DENTAQUEST EPO FOR INDIVIDUALS AND FAMILIES CERTIFICATE OF COVERAGE - DENTAQUEST OF FLORIDA, INC.
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DentaQuest of Florida, Inc.
465 Medford St.
Boston, MA 02129
DentaQuest EPO for Individuals and Families
Certificate of Coverage
DQF.IND.COC.HIX 3.15
1WELCOME
Dear Member:
You have joined the growing number of individuals who are enhancing their dental health by joining
DentaQuest of Florida, Inc. (DentaQuest). We are proud to have you as our member.
We invite you to take full advantage of your dental benefits. DentaQuest is committed to giving you the
widest range of high quality providers possible, so that you can obtain the best dental care.
Again, welcome to DentaQuest. This Certificate of Coverage explains how to use your dental benefits.
Should you have questions at any time, our member services representatives, at our toll free number
877-453-8457 will be pleased to assist you.
Brett A. Bostrack
President & CEO
DENTAQUEST is in compliance with the Federal Patient Protection and Affordable Coverage Act of
2010 (PPACA). If any provision of PPACA conflicts with any of the provisions of this Certificate of
Coverage, the Certificate will be interpreted to be compliant with PPACA.
Visit our website:
www.dentaquest.com
DentaQuest of Florida, Inc.
465 Medford St.
Boston, MA 02129
1Table of Contents How to Use Your Dental Benefits .................................................. 3 Helpful Guidelines .......................................................................... 9 Member Rights and Responsibilities .............................................. 9 Plan Definitions ............................................................................ 10 Glossary of Dental Terms ............................................................. 11 Types of Specialists ........................................................................ 11 HIPAA Policy/Notice of Privacy Practices .................................. 12 Exclusions and Limitations ........................................................... 13 Attachment: Benefit Schedule DentaQuest of Florida, Inc. provides benefits as a Prepaid Limited Health Service Organization as described in Chapter 636 of the Florida Statutes. 2
HOW TO USE YOUR DENTAL amounts of coverage to cover damage to the Department of Financial Services,
person or property of Members. Division of Consumer Services, 200 E.
BENEFITS
DentaQuest is not liable for any damage Gaines Street, Larson Building,
or injury to person or property resulting Tallahassee, FL 32399,
CUSTOMER SERVICES DEPARTMENT directly or indirectly from the negligent 1-877-693-5236.
DentaQuest’s Member Services act or omission of or malpractice of a
Representatives are available to assist you participating dentist or any other dentist THIRD PARTY INJURY
Our representatives are trained and or auxiliary providing service to a If the services rendered are required due
educated on dental terminology and your Member, whether of an emergency nature to injury caused by the negligence of a
plan benefits and can assist you with or any otherwise, or for any other damage third person, and if the Member receives a
eligibility verification, finding a dentist, or injury to person or property resulting recovery against the negligent party, or if
identification card replacements, from, arising out of or in any way the Member receives Workers'
explaining your benefits, understanding connected with any defective or Compensation or other insurance benefits,
your treatment plan and providing dangerous conditions in, on, around or then any DentaQuest dentist shall be
information about dental specialists. about a participating dental office or such entitled to charge and collect from the
English, Spanish, and Creole translation other office or dental facility which may Member, his/her usual, customary and
services are available. provide a service to a Member. reasonable fees for any dental services
DentaQuest will not be liable or rendered up to the time and to the extent
DentaQuest of Florida, Inc. responsible for any financial agreements of recovery for such dental services.
465 Medford St. made between a participating dentist and
Boston, MA 02129 a Member. DENTAL RECORDS
877-453-8457 Participating dentists are required to keep
Monday-Friday: 8 a.m.-7 p.m. EST MEMBER GRIEVANCE PROCEDURE records and charts of all dental services
Members are encouraged to attempt to rendered to Members in accordance with
YOUR BENEFITS resolve any issues or grievances with the the Florida Dental Practice Act and
Your plan benefit schedule lists all of the participating dentist without initiating a Regulations. These records are the
procedures that are covered, as well as the grievance with DentaQuest. If the property of the participating dentist. Upon
cost (if any) for each procedure and any grievance cannot be resolved enrollment the member authorizes
limitations or exclusions. You are satisfactorily, you may submit a grievance DentaQuest to request and obtain, for use
responsible for paying the cost for any to DentaQuest, in writing, within 12 exclusively by DentaQuest, Member
procedures performed directly to the dental months of the incident. The written records, radiographs or any other
office at the time you receive the services. grievance must be specifically identified information from any dentist that has
Payment for any services not listed on the as a grievance, and must include a rendered treatment to the Member. Upon
applicable benefit schedule will be the sole summary of the incident and a statement the request of the Member, the
responsibility of the member. of the action requested of DentaQuest. participating dentist will furnish copies of
The Member’s name, address, x-rays and service records. The
OBTAINING DENTAL SERVICES identification number, signature, the participating dentist has the right to
DentaQuest contracts with dentists to current date and a copy of the paid charge the Member an amount not to
provide dental services to our Members. receipt, if available, if the grievance exceed the amount charged by the Clerk
You may schedule appointments by involves a payment issue, must also be of Courts for the specific county in which
contacting a participating general dental included. Formal grievances should be the dental office is located for
office directly, at any time after your forwarded to: photocopies of dental records and copies
effective date of coverage. Please identify of x-rays requested by the Member.
yourself as an DentaQuest Member. Make DentaQuest of Florida, Inc. Neither any participating dentist nor
sure that you verify that the dental office P.O. Box 2906 DentaQuest will be required to transfer
is participating with DentaQuest before Milwaukee, WI 53201-2906 any original records or x-rays, unless
making each dental appointment and 1-877-453-8457 required by law.
before receiving services. Pre-approval is Monday-Friday: 8 a.m.-7 p.m. EST
required before obtaining covered SPECIALIST SERVICES
services from a dental specialist. The grievance will be reviewed by DentaQuest contracts with dental
DentaQuest, and the decision will be specialists in all fields. Oral surgeons for
INDEPENDENT DENTAL FACILITIES communicated to the member, in writing. extractions, periodontists for treatment of
DentaQuest contracts with independently All grievances shall be processed within 60 the gums, endodontists who specialize in
owned dental offices. All participating days of receipt. If members are not root canals, pedodontists for children and
dentists agree to perform their obligations satisfied with the grievance resolution, a orthodontists for braces.
in accordance with prevailing professional second level appeal may be requested. The
standards of the dental profession, to second level appeal includes presentation Members are urged to visit their
maintain in full force and effect to and review by the Grievance participating general dentist to determine
professional liability (malpractice) Committee. The determination of the if specialty care is required. You may call
insurance and to maintain general and Grievance Committee is final. Members DentaQuest for a list of participating
premises liability insurance in reasonable also have the right to submit grievances to
3specialists and assistance in accessing ELIGIBLE DEPENDENTS Child-Only Qualified Health Plan. If
specialty care. The Primary Subscriber may elect eligible, the benefits the child will receive
coverage for the following eligible through this plan are set forth in the
EMERGENCY SERVICES dependents: Pediatric Benefit Schedule.
Members are covered for emergency • The legal spouse of the Primary
dental services at participating dental ENROLLING DEPENDENTS
Subscriber.
offices. If you have a dental emergency, Eligible dependents must be included on
• The domestic partner of the Primary the Primary Subscriber’s initial
please call a participating dental office. Subscriber with proper legal
Emergency office visits may be subject to application with DentaQuest sent to the
documentation. Marketplace in order to be enrolled in the
additional charges as stipulated in the • The dependent child of the Primary
applicable benefit schedule. Members are Plan. Other eligible dependents may be
Subscriber or spouse or domestic added to the Primary Subscriber’s
also covered for emergency dental partner who is under the age of
services while temporarily more than 50 coverage only during the Annual Open
twenty-six. Enrollment Period or if eligible, Special
miles from a participating dentist.
• Any unmarried child who is currently Enrollment Period.
Palliative treatment should be obtained
covered will be eligible for benefits
from a licensed dentist and payment made
beyond the age of 26 if he or she: Newly Eligible Dependents as defined
for services rendered. DentaQuest will
a) is incapable of self-sustaining above and acquired after initial enrollment
reimburse Members the usual and
employment by reason of mental or may be added to the Primary Subscriber’s
customary fees for covered dental
physical handicap or disability coverage and enrollment must take place
services, subject to any applicable fees,
b) is predominately dependent upon within thirty (30) days of the life change
not exceeding $100.00 per claim. To
the Primary Subscriber for support event (marriage, birth, etc.). If the newly
receive reimbursement, the Member must
and maintenance. acquired dependent is not enrolled during
submit the following information to
DentaQuest within ninety (90) days of the this time period, the dependent will not be
Proof of domestic partnership, or physical eligible for coverage. Thirty (30) days
date of service: or mental handicap may be requested by prior to the Primary Subscriber’s annual
1. Paid receipt; DentaQuest for continued coverage. renewal date, the Primary Subscriber can
2. Member’s name, ID number, Address enroll eligible dependents not previously
and Phone number; ENROLLMENT PROCEDURES covered. If an enrollment form and
3. Primary subscriber’s name and ID All initial and subsequent applications for premium is received by us prior to
number; and coverage under a Qualified Health Plan renewal, coverage for the new enrollee
4. Any other supporting documentation must be sent to the Health Insurance will be effective at midnight on the
necessary to process the marketplace. The Marketplace will notify Primary Subscriber’s renewal date.
reimbursement. DentaQuest whether each individual
applicant is a Qualified Individual. ANNUAL OPEN ENROLLMENT
ELIGIBILITY DETERMINATION PERIOD
Individuals who are at least 18 years of If an individual did not enroll in the Initial
SUBSCRIBER ELEIGIBILITY IS age and residents of the State of Florida Enrollment Period but wants to enroll
LIMITED TO RESIDENTS OF are eligible for enrollment with during the next Annual Open Enrollment
FLORIDA. DentaQuest. The Primary Subscriber and Period, the individual must apply to the
The Health Insurance Marketplace must any eligible dependents will be covered as Marketplace who will determine whether
accept an individual’s application and of midnight on the coverage effective date the individual is a Qualified Individual.
make an eligibility determination at any of the application between DentaQuest The Annual Open Enrollment Period will
point in time during the year in a prompt and the Individual. DentaQuest’s occur annually on dates established by the
and timely manner. The Marketplace will eligibility requirements strictly comply Marketplace. The Annual Open
provide timely written notification to an with all applicable federal and state laws, Enrollment for 2016 will begin November
applicant of the eligibility determination. rules and regulations. 1, 2015 and end January 31, 2016.
Qualified Individuals currently enrolled in
SUBSCRIBER ELIGIBLITY CHILD-ONLY COVERAGE a Qualified Health Plan may also change
To be eligible to be enrolled as the A dependent child who is under age 19 plans at this time and enrollees will be
Primary Subscriber in this plan, an may apply to the Health Insurance notified in writing about the Annual Open
individual must apply to the Health Marketplace to obtain a Child-Only Enrollment Period in September of each
Insurance Marketplace. The Marketplace Qualified Health Plan. The Marketplace Benefit Year.
will notify DentaQuest if the applicant is a will determine eligibility and will notify
Qualified Individual. You may also apply DentaQuest if the child is a Qualified AUTOMATIC ENROLLMENTS
to enroll any eligible dependent(s) as Individual. If eligible, the benefits the The Marketplace may automatically
defined below and the Marketplace will child will receive through this plan are set enroll Qualified Individuals for good
determine each dependent’s eligibility as forth in the Pediatric Benefit Schedule. cause which will be determined by the
a Qualified Individual. Marketplace.
A dependent child who is under age 19
may apply to DentaQuest to obtain a
4SPECIAL ENROLLMENT PERIOD k. Addition of a dependent through a. Failure to timely pay premium in
A Qualified Individual or Enrollee is marriage, birth, adoption or accordance with the terms of this
allowed to enroll with DentaQuest or placement for adoption; plan;
change from one Qualified Health Plan to l. An individual who was not b. DentaQuest discontinues a
another outside the Annual Open previously a citizen, national or particular product or all coverage
Enrollment Period if the individual lawfully present, gains such in the individual market in
qualifies as a Special Enrollee. status; Florida in accordance with
Application for enrollment with m. Unintentional error in Florida law;
DentaQuest must be made to the enrollment, non-enrollment or c. The Primary Subscriber has
Marketplace within sixty (60) days from disenrollment through the performed an act or practice
any of the following events: Marketplace; constituting fraud or
n. An enrollee’s Qualified Health misrepresentation of a material
a. Birth, adoption, or placement for Plan violates a material provision fact;
adoption; of its contract; d. The Primary Subscriber no
b. Marriage; or o. Becoming newly eligible for longer lives in the DentaQuest
c. Enrollee loses minimum premium tax credits or cost- Service Area;
essential coverage sharing reductions due to an e. DentaQuest elects to discontinue
individual’s employer-sponsored offering dental coverage through
If timely enrolled: coverage becoming unaffordable the Health Insurance
a. Coverage will be effective on the or no longer provides minimum Marketplace.
date of birth, adoption or value;
placement for adoption; p. New Qualified Health Plans DentaQuest will send the Primary
b. Coverage will be effective no offered in the Marketplace Subscriber a renewal packet 60 days prior
later than the first day of the become available to an to the plan renewal date which must be
following month or subsequent individual as a result of a signed and returned within 30 days of the
following month dependent on permanent move; renewal date in order to renew this plan.
the time of the month the q. Exceptional circumstances as
application is received by the determined by the4 Marketplace GRACE PERIOD
Marketplace for marriage and which prevents or impedes an If the Primary Subscriber is receiving
loss of minimum essential individual’s ability to enroll in a premium subsidies, the following
coverage events. timely manner through no fault provision applies:
of his or her own (e.g. national
Loss of minimum essential coverage is disasters). This plan has a 90 day grace period. A
any event that triggers a loss of eligibility grace period means that if any
for other minimum essential coverage. COVEAGE EFFECTIVE DATE requirement premium is not paid on or
Triggering events include: A Qualified Individual’s enrollment in before the date it is due, it may be paid
a. End of dependent status; this plan during an Initial, Annual or during the grace period immediately
b. Legal separation or divorce Special Enrollment Period will be following that premium due date. This
ending eligibility of a spouse or effective as of the date provided to Us by plan will stay in force during the grace
step-child as a dependent; the Marketplace. period. Premiums must be paid and
c. Death of the Primary Subscriber received directly by DentaQuest no later
ending eligibility for covered TERM OF AGREEMENT/ENROLLMENT than the end of the grace period. The
dependents; This contract shall be for a minimum grace period does not apply to the
d. Relocation outside the period of 12 months, unless the Primary premium due on the premium due date if
DentaQuest Service Area; Subscriber requests, in writing, a shorter the Primary Subscriber gave DentaQuest
e. Termination of employment or contract period. At the end of the initial timely written notice that this plan is to be
reduction in hours needed to contract term, the policy will terminated prior to such premium due
maintain group coverage; automatically renew each Benefit Year date. If the premiums are not paid and
f. Termination of employer unless terminated or non-renewed as received directly by DentaQuest by the
contributions who has coverage provided for in this Certificate. Rates end of the grace period, coverage will
that is not COBRA or Florida and plan design changes will occur on a terminate at midnight on the last day of
Continuation of Coverage; Benefit Year basis. the first month of the 3 month grace
g. Exhaustion of COBRA period. We will pay all appropriate
continuation coverage; RENEWAL OF COVERAGE claims during the first month of the grace
h. Reaching a lifetime limit on all DentaQuest guarantees the Primary period, but may pend claims in the second
benefits in a grandfather plan; Subscriber the right to renew this plan and third months of the grace period.
i. Termination of Medicaid or each year. However, DentaQuest may Claims received during the second and
CHIP refuse to renew this plan if one of the third months of the grace period will be
j. Decertification of Qualified following circumstances has occurred: denied if the premium is not received by
Health Plan outside of the the end of the grace period.
Annual Open Enrollment Period;
5If the Primary Subscriber is not Period, the termination effective date will c) A Member willfully misuses any
receiving premium subsidies, the be the day before the effective date of the documents provided as evidence of
following provision applies: new coverage. benefits available under this
Certificate;
Premium payments are due in advance, on TERMINATION OF THIS PLAN DUE d) A Member furnishes to DentaQuest
an annual or a calendar month basis. TO NON-PAYMENT OF PREMIUM incorrect or incomplete information
Monthly payments are due on or before for the purpose of fraudulently
the first day of each month for coverage If the Primary Subscriber is receiving obtaining covered Dental Services;
effective during such month. There is a premium subsidies, the following e) A Member permanently relocates from
ten (10) day grace period. This provision provision applies: the DentaQuest Service Area;
means that if any required premium is not f) Dependent no longer meets eligibility
paid on or before the date it is due, it may If the required monthly premium is not requirements to continue enrollment as
be paid during the grace period. During received by the end of the 90 day grace established by the Marketplace.
the grace period, the Certificate will stay period, We will terminate coverage
in force. effective at midnight on the last day of the Coverage for Dependents shall
first month of the 3 month grace period. automatically terminate in the event the
BILLING Primary Subscriber is disenrolled. In
In the event a monthly premium payment If the Primary Subscriber is not the event the disenrolled Member is not
is not received by DentaQuest prior to the receiving premium subsidies, the the Primary Subscriber, DentaQuest
expiration of the grace period, following provision applies: shall have the option to disenroll any
DentaQuest may terminate all coverage Member listed on the terminated
effective as of the first day of the month If the required premium is not received by Member’s enrollment card if the
following the month for which the the end of the 10 day grace period, we member is found to have committed
premium was due. The Member’s will terminate this plan without prior any of the acts for disenrollment set
obligation to pay all premium due while notification, retroactive to the last date for forth in this section.
coverage remains in effect, shall survive which premium was received, subject to
termination of this Certificate. the grace period provision. Termination TERMINATION OF COVERAGE BY
DentaQuest may, at its discretion, will be effective as of midnight of the date THE HEALTH INSURANCE
reinstate coverage if, prior to that the premium was due. MARKETPLACE OR DENTAQUEST
reinstatement, the Member pays all The Marketplace may terminate coverage
premiums in arrears, all premiums due for TERMINATION OF MEMBERSHIP BY in a Qualified Health Plan and will also
the current period, and a reinstatement DENTAQUEST permit DentaQuest to terminate coverage
fee. Coverage for Primary Subscriber and each for any of the following reasons:
Dependent will cease at midnight on the
PREMIUM last day of the month prior to renewal if a. Loss of eligibility to purchase a
The premium that began on the Primary the Primary Subscriber fails to renew this Qualified Health Plan through
Subscriber’s coverage effective date will plan. Coverage will also cease at the Marketplace.
not change until January 1 of each Benefit midnight for a Subscriber or Member if b. Nonpayment of premiums
Year. DentaQuest will give the Primary coverage is terminated for any reason provided that the grace period
Subscriber, written notice of any change specified in this plan. has elapsed.
in premium at least 45 days prior to c. Coverage is rescinded.
implementation. DentaQuest may also disenroll a Member d. DentaQuest terminates or is
at any time for any of the following decertified by the Marketplace.
TERMINATION OF THIS PLAN BY reasons and will provide 45 days written e. An enrollee switches to another
THE PRIMARY SUBSCRIBER notice: Qualified Health Plan during an
The Primary Subscriber may terminate Annual Open Enrollment Period
a) A members’ behavior is disruptive,
this plan at any time with appropriate or a Special Enrollment Period.
unruly, abusive, unlawful, fraudulent,
notice of at least 14 days to either or uncooperative to the extent that the
DentaQuest or the Health Insurance RESCISSION
Member’s continuing participation
Marketplace. Coverage will terminate on DentaQuest will rescind coverage due to an
would impair DentaQuest’s or a
the date specified or 14 days after act or practice constituting fraud or an
Provider’s ability to provide covered
termination is requested, whichever is intentional misrepresentation of a material
Dental Services to Member or to other
later. fact. We will provide the Primary
Members. DentaQuest will make a
Subscriber forty-five (45) days advance
reasonable effort to resolve any
Should the Primary Subscriber and/or any written notice before coverage is
conflict through the use of the
covered dependents terminate coverage rescinded.
grievance procedures;
because of eligibility for Medicaid, CHIP b) A Member commits fraud or makes a
or a Basic Health Plan or termination is EXTENSION OF BENEFITS
material misrepresentation in seeking
due to the Primary Subscriber moving Upon termination of the Certificate, the
Dental Services;
from one Qualified Health Plan to another Member may be entitled to Extension of
during an Annual or Special Enrollment Benefits. Termination of the Certificate
6by DentaQuest is without prejudice to any b) committing fraud or providing a (1) Plan includes: group and non-group
continuous loss which commenced while material misrepresentation in applying insurance contracts, health maintenance
the Certificate was in force. Benefits will for coverage; organization (HMO) contracts, closed
be extended until the specific covered c) willfully and knowingly misusing the panel plans or other forms of group or
treatment or procedure undertaken is Member ID card; group type coverage (whether insured or
completed or for ninety (90) days from d) willfully and knowingly providing uninsured); medical care components of
the termination date, whichever is the incorrect or incomplete information to long-term care contracts, such as skilled
lesser period of time. fraudulently obtain coverage; nursing care; medical benefits under
e) leaving the geographic service area for group or individual automobile contracts;
DentaQuest Providers shall complete all the purposes of relocation; and Medicare or any other federal
treatments and procedures commenced on f) acting in a way that was so disruptive, governmental plan, as permitted by law.
Members prior to the effective date of unruly, abusive or uncooperative that
termination of the Certificate to the extent continuing coverage would prevent (2) Plan does not include: hospital
that such Members would have been DentaQuest from providing proper indemnity coverage or other fixed
entitled to receive such Dental Services services to that person or any other indemnity coverage; accident only
had this Certificate continued in effect, patients and the grievance process was coverage; specified disease or specified
subject to the following conditions: unable to resolve the problem. accident coverage; limited benefit health
During the period required for completion coverage, as defined by state law; school
of such procedures, each Member shall PRE-EXISTING CONDITIONS accident type coverage; benefits for non-
continue to pay co-payments, directly to There are no exclusions for pre-existing medical components of long-term care
the Participating Dentist, as required conditions. policies; Medicare supplement policies;
under the applicable Benefit Schedule and Medicaid policies; or coverage under
all exclusions and limitations in this BENEFIT WAITING PERIODS other federal governmental plans, unless
Certificate will continue to apply during The benefit waiting period refers to the permitted by law. Each contract for
the extension; amount of time the Primary Subscriber or coverage under (1) or (2) is a separate
dependent must wait before receiving Plan. If a Plan has two parts and COB
The term “treatment or procedures certain covered plan benefits. Please refer rules apply only to one of the two, each of
commenced on such Member prior to the to the Benefit Schedule for any applicable the parts is treated as a separate Plan.
date of termination" shall be construed to waiting periods.
mean only those treatments and/or B. This plan means, in a COB provision,
operative dental procedures actually COORDINATION OF THIS CONTRACT’S the part of the contract providing the
commenced but unfinished, such as BENEFITS WITH OTHER BENEFITS health care benefits to which the COB
prosthetic appliances which have been The Coordination of Benefits (COB) provision applies and which may be
cast, and dentures commenced but provision applies when a person has reduced because of the benefits of other
unfinished, prior to the effective date of health care coverage under more than one plans. Any other part of the contract
termination of the Certificate. It shall not Plan as defined below. The order of providing health care benefits is separate
include dental defects which may have benefit determination rules govern the from this plan. A contract may apply one
been diagnosed, but on which treatment or order in which each Plan will pay a claim COB provision to certain benefits, such as
operative work may not have been for benefits. The Plan that pays first is dental benefits, coordinating only with
commenced, prior to the effective date of called the Primary plan. The Primary similar benefits, and may apply another
termination. plan must pay benefits in accordance with COB provision to coordinate other
its policy terms without regard to the benefits.
Any Dependent of a Primary Subscriber possibility that another Plan may cover
whose coverage with DentaQuest is some expenses. The Plan that pays after C. The order of benefit determination
terminated for any reason, may also elect the Primary plan is the Secondary plan. rules determine whether This plan is a
to continue coverage with DentaQuest The Secondary plan may reduce the Primary plan or Secondary plan when the
directly if he/she was enrolled in a benefits it pays so that payments from all person has health care coverage under
DentaQuest plan at the time of Plans, does not exceed 100% of the total more than one Plan. When This plan is
termination and he/she meets Allowable expense. primary, it determines payment for its
DentaQuest’s eligibility requirements. benefits first before those of any other
DEFINITIONS Plan without considering any other Plan’s
A Member may elect to continue benefits. When This plan is secondary, it
coverage under any of the individual A. A Plan is any of the following that determines its benefits after those of
plans offered by DentaQuest. provides benefits or services for medical another Plan and may reduce the benefits
or dental care or treatment. If separate it pays so that all Plan benefits do not
However, a person may not convert to contracts are used to provide coordinated exceed 100% of the total Allowable
individual coverage if the loss of coverage coverage for members of a group, the expense.
was due to the Member: separate contracts are considered parts of
the same plan and there is no COB among D. Allowable expense is a health care
a) failing to pay Premium; those separate contracts. expense, including deductibles,
coinsurance and copayments, that is
7covered at least in part by any Plan person has failed to comply with the Plan D. Each Plan determines its order of
covering the person. When a Plan provisions is not an Allowable expense. benefits using the first of the following
provides benefits in the form of services, Examples of these types of plan rules that apply:
the reasonable cash value of each service provisions include second surgical
will be considered an Allowable expense opinions, precertification of admissions, (1) Non-Dependent or Dependent. The
and a benefit paid. An expense that is not and preferred provider arrangements. Plan that covers the person other than as a
covered by any Plan covering the person dependent, for example as an employee,
is not an Allowable expense. In addition, E. Closed panel plan is a Plan that member, policyholder, subscriber or
any expense that a provider by law or in provides health care benefits to covered retiree is the Primary plan and the Plan
accordance with a contractual agreement persons primarily in the form of services that covers the person as a dependent is
is prohibited from charging a covered through a panel of providers which have the Secondary plan. However, if the
person is not an Allowable expense. The contracted with or are employed by the person is a Medicare beneficiary and, as a
following are examples of expenses that Plan, and that excludes coverage for result of federal law, Medicare is
are not Allowable expenses: services provided by other providers, secondary to the Plan covering the person
except in cases of emergency or referral as a dependent; and primary to the Plan
(1) The difference between the cost of a by a panel member. Custodial parent is covering the person as other than a
semi-private hospital room and a private the parent awarded custody by a court dependent (e.g. a retired employee); then
hospital room is not an Allowable decree or, in the absence of a court the order of benefits between the two
expense, unless one of the Plans provides decree, is the parent with whom the child Plans is reversed so that the Plan covering
coverage for private hospital room resides more than one half of the calendar the person as an employee, member,
expenses. year excluding any temporary visitation. policyholder, subscriber or retiree is the
Secondary plan and the other Plan is the
(2) If a person is covered by 2 or more ORDER OF BENEFIT Primary plan.
Plans that compute their benefit payments DETERMINATION RULES
on the basis of usual and customary fees (2) Dependent Child Covered Under More
or relative value schedule reimbursement When a person is covered by two or more Than One Plan. Unless there is a court
methodology or other similar Plans, the rules for determining the order decree stating otherwise, when a
reimbursement methodology, any amount of benefit payments are as follows: dependent child is covered by more than
in excess of the highest reimbursement one Plan the order of benefits is
amount for a specific benefit is not an A. The Primary plan pays or provides its determined as follows: (a) For a
Allowable expense. benefits according to its terms of coverage dependent child whose parents are
and without regard to the benefits of married or are living together, whether or
(3) If a person is covered by 2 or more under any other Plan. not they have ever been married:
Plans that provide benefits or services on • The Plan of the parent whose birthday
the basis of negotiated fees, an amount in B. (1) Except as provided in Paragraph falls earlier in the calendar year is the
excess of the highest of the negotiated (2), a Plan that does not contain a Primary plan; or
fees is not an Allowable expense. coordination of benefits provision that is • If both parents have the same birthday,
consistent with this regulation is always the Plan that has covered the parent the
(4) If a person is covered by one Plan that primary unless the provisions of both longest is the Primary plan.
calculates its benefits or services on the Plans state that the complying plan is
basis of usual and customary fees or primary. (2) Coverage that is obtained by (b) For a dependent child whose parents
relative value schedule reimbursement virtue of membership in a group that is are divorced or separated or not living
methodology or other similar designed to supplement a part of a basic together, whether or not they have ever
reimbursement methodology and another package of benefits and provides that this been married:
Plan that provides its benefits or services supplementary coverage shall be excess to (i) If a court decree states that one of the
on the basis of negotiated fees, the any other parts of the Plan provided by parents is responsible for the dependent
Primary plan’s payment arrangement shall the contract holder. Examples of these child’s health care expenses or health care
be the Allowable expense for all Plans. types of situations are major medical coverage and the Plan of that parent has
However, if the provider has contracted coverage that are superimposed over base actual knowledge of those terms, that Plan
with the Secondary plan to provide the plan hospital and surgical benefits, and is primary. This rule applies to Benefit
benefit or service for a specific negotiated insurance type coverage that are written in Years commencing after the Plan is given
fee or payment amount that is different connection with a Closed panel plan to notice of the court decree;
than the Primary plan’s payment provide out-of-network benefits.
arrangement and if the provider’s contract (ii) If a court decree states that both
permits, the negotiated fee or payment C. A Plan may consider the benefits paid parents are responsible for the dependent
shall be the Allowable expense used by or provided by another Plan in calculating child’s health care expenses or health care
the Secondary plan to determine its payment of its benefits only when it is coverage, the provisions of Subparagraph
benefits. secondary to that other Plan. (a) above shall determine the order of
benefits;
(5) The amount of any benefit reduction
by the Primary plan because a covered
8(iii) If a court decree states that the ignored. This rule does not apply if the payable under This plan and other Plans.
parents have joint custody without rule labeled D(1) can determine the order Organization responsibility for COB
specifying that one parent has of benefits. administration] may get the facts it needs
responsibility for the health care expenses from or give them to other organizations
or health care coverage of the dependent (5) Longer or Shorter Length of or persons for the purpose of applying
child, the provisions of Subparagraph (a) Coverage. The Plan that covered the these rules and determining benefits
above shall determine the order of person as an employee, member, payable under This plan and other Plans
benefits; or policyholder, subscriber or retiree longer covering the person claiming benefits.
is the Primary plan and the Plan that Organization responsibility for COB
(iv) If there is no court decree allocating covered the person the shorter period of administration] need not tell, or get the
responsibility for the dependent child’s time is the Secondary plan. consent of, any person to do this. Each
health care expenses or health care person claiming benefits under This plan
coverage, the order of benefits for the (6) If the preceding rules do not determine must give Organization responsibility for
child are as follows: the order of benefits, the Allowable COB administration] any facts it needs to
• The Plan covering the Custodial parent; expenses shall be shared equally between apply those rules and determine benefits
• The Plan covering the spouse of the the Plans meeting the definition of Plan. payable.
Custodial parent; In addition, This plan will not pay more
• The Plan covering the non-custodial than it would have paid had it been the FACILITY OF PAYMENT
parent; and then Primary plan.
• The Plan covering the spouse of the non- A payment made under another Plan may
custodial parent. EFFECT ON THE BENEFITS OF THIS include an amount that should have been
PLAN paid under This plan. If it does,
(c) For a dependent child covered under Organization responsibility for COB
more than one Plan of individuals who are A. When This plan is secondary, it may administration may pay that amount to the
the parents of the child, the provisions of reduce its benefits so that the total organization that made that payment. That
Subparagraph (a) or (b) above shall benefits paid or provided by all Plans amount will then be treated as though it
determine the order of benefits as if those during a Benefit Year are not more than were a benefit paid under This plan.
individuals were the parents of the child. the total Allowable expenses. In Organization responsibility for COB
determining the amount to be paid for any administration will not have to pay that
(3) Active Employee or Retired or Laid- claim, the Secondary plan will calculate amount again. The term “payment made”
off Employee. The Plan that covers a the benefits it would have paid in the includes providing benefits in the form of
person as an active employee, that is, an absence of other health care coverage and services, in which case “payment made”
employee who is neither laid off nor apply that calculated amount to any means the reasonable cash value of the
retired, is the Primary plan. The Plan Allowable expense under its Plan that is benefits provided in the form of services.
covering that same person as a retired or unpaid by the Primary plan. The
laid-off employee is the Secondary plan. Secondary plan may then reduce its RIGHT OF RECOVERY
The same would hold true if a person is a payment by the amount so that, when
dependent of an active employee and that combined with the amount paid by the If the amount of the payments made by
same person is a dependent of a retired or Primary plan, the total benefits paid or Organization responsibility for COB
laid-off employee. If the other Plan does provided by all Plans for the claim do not administration is more than it should have
not have this rule, and as a result, the exceed the total Allowable expense for paid under this COB provision, it may
Plans do not agree on the order of that claim. In addition, the Secondary plan recover the excess from one or more of
benefits, this rule is ignored. This rule shall credit to its plan deductible any the persons it has paid or for whom it has
does not apply if the rule labeled D(1) can amounts it would have credited to its paid; or any other person or organization
determine the order of benefits. deductible in the absence of other health that may be responsible for the benefits or
care coverage. services provided for the covered person.
(4) COBRA or State Continuation The “amount of the payments made”
Coverage. If a person whose coverage is B. If a covered person is enrolled in two includes the reasonable cash value of any
provided pursuant to COBRA or under a or more Closed panel plans and if, for any benefits provided in the form of services.
right of continuation provided by state or reason, including the provision of service
other federal law is covered under another by a non-panel provider, benefits are not HELPFUL GUIDELINES
Plan, the Plan covering the person as an payable by one Closed panel plan, COB For Making the Most of Your Dental Plan
employee, member, subscriber or retiree shall not apply between that Plan and
or covering the person as a dependent of other Closed panel plans. What to Do in Case of Dental Emergency
an employee, member, subscriber or If you should have a dental emergency,
retiree is the Primary plan and the RIGHT TO RECEIVE AND RELEASE don’t panic. Call a DentaQuest
COBRA or state or other federal NEEDED INFORMATION participating dental office for an
continuation coverage is the Secondary appointment. If the office is not available
plan. If the other Plan does not have this Certain facts about health care coverage immediately, call the DentaQuest Member
rule, and as a result, the Plans do not and services are needed to apply these Services Department for assistance with
agree on the order of benefits, this rule is COB rules and to determine benefits
9obtaining an emergency appointment. In To read the benefit schedules and through an application submitted or
case of an acute emergency, seek familiarize yourself with all of the transmitted to the Marketplace for
immediate hospital care. aspects of the dental plan. enrollment in this plan.
To cooperate and be respectful of the
How to Schedule an Appointment participating dentist and dental office “Benefit Schedule” or “Benefit
Not everyone can get an appointment staff. Schedules” shall mean those dental
early in the morning or late in the To give the participating dentist and services to which a Member is entitled,
afternoon. If you are flexible with your the dental office staff accurate and subject to all provisions, definitions, and
time, appointment availability will complete information needed to care limitations outlined in the Certificate of
increase significantly. Make sure you are for you. Coverage.
visiting a DentaQuest participating dentist To keep your scheduled appointments
and be on time. To notify the “Benefit Year” means: a calendar year for
It is very important to keep your participating dental office as soon as which the Plan provides coverage for
scheduled appointments. If you need to possible when you cannot make an dental benefits.
cancel, please contact the dental office appointment.
within 24 hours before your scheduled To respect the rights of fellow “Certificate of Coverage or Certificate”
visit. Your dental office may have a fee patients. means this written document which is the
for broken or missed appointments, which To follow the treatment plan and agreement between the individual and
will be your responsibility. instructions for dental care that you DentaQuest whereby coverage and
have agreed to with your participating benefits specified herein will be provided
MEMBER RIGHTS AND dentist and dental office staff. to Members. The Certificate, Plan
To carry your identification card and Information Page, enrollment
RESPONSIBILITIES applications, addenda exhibits, riders,
present it before you receive services.
To pay all charges for missed schedules of benefits and any amendments
YOUR RIGHTS: appointments and services not covered which may be incorporated in this
To be treated with courtesy and by the dental plan. Certificate from time to time constitutes
respect with appreciation, dignity and To pay all co-payments (if applicable) the entire agreement between the Primary
protection of your privacy. at the time services are rendered. Subscriber and DentaQuest.
To know what member services are To follow the participating dental
available and to be assisted promptly office rules and regulations regarding “Deductible” is the total amount a
and courteously. patient care and conduct. Member must pay toward covered
To know who the DentaQuest To receive services only from treatment per Benefit Year before dental
participating dentists are. participating general dentists and pre- benefits are paid by DentaQuest. Please
To be given information by your approved participating specialists refer to the Benefit Schedule for
participating dentist concerning except for dental emergencies outside applicable Deductibles.
diagnosis, planned course of treatment, of the service area, or hospital care for
alternatives, risks and expected acute emergencies. “Dental Office”, “Dental Facility”,
outcomes. “Participating Dental Office”, or
To refuse treatment and to ask the PLAN DEFINITIONS “Participating Dental Facility” shall mean
participating dentist about the the location of a Participating General
“Act” means the Patient Protection and
consequences of refusing treatment. Dentist’s or Participating Specialist’s
Affordable Care Act (PPACA).
To be given access to dental services office where Member may obtain Dental
regardless of your race, national Services.
“Acute emergency” shall mean a situation
origin, religion or physical handicap.
where the provision of emergency
To receive information about the “Dental Services” shall mean those dental
medical services is necessary to evaluate
dental plan. services set forth in the applicable Benefit
or treat a medical condition manifesting
To voice complaints or file a grievance Schedule and determined by the Dentist to
itself by the sudden and/or at the time,
about the dental plan or the dental be required to establish and maintain the
unexpected onset of symptoms that
services you receive. Member’s good oral health.
require immediate medical attention and
To participate in making decisions
for which failure to provide medical
with the participating dentist about “Effective Date of Coverage” or
attention would result in serious
your dental care. “Effective Date” shall mean, as to an
impairment to bodily function.
To confidentiality of your dental individual Member, the first (1st) day of
records and all other information the month after such Member has
“Annual Maximum/Maximum Benefit”
unless you allow it to be released, or enrolled, has satisfied any applicable
means the total amount DentaQuest will
unless the law requires it to be waiting period or is a Dependent or a
make per covered adult Member for
released. Primary Subscriber. Coverage is effective
covered dental services per Benefit Year.
at 12:00 a.m., local standard time on the
YOUR RESPONSIBILITIES: date so specified on the Plan Information
“Applicant” means an individual who is
seeking eligibility for him or herself Page.
10“Emergency Dental Services” shall mean “Out-of-Pocket Maximum” means the Bridge: A prosthetic replacement of one
those services which are required maximum amount a Member will pay in or more missing teeth.
immediately due to an injury or deductible and coinsurance for allowable
unforeseen condition, and which provide expenses in any Benefit Year. Please Cavity: A hole in one of your teeth
for the relief of pain or prevent worsening refer to the Benefit Schedule for caused by decay.
of any condition that would be caused by applicable Out-of-Pocket amounts.
delay. Refer also to the definition of Crown: Also called a cap, a lab
Acute Emergency. “Palliative Treatment” shall mean only fabricated false tooth used to restore a
those procedures which alleviate pain or tooth that has heavy decay, a fracture or a
“Enrollee” means a Qualified Individual discomfort. root canal.
enrolled in a Qualified Health Plan.
“Premium” shall mean the advance Examination/Oral Evaluation: A
“Experimental” shall mean any payments due to DentaQuest on behalf of thorough examination of the hard and soft
evaluation, treatment or therapy which Members to receive Dental Services as set tissues of the oral cavity and surrounding
involves the application, administration or forth in this Certificate. structures.
use of procedures, techniques, equipment,
supplies, products or remedies that are “Primary Subscriber” shall mean the Extraction: Removal of a tooth.
considered experimental by DentaQuest Qualified Individual who is eligible to
based on reports, articles or written enroll on behalf of himself/herself and Fluoride: A substance applied to teeth
assessments published by the American his/her Dependents with DentaQuest for after a cleaning is performed. Fluoride
Dental Association or in other Dental Services through the Marketplace. helps prevent tooth decay by stopping the
authoritative medical and scientific breakdown of enamel.
literature published in the United States. “Provider” or “Participating Dentist” shall
mean a participating general dentist or Gingivitis: The inflammation of your
“Fees” shall mean the specific dollar specialist who has executed an agreement gums. The first sign of gum disease.
amount or percentage discount, as with DentaQuest to provide Dental
specified in the applicable Benefit Services to Members. Impacted Tooth: A tooth that is unable
Schedule, payable by the Member directly to break through the gums.
to the Provider upon receipt of covered “Qualified Health Plan (QHP)” means a
Dental Services. A Member is not health benefit plan that has in effect a Malocclusion: Improper alignment of
responsible for paying contracted fees certification that it meets the standards biting or chewing surfaces of upper and
owed by DentaQuest to its Participating described in the Act, or recognized by lower teeth.
Providers. each Marketplace through which the plan
is offered. Medically Necessary Orthodonture
“Health Insurance Marketplace means for enrollees under the age of 19, a
(Marketplace)” means a governmental “Qualified Individual” means an severe handicapping malocclusion as
agency or non-profit entity that makes individual who has been determined defined by an IAF Score of 26 and/or one
Qualified Health Plans available to eligible to enroll in a Qualified Health or more auto qualifier.
Qualified Individuals. Unless otherwise Plan through the Marketplace.
identified, this term refers to State Plaque: A sticky, white film of bacteria
Exchanges, regional Exchanges, “Service Area” means the geographic area that forms on teeth, causing tooth decay,
subsidiary Exchanges and a Federally- in Florida in which DentaQuest has inflammation of the gums, periodontal
qualified Exchange. contracted with a network of dental disease and bad breath.
providers as set forth in the Dental
“Identification Card” shall mean, a card Provider Directory. Prophylaxis/Cleaning: Cleaning, scaling
issued by DentaQuest to Members and polishing procedure performed to
enrolled in this Plan. The Identification remove plaque, tartar and stains from
Card is the property of DentaQuest and is teeth above the gum line.
not transferable to another person. GLOSSARY OF DENTAL TERMS
Possession of such card in no way verifies Periodontal Scaling/Deep Cleaning: The
eligibility to receive benefits under this Amalgam “Silver” Filling: A metal removal of plaque and tartar from the
Agreement. restoration that has a silver-like color used crowns and root surfaces above and under
to fill cavities in teeth caused by decay. the gum in Members with periodontal
“Member” shall mean the Primary disease. A routine prophylaxis/cleaning
Subscriber, including a Dependent, for Anesthesia (local): A drug used by a cannot be performed on a Member with
whom all premiums have been paid to dentist to put your mouth to sleep so that untreated periodontal disease.
DentaQuest when due and who is enrolled you don’t feel any pain during dental
and entitled to receive Dental Services procedures. Resin “White” Filling: A plastic-like
pursuant to this Certificate. filling that is tooth colored and is used to
fill cavities in teeth caused by decay.
These fillings can be used on both front
11and back teeth enhancing a cosmetic This Notice takes effect 04/14/03, and will authorization, we cannot use or disclose
effect. remain in effect until we replace it. your health information for any reason
except those described in this Notice.
We reserve the right to change our
Root Canal: Removal of the pulp inside a privacy practices and the terms of this To Your Family and Friends: We must
tooth and its roots due to infection or Notice at any time, provided such changes disclose your health information to you,
fracture. are permitted by applicable law. We as described in the Member Rights section
reserve the right to make the changes in of this Notice. We may disclose your
Sealant: Protective plastic coating that our privacy practices and the new terms of health information to a family member,
covers grooves in healthy teeth to prevent our Notice effective for all health friend or other person to the extent
decay. Sealants are usually applied to information that we maintain, including necessary to help with your healthcare or
permanent back teeth. health information we created or received with payment for your healthcare, but
before we made the changes. Before we only if you agree that we may do so.
Space Maintainer: An appliance inserted make a significant change in our privacy
in the mouth to prevent drifting and Persons Involved In Care: We may use
practices, we will change this Notice and
crowding of teeth after removal of a baby or disclose health information to notify, or
make the new Notice available upon
tooth. assist in the notification of (including
request.
identifying or locating) a family member,
You may request a copy of our Notice at your personal representative or another
TYPES OF SPECIALISTS
any time. For more information about our person responsible for your care, of your
privacy practices, or for additional copies location, your general condition, or death.
Endodontist: Specializes in root canal of this Notice, please contact us using the If you are present, then prior to use or
therapy. information listed at the end of this disclosure of your health information, we
Notice. will provide you with an opportunity to
Oral Surgeon: Specializes in extractions object to such uses or disclosures. In the
and surgery. event of your incapacity or emergency
USES AND DISCLOSURES OF
HEALTH INFORMATION circumstances, we will disclose health
Orthodontist: Specializes in adjustment information based on a determination
We use and disclose health information
of bite and braces. using our professional judgment
about you for treatment, payment, and
healthcare operations. For example: disclosing only health information that is
Pedodontist: Specializes in the care of directly relevant to the person’s
children. Treatment: We may use or disclose your
health information to a dentist or other involvement in your healthcare. We will
healthcare provider providing treatment to also use our professional judgment and
Periodontist: Specializes in the care of our experience with common practice to
gums. you.
make reasonable inferences of your best
Payment: We may use and disclose your interest in allowing a person to pick up
Prosthodontist: Specializes in the health information to make payments for dental payment records, dental records,
replacement of missing teeth (dentures services provided to you. study models, x-rays, or other similar
and bridges). forms of health information.
Healthcare Operations: We may use and
disclose your health information in Marketing Health-Related Services: We
connection with our healthcare operations. will not use your health information for
Healthcare operations include quality marketing communications without your
HIPAA POLICY/NOTICE OF assessment and improvement activities, written authorization.
reviewing the competence or
PRIVACY PRACTICES Required by Law: We may use or
qualifications of healthcare professionals,
This notice describes how health evaluating practitioner and provider disclose your health information when we
information about you may be used and performance, conducting training are required to do so by law.
disclosed and how you can get access to programs, accreditation, certification, Abuse or Neglect: We may disclose your
this information. Please review it licensing or credentialing activities. health information to appropriate
carefully. The privacy of your health authorities if we reasonably believe that
information is important to us. Your Authorization: In addition to our
use of your health information for you are a possible victim of abuse,
treatment, payment or healthcare neglect, or domestic violence or the
OUR LEGAL DUTY possible victim of other crimes. We may
We are required by applicable federal and operations, you may give us written
authorization to use your health disclose your health information to the
state law to maintain the privacy of your extent necessary to avert a serious threat
health information. We are also required to information or to disclose it to anyone for
any purpose. If you give us an to your health or safety or the health or
give you this Notice about our privacy safety of others.
practices, our legal duties, and your rights authorization, you may revoke it in
concerning your health information. We writing at any time. Your revocation will National Security: We may disclose to
must follow the privacy practices that are not affect any use or disclosures permitted military authorities the health information
described in this Notice while it is in effect. by your authorization while it was in of Armed Forces personnel under certain
effect. Unless you give us a written
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