conversion premiums may not exceed 200% of
Cigna Dental’s premiums charged to groups with similar
coverage. Please call the Cigna Dental Conversion
Department at 1-800-Cigna24 to obtain rates and make
arrangements for continuing coverage.
E. Conformity With State Law: If this Certificate of
Coverage contains any provision not in conformity with
the Texas Insurance Code Chapter 1271 or other
applicable laws, it shall not be rendered invalid but shall
be considered and applied as if it were in full compliance
with the Texas Insurance Code Chapter 1271 and other
applicable laws.
procedures by calling Customer Service at 1-800-Cigna24 or
PB09TX
12.01.12
A. As a Cigna Dental plan customer you may also be eligible
for additional dental benefits during certain health
programs. Please review your plan enrollment materials
for details.
B. Notice: Any notice required by the Group Contract shall
be in writing and mailed with postage fully prepaid and
addressed to the entities named in the Group Contract.
C. Incontestability: All statements made by a Subscriber on
the enrollment application shall be considered
representations and not warranties. The statements are
considered to be truthful and are made to the best of the
Subscriber’s knowledge and belief. A statement may not
be used in a contest to void, cancel, or non-renew an
enrollee’s coverage or reduce benefits unless it is in a
written enrollment application signed by you, and a
signed copy of the enrollment application is or has been
furnished to you or your personal representative.
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Cigna Dental Health
Texas Service Areas
Amarillo Area:
Armstrong
Houston-Beaumont Area:
Austin
Lubbock Area:
Bailey
Fort Worth Area:
Clay
Briscoe
Brazoria
Borden
Collin
Carson
Chambers
Cochran
Cooke
Castro
Colorado
Cottle
Dallas
Childress
Fort Bend
Crosby
Denton
Collingsworth
Galveston
Dawson
Ellis
Dallam
Grimes
Dickson
Fannin
Deaf Smith
Hardin
Floyd
Grayson
Donley
Harris
Gaines
Hill
Gray
Jasper
Garza
Hood
Hall
Jefferson
Hale
Hunt
Hansford
Liberty
Hockley
Jack
Hartley
Montgomery
Kent
Johnson
Hemphill
Newton
King
Kaufman
Hutchinson
Orange
Lamb
Montague
Lipscomb
Polk
Lubbock
Navarro
Moore
San Jacinto
Lynn
Parker
Ochiltree
Tyler
Motley
Rockwall
Oldham
Walker
Scurry
Somerville
Parmer
Waller
Stonewall
Tarrant
Potter
Washington
Terry
Wise
Randall
Wharton
Yoakum
Roberts
Sherman
Brownsville, McAllen,
Swisher
San Angelo Area:
Coke
Lufkin Area:
Angelina
Laredo Area:
Cameron
Wheeler
Concho
Houston
Dimmit
Irion
Leon
Hidalgo
Austin Area:
Bastrop
Menard
Madison
Jim Hogg
Runnels
Nacogdoches
LaSalle
Caldwell
Schleicher
Sabine
Starr
Fayette
Sterling
San Augustine
Web
Hays
Tom Greene
Shelby
Willacy
Trinity
Zapata
Travis
Williamson
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Tyler/Longview Area:
Anderson
Abilene Area:
Brown
San Antonio Area:
Atascosa
Wichita Falls Area:
Archer
Cherokee
Callahan
Bandera
Baylor
Camp
Coleman
Bexar
Erath
Cass
Comanche
Blanco
Foard
Franklin
Eastland
Comal
Hardeman
Gregg
Fisher
Frio
Haskell
Harrison
Hamilton
Gillespie
Knox
Henderson
Llano
Gonzales
Palo Pinto
Hopkins
Jones
Guadeloupe
Stephins
Marion
Mason
Karnes
Throckmorton
Morris
McCulloch
Kendall
Wichita
Panola
Mills
Kerr
Wilbarge
Rains
Mitchell
Medina
Young
Rusk
Nolan
Wilson
Smith
San Saba
Titus
Shackelford
Upshur
Taylor
Corpus Christi Area:
Bee
Van Zandt
Midland Odessa Area:
Andrews
Crane
Brooks
Ector
Waco Area:
Bell
Duval
Glasscock
Goliad
Howard
Victoria Area:
Aransas
Bosque
Jim Wells
Loving
Burnet
Kennedy
Martin
Bastrop
Coryell
Kleberg
Midland
Calhoun
Falls
Live Oak
Reagan
DeWitt
Freestone
McMullen
Upton
Jackson
Lampasas
Nueces
Ward
Lavaca
Limestone
Refugio
Winkler
Lee
McClennan
San Patricio
Matagorda
Milam
Victoria
Robertson
El Paso Area:
Culberson
College Station-Bryan Area:
Brazos
Texarkana Area:
Bowie
El Paso
Burleson
Delta
Jeff Davis
Madison
Lamar
Reeves
Wood
Hudspeth
Red River
PB09TX
12.01.12
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PB09TX
12.01.12
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The rider(s) listed in the next section are general provisions that apply to the residents of: AZ, CA, CO, CT, DE, FL, IL,
KS/NE, KY, MD, MO, NJ, NC, OH, PA, TX, VA
CDO22
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B. Qualified Medical Child Support Order Defined
A Qualified Medical Child Support Order is a judgment,
decree or order (including approval of a settlement agreement)
or administrative notice, which is issued pursuant to a state
domestic relations law (including a community property law),
or to an administrative process, which provides for child
support or provides for health benefit coverage to such child
and relates to benefits under the group health plan, and
satisfies all of the following:
Federal Requirements
The following pages explain your rights and responsibilities
under federal laws and regulations. Some states may have
similar requirements. If a similar provision appears elsewhere
in this booklet, the provision which provides the better benefit
will apply.
FDRL1
1. the order recognizes or creates a child’s right to receive
group health benefits for which a participant or beneficiary
is eligible;
V2
Notice of Provider Directory/Networks
2. the order specifies your name and last known address, and
the child’s name and last known address, except that the
name and address of an official of a state or political
subdivision may be substituted for the child’s mailing
address;
Notice Regarding Provider Directories and Provider
Networks
If your Plan utilizes a network of Providers, a separate listing
of Participating Providers who participate in the network is
available to you without charge by visiting www.cigna.com;
mycigna.com or by calling the toll-free telephone number on
your ID card.
3. the order provides a description of the coverage to be
provided, or the manner in which the type of coverage is to
be determined;
4. the order states the period to which it applies; and
Your Participating Provider network consists of a group of
local dental practitioners, of varied specialties as well as
general practice, who are employed by or contracted with
Cigna HealthCare or Cigna Dental Health.
5. if the order is a National Medical Support Notice
completed in accordance with the Child Support
Performance and Incentive Act of 1998, such Notice meets
the requirements above.
The QMCSO may not require the health insurance policy to
provide coverage for any type or form of benefit or option not
otherwise provided under the policy, except that an order may
require a plan to comply with State laws regarding health care
coverage.
FDRL79
Qualified Medical Child Support Order
(QMCSO)
C. Payment of Benefits
Any payment of benefits in reimbursement for Covered
Expenses paid by the child, or the child’s custodial parent or
legal guardian, shall be made to the child, the child’s custodial
parent or legal guardian, or a state official whose name and
address have been substituted for the name and address of the
child.
A. Eligibility for Coverage Under a QMCSO
If a Qualified Medical Child Support Order (QMCSO) is
issued for your child, that child will be eligible for coverage as
required by the order and you will not be considered a Late
Entrant for Dependent Insurance.
You must notify your Fund and elect coverage for that child
and yourself, if you are not already enrolled, within 31 days of
the QMCSO being issued.
FDRL2
V1
Effect of Section 125 Tax Regulations on This
Plan
Your Fund has chosen to administer this Plan in accordance
with Section 125 regulations of the Internal Revenue Code.
Per this regulation, you may agree to a pretax salary reduction
put toward the cost of your benefits. Otherwise, you will
receive your taxable earnings as cash (salary).
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A. Coverage Elections
Per Section 125 regulations, you are generally allowed to
enroll for or change coverage only before each annual benefit
period. However, exceptions are allowed if your Fund agrees
and you enroll for or change coverage within 30 days of the
date you meet the criteria shown in the following Sections B
through F.
Change in Status, Court Order or Medicare or Medicaid
Eligibility/Entitlement; or (c) this Plan and the other plan have
different periods of coverage or open enrollment periods.
B. Change of Status
A change in status is defined as:
Eligibility for Coverage for Adopted Children
1.
change in legal marital status due to marriage, death of a
spouse, divorce, annulment or legal separation;
2.
change in number of Dependents due to birth, adoption,
placement for adoption, or death of a Dependent;
3.
change in employment status of Member, spouse or
Dependent due to termination or start of employment,
strike, lockout, beginning or end of unpaid leave of
absence, including under the Family and Medical Leave
Act (FMLA), or change in worksite;
FDRL70 M
Any child under the age of 18 who is adopted by you,
including a child who is placed with you for adoption, will be
eligible for Dependent Insurance upon the date of placement
with you. A child will be considered placed for adoption when
you become legally obligated to support that child, totally or
partially, prior to that child’s adoption.
If a child placed for adoption is not adopted, all health
coverage ceases when the placement ends, and will not be
continued.
4.
changes in employment status of Member, spouse or
Dependent resulting in eligibility or ineligibility for
coverage;
The provisions in the “Exception for Newborns” section of
this document that describe requirements for enrollment and
effective date of insurance will also apply to an adopted child
or a child placed with you for adoption.
5.
change in residence of Member, spouse or Dependent to
a location outside of the Fund’s network service area; and
FDRL6
6.
changes which cause a Dependent to become eligible or
ineligible for coverage.
Group Plan Coverage Instead of Medicaid
C. Court Order
A change in coverage due to and consistent with a court order
of the Member or other person to cover a Dependent.
If your income and liquid resources do not exceed certain
limits established by law, the state may decide to pay
premiums for this coverage instead of for Medicaid, if it is
cost effective. This includes premiums for continuation
coverage required by federal law.
D. Medicare or Medicaid Eligibility/Entitlement
The Member, spouse or Dependent cancels or reduces
coverage due to entitlement to Medicare or Medicaid, or
enrolls or increases coverage due to loss of Medicare or
Medicaid eligibility.
FDRL75
E. Change in Cost of Coverage
If the cost of benefits increases or decreases during a benefit
period, your Fund may, in accordance with plan terms,
automatically change your elective contribution.
Requirements of Medical Leave Act of 1993 (as
amended) (FMLA)
When the change in cost is significant, you may either
increase your contribution or elect less-costly coverage. When
a significant overall reduction is made to the benefit option
you have elected, you may elect another available benefit
option. When a new benefit option is added, you may change
your election to the new benefit option.
Any provisions of the policy that provide for: (a) continuation
of insurance during a leave of absence; and (b) reinstatement
of insurance following a return to Active Service; are modified
by the following provisions of the federal Family and Medical
Leave Act of 1993, as amended, where applicable:
A. Continuation of Health Insurance During Leave
Your health insurance will be continued during a leave of
absence if:
F. Changes in Coverage of Spouse or Dependent Under
Another Fund’s Plan
You may make a coverage election change if the plan of your
spouse or Dependent: (a) incurs a change such as adding or
deleting a benefit option; (b) allows election changes due to

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that leave qualifies as a leave of absence under the Family
and Medical Leave Act of 1993, as amended; and
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
you are an eligible Member under the terms of that Act.
B. Reinstatement of Benefits (applicable to all coverages)
If your coverage ends during the leave of absence because you
do not elect USERRA or an available conversion plan at the
expiration of USERRA and you are reemployed by your
current Fund, coverage for you and your Dependents may be
reinstated if (a) you gave your Fund advance written or verbal
notice of your military service leave, and (b) the duration of
all military leaves while you are employed with your current
Fund does not exceed 5 years.
The cost of your health insurance during such leave must be
paid, whether entirely by your Fund or in part by you and your
Fund.
B. Reinstatement of Canceled Insurance Following Leave
Upon your return to Active Service following a leave of
absence that qualifies under the Family and Medical Leave
Act of 1993, as amended, any canceled insurance (health, life
or disability) will be reinstated as of the date of your return.
You and your Dependents will be subject to only the balance
of a Pre-Existing Condition Limitation (PCL) or waiting
period that was not yet satisfied before the leave began.
However, if an Injury or Sickness occurs or is aggravated
during the military leave, full Plan limitations will apply.
You will not be required to satisfy any eligibility or benefit
waiting period or the requirements of any Pre-existing
Condition limitation to the extent that they had been satisfied
prior to the start of such leave of absence.
Your Fund will give you detailed information about the
Family and Medical Leave Act of 1993, as amended.
Any 63-day break in coverage rule regarding credit for time
accrued toward a PCL waiting period will be waived.
If your coverage under this plan terminates as a result of your
eligibility for military medical and dental coverage and your
order to active duty is canceled before your active duty service
commences, these reinstatement rights will continue to apply.
FDRL74 M
Uniformed Services Employment and ReEmployment Rights Act of 1994 (USERRA)
FDRL58 M
The Uniformed Services Employment and Re-employment
Rights Act of 1994 (USERRA) sets requirements for
continuation of health coverage and re-employment in regard
to an Member’s military leave of absence. These requirements
apply to medical and dental coverage for you and your
Dependents. They do not apply to any Life, Short-term or
Long-term Disability or Accidental Death & Dismemberment
coverage you may have.
Claim Determination Procedures Under ERISA
Procedures Regarding Medical Necessity Determinations
In general, health services and benefits must be Medically
Necessary to be covered under the plan. The procedures for
determining Medical Necessity vary, according to the type of
service or benefit requested, and the type of health plan.
A. Continuation of Coverage
For leaves of less than 31 days, coverage will continue as
described in the Termination section regarding Leave of
Absence.
You or your authorized representative (typically, your health
care provider) must request Medical Necessity determinations
according to the procedures described below, in the
Certificate, and in your provider's network participation
documents as applicable.
For leaves of 31 days or more, you may continue coverage for
yourself and your Dependents as follows:
When services or benefits are determined to be not Medically
Necessary, you or your representative will receive a written
description of the adverse determination, and may appeal the
determination. Appeal procedures are described in the
Certificate, in your provider's network participation
documents, and in the determination notices.
You may continue benefits by paying the required premium to
your Fund, until the earliest of the following:

24 months from the last day of employment with the Fund;

the day after you fail to return to work; and

the date the policy cancels.
Postservice Medical Necessity Determinations
When you or your representative requests a Medical Necessity
determination after services have been rendered, Cigna will
notify you or your representative of the determination within
30 days after receiving the request. However, if more time is
needed to make a determination due to matters beyond Cigna's
control Cigna will notify you or your representative within 30
days after receiving the request. This notice will include the
Your Fund may charge you and your Dependents up to 102%
of the total premium.
Following continuation of health coverage per USERRA
requirements, you may convert to a plan of individual
coverage according to any “Conversion Privilege” shown in
your certificate.
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date a determination can be expected, which will be no more
than 45 days after receipt of the request.
Notice of Adverse Determination
Every notice of an adverse benefit determination will be
provided in writing or electronically, and will include all of
the following that pertain to the determination: (1) the specific
reason or reasons for the adverse determination; (2) reference
to the specific plan provisions on which the determination is
based; (3) a description of any additional material or
information necessary to perfect the claim and an explanation
of why such material or information is necessary; (4) a
description of the plan's review procedures and the time limits
applicable, including a statement of a claimant's rights to bring
a civil action under section 502(a) of ERISA following an
adverse benefit determination on appeal; (5) upon request and
free of charge, a copy of any internal rule, guideline, protocol
or other similar criterion that was relied upon in making the
adverse determination regarding your claim, and an
explanation of the scientific or clinical judgment for a
determination that is based on a Medical Necessity,
experimental treatment or other similar exclusion or limit; and
(6) in the case of a claim involving urgent care, a description
of the expedited review process applicable to such claim.
If more time is needed because necessary information is
missing from the request, the notice will also specify what
information is needed. The determination period will be
suspended on the date Cigna sends such a notice of missing
information, and the determination period will resume on the
date you or your representative responds to the notice.
FDRL64
Postservice Claim Determinations
When you or your representative requests payment for
services which have been rendered, Cigna will notify you of
the claim payment determination within 30 days after
receiving the request. However, if more time is needed to
make a determination due to matters beyond Cigna's control,
Cigna will notify you or your representative within 30 days
after receiving the request. This notice will include the date a
determination can be expected, which will be no more than 45
days after receipt of the request. If more time is needed
because necessary information is missing from the request, the
notice will also specify what information is needed, and you or
your representative must provide the specified information
within 45 days after receiving the notice. The determination
period will be suspended on the date Cigna sends such a notice
of missing information, and resume on the date you or your
representative responds to the notice.
FDRL36
COBRA Continuation Rights Under Federal
Law
For You and Your Dependents
What is COBRA Continuation Coverage?
Under federal law, you and/or your Dependents must be given
the opportunity to continue health insurance when there is a
“qualifying event” that would result in loss of coverage under
the Plan. You and/or your Dependents will be permitted to
continue the same coverage under Basic Benefits which you or
your Dependents were covered on the day before the
qualifying event occurred, unless you move out of that plan’s
coverage area or the plan is no longer available. You and/or
your Dependents cannot change coverage options until the
next open enrollment period.
When is COBRA Continuation Available?
For you and your Dependents, COBRA continuation is

your termination of employment for any reason, other than
gross misconduct, or

your reduction in work hours.
For your Dependents, COBRA continuation coverage is
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
your death;

your divorce or legal separation; or

for a Dependent child, failure to continue to qualify as a
Dependent under the Plan.
Disability Extension
If, after electing COBRA continuation coverage due to your
termination of employment or reduction in work hours, you or
one of your Dependents is determined by the Social Security
Administration (SSA) to be totally disabled under title II or
XVI of the SSA, you and all of your Dependents who have
elected COBRA continuation coverage may extend such
continuation for an additional 11 months, for a maximum of
29 months from the initial qualifying event.
Who is Entitled to COBRA Continuation?
Only a “qualified beneficiary” (as defined by federal law) may
elect to continue health insurance coverage. A qualified
beneficiary may include the following individuals who were
covered by the Plan on the day the qualifying event occurred:
you, your spouse, and your Dependent children. Each
qualified beneficiary has their own right to elect or decline
COBRA continuation coverage even if you decline or are not
eligible for COBRA continuation.
To qualify for the disability extension, all of the following
requirements must be satisfied:
1. SSA must determine that the disability occurred prior to or
within 60 days after the disabled individual elected COBRA
continuation coverage; and
2. A copy of the written SSA determination must be provided
to the Plan Administrator within 60 calendar days after the
date the SSA determination is made AND before the end of
the initial 18-month continuation period.
The following individuals are not qualified beneficiaries for
purposes of COBRA continuation: domestic partners, same
sex spouses, grandchildren (unless adopted by you),
stepchildren (unless adopted by you). Although these
individuals do not have an independent right to elect COBRA
continuation coverage, if you elect COBRA continuation
coverage for yourself, you may also cover your Dependents
even if they are not considered qualified beneficiaries under
COBRA. However, such individuals’ coverage will terminate
when your COBRA continuation coverage terminates. The
sections titled “Secondary Qualifying Events” and “Medicare
Extension For Your Dependents” are not applicable to these
individuals.
If the SSA later determines that the individual is no longer
disabled, you must notify the Plan Administrator within 30
days after the date the final determination is made by SSA.
The 11-month disability extension will terminate for all
covered persons on the first day of the month that is more than
30 days after the date the SSA makes a final determination
that the disabled individual is no longer disabled.
All causes for “Termination of COBRA Continuation” listed
below will also apply to the period of disability extension.
Medicare Extension for Your Dependents
When the qualifying event is your termination of employment
or reduction in work hours and you became enrolled in
Medicare (Part A, Part B or both) within the 18 months before
the qualifying event, COBRA continuation coverage for your
Dependents will last for up to 36 months after the date you
became enrolled in Medicare. Your COBRA continuation
coverage will last for up to 18 months from the date of your
termination of employment or reduction in work hours.
FDRL85
Secondary Qualifying Events
If, as a result of your termination of employment or reduction
in work hours, your Dependent(s) have elected COBRA
continuation coverage and one or more Dependents experience
another COBRA qualifying event, the affected Dependent(s)
may elect to extend their COBRA continuation coverage for
an additional 18 months (7 months if the secondary event
occurs within the disability extension period) for a maximum
of 36 months from the initial qualifying event. The second
qualifying event must occur before the end of the initial 18
months of COBRA continuation coverage or within the
disability extension period discussed below. Under no
circumstances will COBRA continuation coverage be
available for more than 36 months from the initial qualifying
event. Secondary qualifying events are: your death; your
divorce or legal separation; or, for a Dependent child, failure
to continue to qualify as a Dependent under the Plan.
FDRL21
Termination of COBRA Continuation
COBRA continuation coverage will be terminated upon the
occurrence of any of the following:
150

the end of the COBRA continuation period of 18, 29 or 36
months, as applicable;

failure to pay the required premium within 30 calendar days
after the due date;

cancellation of the Fund’s policy with Cigna;
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
beneficiary enrolls in Medicare (Part A, Part B, or both);

beneficiary becomes covered under another group health
plan, unless the qualified beneficiary has a condition for
which the new plan limits or excludes coverage under a preexisting condition provision. In such case coverage will
continue until the earliest of: (a) the end of the applicable
maximum period; (b) the date the pre-existing condition
provision is no longer applicable; or (c) the occurrence of an
event described in one of the first three bullets above; or

any reason the Plan would terminate coverage of a
participant or beneficiary who is not receiving continuation
coverage (e.g., fraud).
FDRL22
include instructions for electing COBRA continuation
coverage. You must notify the Plan Administrator of your
election no later than the due date stated on the COBRA
election notice. If a written election notice is required, it must
be post-marked no later than the due date stated on the
COBRA election notice. If you do not make proper
notification by the due date shown on the notice, you and your
Dependents will lose the right to elect COBRA continuation
coverage. If you reject COBRA continuation coverage before
the due date, you may change your mind as long as you
furnish a completed election form before the due date.
Each qualified beneficiary has an independent right to elect
COBRA continuation coverage. Continuation coverage may
be elected for only one, several, or for all Dependents who are
qualified beneficiaries. Parents may elect to continue coverage
on behalf of their Dependent children. You or your spouse
may elect continuation coverage on behalf of all the qualified
beneficiaries. You are not required to elect COBRA
continuation coverage in order for your Dependents to elect
COBRA continuation.
V1
Fund’s Notification Requirements
Your Fund is required to provide you and/or your Dependents
with the following notices:


FDRL23 M
An initial notification of COBRA continuation rights must
be provided within 90 days after your (or your spouse’s)
coverage under the Plan begins (or the Plan first becomes
subject to COBRA continuation requirements, if later). If
you and/or your Dependents experience a qualifying event
before the end of that 90-day period, the initial notice must
be provided within the time frame required for the COBRA
continuation coverage election notice as explained below.
How Much Does COBRA Continuation Coverage Cost?
Each qualified beneficiary may be required to pay the entire
cost of continuation coverage. The amount may not exceed
situated active Member or family member. The premium
during the 11-month disability extension may not exceed
situated active Member or family member. For example:
A COBRA continuation coverage election notice must be
provided to you and/or your Dependents within the
following timeframes:
(a) if the Plan provides that COBRA continuation coverage
and the period within which an Fund must notify the
Plan Administrator of a qualifying event starts upon the
loss of coverage, 44 days after loss of coverage under
the Plan;
If the Member alone elects COBRA continuation coverage,
the Member will be charged 102% (or 150%) of the active
Member premium. If the spouse or one Dependent child alone
elects COBRA continuation coverage, they will be charged
102% (or 150%) of the active Member premium. If more than
one qualified beneficiary elects COBRA continuation
coverage, they will be charged 102% (or 150%) of the
applicable family premium.
(b) if the Plan provides that COBRA continuation coverage
and the period within which an Fund must notify the
Plan Administrator of a qualifying event starts upon the
occurrence of a qualifying event, 44 days after the
qualifying event occurs; or
When and How to Pay COBRA Premiums
First payment for COBRA continuation
(c) in the case of a multi- Fund plan, no later than 14 days
after the end of the period in which Fund s must
provide notice of a qualifying event to the Plan
Administrator.
If you elect COBRA continuation coverage, you do not have
to send any payment with the election form. However, you
must make your first payment no later than 45 calendar days
after the date of your election. (This is the date the Election
Notice is postmarked, if mailed.) If you do not make your first
payment within that 45 days, you will lose all COBRA
continuation rights under the Plan.
How to Elect COBRA Continuation Coverage
The COBRA coverage election notice will list the individuals
who are eligible for COBRA continuation coverage and
inform you of the applicable premium. The notice will also
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affected by the qualifying event; the qualifying event; the date
the qualifying event occurred; and supporting documentation
(e.g., divorce decree, birth certificate, disability determination,
etc.).
Subsequent payments
After you make your first payment for COBRA continuation
coverage, you will be required to make subsequent payments
of the required premium for each additional month of
coverage. Payment is due on the first day of each month. If
you make a payment on or before its due date, your coverage
under the Plan will continue for that coverage period without
any break.
Newly Acquired Dependents
If you acquire a new Dependent through marriage, birth,
adoption or placement for adoption while your coverage is
being continued, you may cover such Dependent under your
COBRA continuation coverage. However, only your newborn
or adopted Dependent child is a qualified beneficiary and may
continue COBRA continuation coverage for the remainder of
the coverage period following your early termination of
COBRA coverage or due to a secondary qualifying event.
COBRA coverage for your Dependent spouse and any
Dependent children who are not your children (e.g.,
stepchildren or grandchildren) will cease on the date your
COBRA coverage ceases and they are not eligible for a
secondary qualifying event.
Grace periods for subsequent payments
Although subsequent payments are due by the first day of the
month, you will be given a grace period of 30 days after the
first day of the coverage period to make each monthly
payment. Your COBRA continuation coverage will be
provided for each coverage period as long as payment for that
coverage period is made before the end of the grace period for
that payment. However, if your payment is received after the
due date, your coverage under the Plan may be suspended
during this time. Any providers who contact the Plan to
confirm coverage during this time may be informed that
coverage has been suspended. If payment is received before
the end of the grace period, your coverage will be reinstated
back to the beginning of the coverage period. This means that
any claim you submit for benefits while your coverage is
suspended may be denied and may have to be resubmitted
once your coverage is reinstated. If you fail to make a
payment before the end of the grace period for that coverage
period, you will lose all rights to COBRA continuation
coverage under the Plan.
FDRL24
FDRL25
Trade Act of 2002
The Trade Act of 2002 created a new tax credit for certain
individuals who become eligible for trade adjustment
assistance and for certain retired Members who are receiving
pension payments from the Pension Benefit Guaranty
Corporation (PBGC) (eligible individuals). Under the new tax
provisions, eligible individuals can either take a tax credit or
get advance payment of 72.5% of premiums paid for qualified
health insurance, including continuation coverage. If you have
questions about these new tax provisions, you may call the
Health Coverage Tax Credit Customer Contact Center toll-free
at 1-866-628-4282. TDD/TYY callers may call toll-free at 1866-626-4282. More information about the Trade Act is also
available at www.doleta.gov/tradeact.
V2 M
You Must Give Notice of Certain Qualifying Events
If you or your Dependent(s) experience one of the following
qualifying events, you must notify the Plan Administrator
within 60 calendar days after the later of the date the
qualifying event occurs or the date coverage would cease as a
result of the qualifying event:

Your divorce or legal separation;

Your child ceases to qualify as a Dependent under the Plan;
or

The occurrence of a secondary qualifying event as discussed
under “Secondary Qualifying Events” above (this notice
must be received prior to the end of the initial 18- or 29month COBRA period.
V1
In addition, if you initially declined COBRA continuation
coverage and, within 60 days after your loss of coverage under
the Plan, you are deemed eligible by the U.S. Department of
Labor or a state labor agency for trade adjustment assistance
(TAA) benefits and the tax credit, you may be eligible for a
special 60 day COBRA election period. The special election
period begins on the first day of the month that you become
TAA-eligible. If you elect COBRA coverage during this
special election period, COBRA coverage will be effective on
the first day of the special election period and will continue for
18 months, unless you experience one of the events discussed
under “Termination of COBRA Continuation” above.
Coverage will not be retroactive to the initial loss of coverage.
If you receive a determination that you are TAA-eligible, you
must notify the Plan Administrator immediately.
(Also refer to the section titled “Disability Extension” for
additional notice requirements.)
Notice must be made in writing and must include: the name of
the Plan, name and address of the Member covered under the
Plan, name and address(es) of the qualified beneficiaries
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Interaction With Other Continuation Benefits
You may be eligible for other continuation benefits under state
law. Refer to the Termination section for any other
continuation benefits.
copy is available for examination from the Plan Administrator
upon written request.
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Discretionary Authority
The Plan Administrator delegates to Cigna the discretionary
authority to interpret and apply plan terms and to make factual
determinations in connection with its review of claims under
the plan. Such discretionary authority is intended to include,
but not limited to, the determination of the eligibility of
persons desiring to enroll in or claim benefits under the plan,
the determination of whether a person is entitled to benefits
under the plan, and the computation of any and all benefit
payments. The Plan Administrator also delegates to Cigna the
discretionary authority to perform a full and fair review, as
required by ERISA, of each claim denial which has been
appealed by the claimant or his duly authorized representative.
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ERISA Required Information
The name of the Plan is:
UNITE HERE HEALTH
of the sponsor of the Plan is:
UNITE HERE HEALTH
P.O.Box 6020
Aurora, IL 60598
(630) 236-5100
Employer Identification
Number (EIN)
Plan Number
237385560
501
Plan Modification, Amendment and Termination
The Fund as Plan Sponsor reserves the right to, at any time,
change or terminate benefits under the Plan, to change or
terminate the eligibility of classes of employees to be covered
by the Plan, to amend or eliminate any other plan term or
condition, and to terminate the whole plan or any part of it.
The procedure by which benefits may be changed or
terminated, by which the eligibility of classes of employees
may be changed or terminated, or by which part or all of the
Plan may be terminated, is contained in the Fund’s Plan
Document, which is available for inspection and copying from
the Plan Administrator designated by the Fund. No consent of
any participant is required to terminate, modify, amend or
change the Plan.
of the Plan Administrator is:
Fund named above
The name, address and ZIP code of the person designated as
agent for the service of legal process is:
Fund named above
The office designated to consider the appeal of denied claims
is:
The Cigna Claim Office responsible for this Plan
Termination of the Plan together with termination of the
insurance policy(s) which funds the Plan benefits will have no
adverse effect on any benefits to be paid under the policy(s)
for any covered medical expenses incurred prior to the date
that policy(s) terminates. Likewise, any extension of benefits
under the policy(s) due to you or your Dependent’s total
disability which began prior to and has continued beyond the
date the policy(s) terminates will not be affected by the Plan
termination. Rights to purchase limited amounts of life and
medical insurance to replace part of the benefits lost because
the policy(s) terminated may arise under the terms of the
policy(s). A subsequent Plan termination will not affect the
extension of benefits and rights under the policy(s).
The cost of the Plan is shared by Employee and Fund.
The Plan's fiscal year ends on 03/31.
The preceding pages set forth the eligibility requirements and
benefits provided for you under this Plan.
Plan Trustees
A list of any Trustees of the Plan, which includes name, title
and address, is available upon request to the Plan
Administrator.
Plan Type
The plan is a healthcare benefit plan.
Collective Bargaining Agreements
You may contact the Plan Administrator to determine whether
the Plan is maintained pursuant to one or more collective
bargaining agreements and if a particular Fund is a sponsor. A
Your coverage under the Plan’s insurance policy(s) will end
on the earliest of the following dates:
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
the last day of the calendar month in which you leave
Active Service;

the date you are no longer in an eligible class;
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
if the Plan is contributory, the date you cease to contribute;

the date the policy(s) terminates.
creditable coverage, you may be subject to a preexisting
condition exclusion for 12 months (18 months for late
enrollees) after your enrollment date in your coverage.
See your Plan Administrator to determine if any extension of
benefits or rights are available to you or your Dependents
under this policy(s). No extension of benefits or rights will be
available solely because the Plan terminates.
Prudent Actions by Plan Fiduciaries
In addition to creating rights for plan participants, ERISA
imposes duties upon the people responsible for the operation
of the employee benefit plan. The people who operate your
plan, called “fiduciaries” of the Plan, have a duty to do so
prudently and in the interest of you and other plan participants
and beneficiaries. No one, including your Fund, your union, or
any other person may fire you or otherwise discriminate
against you in any way to prevent you from obtaining a
welfare benefit or exercising your rights under ERISA. If your
claim for a welfare benefit is denied or ignored you have a
right to know why this was done, to obtain copies of
documents relating to the decision without charge, and to
appeal any denial, all within certain time schedules.
Statement of Rights
As a participant in the plan you are entitled to certain rights
and protections under the Employee Retirement Income
Security Act of 1974 (ERISA). ERISA provides that all plan
participants shall be entitled to:
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Receive Information About Your Plan and Benefits
 examine, without charge, at the Plan Administrator’s office
and at other specified locations, such as worksites and union
halls, all documents governing the plan, including insurance
contracts and collective bargaining agreements and a copy
of the latest annual report (Form 5500 Series) filed by the
plan with the U.S. Department of Labor and available at the
Public Disclosure room of the Employee Benefits Security
Administration.

obtain, upon written request to the Plan Administrator,
copies of documents governing the Plan, including
insurance contracts and collective bargaining agreements,
and a copy of the latest annual report (Form 5500 Series)
and updated summary plan description. The administrator
may make a reasonable charge for the copies.

receive a summary of the Plan’s annual financial report. The
Plan Administrator is required by law to furnish each person
under the Plan with a copy of this summary financial report.
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Enforce Your Rights
Under ERISA, there are steps you can take to enforce the
above rights. For instance, if you request a copy of plan
documents or the latest annual report from the plan and do not
receive them within 30 days, you may file suit in a federal
court. In such a case, the court may require the plan
administrator to provide the materials and pay you up to $110
a day until you receive the materials, unless the materials were
not sent because of reasons beyond the control of the
administrator. If you have a claim for benefits which is denied
or ignored, in whole or in part, you may file suit in a state or
federal court.
In addition, if you disagree with the plan’s decision or lack
thereof concerning the qualified status of a domestic relations
order or a medical child support order, you may file suit in
federal court. If it should happen that plan fiduciaries misuse
the plan’s money, or if you are discriminated against for
asserting your rights, you may seek assistance from the U.S.
Department of Labor, or you may file suit in a federal court.
The court will decide who should pay court costs and legal
fees. If you are successful the court may order the person you
have sued to pay these costs and fees. If you lose, the court
may order you to pay these costs and fees, for example if it
finds your claim is frivolous.
Continue Group Health Plan Coverage
 continue health care coverage for yourself, your spouse or
Dependents if there is a loss of coverage under the Plan as a
result of a qualifying event. You or your Dependents may
have to pay for such coverage. Review this summary plan
description and the documents governing the Plan on the
rules governing your federal continuation coverage rights.

reduction or elimination of exclusionary periods of coverage
for preexisting conditions under your group health plan, if
you have creditable coverage from another plan. You should
be provided a certificate of creditable coverage, free of
charge, from your group health plan or health insurance
issuer when you lose coverage under the plan, when you
become entitled to elect federal continuation coverage,
when your federal continuation coverage ceases, if you
request it before losing coverage, or if you request it up to
24 months after losing coverage. Without evidence of
Assistance with Your Questions
If you have any questions about your plan, you should contact
the plan administrator. If you have any questions about this
statement or about your rights under ERISA, or if you need
assistance in obtaining documents from the plan administrator,
you should contact the nearest office of the Employee Benefits
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Security Administration, U.S. Department of Labor listed in
your telephone directory or the Division of Technical
Assistance and Inquiries, Employee Benefits Security
Administration, U.S. Department of Labor, 200 Constitution
Avenue N.W., Washington, D.C. 20210. You may also obtain
certain publications about your rights and responsibilities
under ERISA by calling the publications hotline of the
Employee Benefits Security Administration.
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