Preferred Smile Kit.doc

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Preferred Smile Kit.doc

  1. 1. Voluntary Dental Good news about dental benefits for employees of Hardin-Simmons University Your Dental Plan The allowable amount for dentists is based on the 90th percentile of usual and customary. As a valued employee of Hardin-Simmons Patients are responsible for fees in excess of University, you have the opportunity to enroll usual and customary. in a payroll-deduction dental program. Plan frequencies, limitations and waiting Plan Features: periods apply. • Freedom to Choose any Dentist, Including Specialists • Fast and Accurate Claims Service • 12-Month Rate Guarantee • No Referrals Required How the Plan Works This dental plan provides a variety of benefits and allows you and your family to use any dentist or specialist you choose. Benefits are paid after any applicable deductible has been met, up to the annual maximum. Claim payments may be made to you or your dentist, whichever you prefer, unless benefits have been assigned to the provider. Vision Care Program Your dental plan includes a valuable vision care program. You may have access to coverage and/or discounts on eye exams, eyeglasses, contact lenses and other prescription eyewear. IMPORTANT: Coverage for eligible employees will begin January 1, 2005. You must sign up by the Initial Enrollment Deadline, or forfeit the opportunity until the next plan anniversary date. IN Freedom – page 1 09/13/2004 10:15:34 906391/8
  2. 2. Type II Basic Dental Services, Including:Savings You ♦ X-Rays: ♦ Complete series – once in any 60-month period ♦ Bitewing – once in any 12-month period ♦ Panoramic – once in any 60-month period (may also be payable in connection with the removal of impacted teeth)Can See ♦ Other X-Rays (See Certificate of Insurance) ♦ New Fillings ♦ Replacement Fillings – once in any 24-month period per Filling ♦ Simple Extractions, Removal of Exposed Roots, Incision and Drainage ♦ Certain Lab Tests, Pain Treatment, Therapeutic Drug InjectionsPayroll Deduction Bi-Weekly Monthly Type III Major Dental Services, Including:Employee $16.92 $36.67 ♦ Endodontics (includes root canal therapy) ♦ Endodontic retreatment (covered after 24 months have passed fromEmployee + Spouse $32.88 $71.26 initial treatment) ♦ Complex Oral Surgery; General Anesthesia and IV Sedation whenEmployee + Child(ren) $36.61 $79.34 medically required for such SurgeryEmployee + Family $52.58 $113.93 ♦ Minor Gum Disease Treatment: (Minor Periodontics) ♦ Provisional Splinting, Occlusal Adjustments – once in any 12-month periodFreedom Preferred ♦ ♦ Scaling and Root Planing – Periodontal Maintenance – once in any 24-month period once in any 6-month period (Frequencies combined with Routine Dental Cleanings) ♦ Major Gum Disease Treatment: (Major Periodontics) ♦ Gingivectomy, Osseous Surgery, other major periodontic proceduresBenefit Maximum: – once in any 36-month period per areaPer Person, Per Policy Year $1,500 ♦ Initial Placement, Replacement and Maintenance of Inlays, Onlays, Crowns, Fixed Partial Dentures (Bridges), and Partial and Complete DenturesCoinsurance Percentage Per Person: Type IV Orthodontic Dental ServicesType I Dental Services 100%Type II Dental Services 80% Only for dependent children under age 19 ♦ Limited Orthodontic TreatmentType III Dental Services 50% ♦ Interceptive Orthodontic Treatment ♦ Comprehensive Orthodontic TreatmentDeductible: ♦ Minor Treatment to control harmful habitsPer Person, Per Policy Year $50Waived for Type I Services Yes Waiting Periods for From Your Certain Services Effective Date Repairs, Re-Cementing of Fixed Partials (Bridges),Orthodontia Benefits: Inlays, Onlays, or Crowns.................................................................................NoneType IV Deductible $0 Accidental Non-Chewing Injury.........................................................................None All Services under EndodonticsType IV Coinsurance 50% (Includes root canal therapy)......................................................................6 months Stainless Steel/Plastic CrownsLifetime Orthodontia Maximum $1,000 Only for children under age 16...................................................................6 monthsOnly for dependent children under age 19 Relines, Rebases, Denture Adjustment.....................................................6 months Complex Oral Surgery..............................................................................12 months All Services under Minor and Major Periodontics....................................12 months Crown/Inlays/Onlays/Labial Veneers.......................................................12 monthsType I Preventive Dental Services, Including: Dentures (Partial or Complete).................................................................12 months Fixed Partial Dentures (Bridges)/Diagnostic Casts..................................12 months♦ Oral Evaluations – once in any 12– month period Orthodontia...............................................................................................12 months♦ Routine Dental Cleanings – once in any 6-month period (Frequencies combined with Periodontal Maintenance) If you are covered under the current dental program on the day it terminates,♦ Fluoride Treatment – once in any 12-month period your waiting periods will be reduced by 12 months or waived and if you are Only for children under age 14 covered under the current indemnity dental program, your Orthodontic waiting period will be reduced by 12 months.♦ Sealants – No more than once per tooth per person, only for permanent molar teeth Other Policy Provisions Only for children under age 16♦ Space Maintainer Benefit Adjustments Only for children under age 16 (Includes adjustments within 6 months of installation) Benefits will be coordinated with any other dental coverage. Under the Alternative Treatment provision, benefits will be payable for the most♦ Harmful Habit Appliance – once per person economical services or supplies meeting broadly accepted standards of dental Only for children under age 16 care. If the cost of a proposed Dental Treatment Plan exceeds $300, it should (Not covered if Orthodontic related) be submitted for an estimate of benefits payable. Eligibility Hardin-Simmons University w/ortho 09/13/2004 10:15:34 906391/8 Freedom - page 2
  3. 3. Full-time employee, spouse and unmarried dependent children less than age25. Unmarried grandchildren who, for Federal income tax purposes, are yourdependents at the time of application will also be included as dependents forinsurance coverage.Late EntrantsIf you elect coverage more than 31 days after your Eligibility Date, yourEffective Date will be delayed to the next plan Anniversary Date.This is a brief description only. It is not a Certificate of Coverage. Please seethe Group Policy, which alone determines all rights, benefits, and applicableLimitations and Exclusions. Fortis Benefits and the policyholder have theoption to cancel the group policy. Hardin-Simmons University w/ortho 09/13/2004 10:15:34 906391/8 Freedom - page 2
  4. 4. Vision Discount Services ACCESS PLANYour dental plan includes a vision discount plan through Vision Service Plan (VSP). The vision plan includesdiscounts on exams and the purchase of eyeglasses, contact lenses, sunglasses and other prescription eyewearwhen provided by VSP doctors. VSP is available for you and everyone covered on your dental plan!Services Available from a VSP Doctor Other Valuable Features for You• Eye Exams – 20% discount applied to VSP • Immediate savings when using a VSP doctor’s usual and customary fees for eye exams1 doctor• Glasses – 20% discount applied to VSP doctor’s • You may use the discounts as often as you usual and customary fees for complete pairs of wish prescription glasses and spectacle lens options2 • No waiting periods• Contact Lenses – 15% discount on doctor’s • No deductibles professional services when purchasing all prescription contact lenses2 (materials at doctor’s • No claim forms to fill out usual and customary fees)3• Laser VisionCareSM – VSP has contracted with many of the nations laser surgery facilities and doctors, offering you a discount off PRK and LASIK surgeries, available through contracted laser centers How to Use VSPLocate a VSP doctor near you. You may either use our Web-based doctor locator at www.vsp.com, or call VSP at1-800-877-7195 to request a doctor listing.Identify yourself as a VSP member and be prepared to provide the enrolled member’s social security numberwhen you make your appointment. (The VSP doctor will verify your eligibility and vision plan coverage, and willobtain authorization for services and materials. If you are not currently eligible for services, the VSP doctor isresponsible for communicating this to you.)Your fees are automatically reduced at the time of service – with no claim forms to fill out! THIS VISION DISCOUNT PLAN IS NOT INSURANCE. 1 Note: Does not apply to contact lens services. See contact lens section for applicable discount. 2 Discounts only offered through the VSP doctor who provided an eye exam within the last 12 months. 3 VSP offers valuable savings on annual supplies of selected brands of contact lenses. VSP Member Services Support: 1-800-877-7195 Visit our Web site at www.vsp.comVSP Freedom - page 4 09/13/2004 10:15:34 906391/8
  5. 5. Group Insurance Enrollment Card Check one – Employer Use  Initial Employee:  Transfer from Prior Dental  Non-Transfer  New Employee Date of Hire __________  Change(Please print clearly.)  Open EnrollmentEmployer Hardin-Simmons University -603835 Effective Date Location/DivisionEmployee first name MI Last NameAddress City State ZipSocial Security No. Birthdate Phone SexDENTAL COVERAGE  M   F I APPLY FOR:  I DECLINE COVERAGE FOR:  Employee only  Employee  Employee and eligible dependents  Spouse  Child(ren) For children age 19Do you have eligible dependents?  Yes  No or older, indicate if aIf “Yes,” complete below to enroll them. Birthdate full-time student. Relation Sex Mo Day Year Yes NoSpouseChild(ren) List additional Children on reverse side and check box.• If the address of any child is different than the employee’s address, please show that child’s name and address below. _______________________________________________________________________________________________• If requesting coverage for a dependent child other than a son or daughter, please forward legal custody papers.To the best of my knowledge and belief, each of the statements and answers supplied in this form is completeand true, and they constitute the sole basis for, and are the inducement for, the issuance of any insurance.I hereby apply as indicated herein for the insurance for which I am not now insured and for which I am or may becomeeligible under the terms of Fortis Benefits Insurance Company’s group policy or policies (including any futureamendments) applying to, or requested to apply to, the employer named above. If such insurance becomes effective, Iauthorize deductions from my earnings of my contributions required from time to time toward the cost of such insurance. Irepresent that I am an active full-time employee of that employer. When necessary, I may be asked to execute a HIPAAauthorization form, allowing Fortis Benefits Insurance Company to use and disclose protected health information.Date_____________________________ Signature______________________________________________________Fortis Benefits Insurance CompanyForm 59 (12/01) KC3018 (1/2003)

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