Notice This Is An Electronic Representation Of A Document Originally
1. NOTICE
This is an electronic representation of a document originally issued in paper
format. Accordingly, it is understood that all legal rights, responsibilities and/or
obligations are governed by the original paper version of this document, a copy
of which is available upon request.
2.
3. Employer:
Employee:
Certificate Number:
___________________________________________________
CERTIFICATE OF INSURANCE
PPO Plan
HumanaDental Insurance Company
___________________________________________________
PACIFIC HEALTH ADVANTAGE
also known as
THE HEALTH INSURANCE PLAN OF CALIFORNIA
GERALD L. GANONI
PRESIDENT
CA-59657-HD PPO COV
7. NOTICE
Answers to questions and information on eligibility, enrollment, open enrollment period, disenrollment, effective
dates of coverage, transfers of enrollment, and premium payment are included with the application materials
completed by you to enroll in the program. If you have questions on these topics or would like to receive another
copy of the materials related to these topics please contact your employer or call toll free 1−877−4PACADV.
This Evidence of Coverage and Disclosure Form is a summary of the Group Agreement between HumanaDental
Insurance Company and the Pacific Health Advantage, also known as the Health Insurance Plan of California, a
program of the State of California. Disclosure of the Group Agreement is pursuant to Section 6254 of the
government Code of the Statutes of California. To determine the exact terms and conditions of coverage, it may
be necessary to consult the Program Governing Rules. Please call toll free 1−877−4PACADV to request a copy.
8.
9. NOTICE TO INSUREDS REGARDING FILING OF COMPLAINTS
As our insured, your satisfaction is very important to us. If you have a question about your policy, if you need
assistance with a problem, or if you have a claim, you should first contact your insurance agent or contact us at:
HumanaDental Insurance Company
Green Bay, Wisconsin 54344
(800)−233−4013
Should you have a valid claim, we fully expect to provide a fair settlement in a timely fashion.
If you have not received a satisfactory resolution to your problem from either your insurance agent or us, you may
contact the California Department of Insurance with your complaint.
To contact the Department, write or call:
California Department of Insurance
Consumer Affairs Unit
300 S Spring Street 14th Floor
Los Angeles, CA 90013
(800)−927−4357
CA−70091−HD GRIEV
11. DISABILITY ACCESS NOTICE
Physical Access
We have made every effort to ensure that our offices and the offices and facilities of the plan providers are
accessible to the disabled. If you are not able to locate an accessible provider, please call our toll free customer
service number at 1−800−233−4013and a customer service representative will help you find an alternate provider.
Access for the Hearing Impaired:
The hearing impaired may contact our customer service representative through our TTD number at
1−800−325−2025.
Access for the Vision Impaired:
This Certificate of Insurance and other important plan materials will be made available in alternate formats for the
vision impaired. Large print and enlarged computer disk formats are available and this Certificate of Insurance is
available on an audiotape. For alternate formats, or for direct help in reading the Certificate of Insurance and
other materials, please call a customer services representative at 1−800−233−4013.
15. SCHEDULE OF DENTAL BENEFITS
ALL COVERED EXPENSES ARE PAYABLE ONLY IF DENTALLY NECESSARY
The Benefits outlined in this Schedule of Benefits are a summary of Coverage and limitations provided under this
plan. A more detailed explanation of Your Coverage , limitations and exclusions is provided in the Certificate.
PREFERRED PROVIDER ORGANIZATION PROVISION
Your Certificate contains a Preferred Provider Organization Rider. Benefits may be higher if services are provided
by a Preferred Provider. All Preferred Dentists have agreed to render services at predetermined charges. Your
benefits are always calculated on these predetermined charges. HumanaDental Insurance Company pays the
same benefit whether Your Dentist of choice is a Preferred Dentist or a Non−Preferred Dentist . However,
Non−Preferred Dentists have not agreed to provide services at the same predetermined charge levels as the
Preferred Dentists, so You are responsible for the difference between the Non−Preferred Dentist charge and the
predetermined charge level. Please see the Schedule of Dental Benefits and the Preferred Provider Organization
Rider.
DENTAL BENEFITS
INDIVIDUAL MAXIMUM BENEFIT:
$1500 per Benefit Year per Covered Person for Covered Expense exclusive of orthodontia, when you see a
Preferred provider.
$1000 per Benefit Year per Covered Person for Covered Expense exclusive of orthodontia, when you see a
Non−Preferred provider.
The combined Preferred Provider and Non−Preferred Provider Individual Maximum Benefit is $1500 per Benefit
Year per Covered Person .
INDIVIDUAL ORTHODONTIA MAXIMUM BENEFIT:
$1500 per lifetime per Covered Person for orthodontia services.
INDIVIDUAL DEDUCTIBLE:
$50 per Benefit Year for each Covered Person. (Does not apply to services when payable at 100%)
MAXIMUM FAMILY DEDUCTIBLE:
$150 per Benefit Year (Does not apply to services when payable at 100%)
CA−59657−HD SCP 3
16. COVERED EXPENSES
Covered Expenses are payable at the Coinsurance shown of the Maximum Allowable Fee:
DIAGNOSTIC AND PREVENTIVE SERVICES
PREFERRED PROVIDER BENEFITS : 100%
NON−PREFERRED PROVIDER BENEFITS : 50%
Except:
Emergency Oral Exams
Palliative Treatments
Specialist Consultations
Full Mouth X−rays
Panoramic Films
Sealants
PREFERRED PROVIDER BENEFITS : 80%
NON−PREFERRED PROVIDER BENEFITS : 50%
Space Maintainers
PREFERRED PROVIDER BENEFITS : 50%
NON−PREFERRED PROVIDER BENEFITS : 50%
RESTORATIVE DENTISTRY
PREFERRED PROVIDER BENEFITS : 80%
NON−PREFERRED PROVIDER BENEFITS : 50%
Except :
If a precious metal (defined as a metal containing in excess of 50% gold or highly noble gold alloy) is used instead
of a non−precious metal, charges for the precious metal are the responsibility of the Covered Person.
ORAL SURGERY:
PREFERRED PROVIDER BENEFITS : 80%
NON−PREFERRED PROVIDER BENEFITS : 50%
Except:
Extractions solely for Orthodontic purposes
PREFERRED PROVIDER BENEFITS : 50%
NON−PREFERRED PROVIDER BENEFITS : 50%
Excision of cysts or neoplasms in conjunction with an extraction
Incisions and drainage of abscesses
Postoperative services
PREFERRED PROVIDER BENEFITS : 100%
NON−PREFERRED PROVIDER BENEFITS : 50%
CA−59657−HD SCP 4
18. ORTHODONTIA
PREFERRED PROVIDER BENEFITS : 50%
NON−PREFERRED PROVIDER BENEFITS : 50%
OTHER DENTAL BENEFITS:
PREFERRED PROVIDER BENEFITS : 100%
NON−PREFERRED PROVIDER BENEFITS : 50%
Note:
For failure to cancel an appointment 24 hours in advance, the Covered Person may incur a charge of up to $20
from a Preferred Provider. A Covered Person is responsible for the Non−Preferred Providers standard penalty for
failure to cancel an appointment.
Covered Persons are responsible for 100% of any additional charges for services provided in excess of the
Benefit level.
WAITING PERIODS
Covered Persons who have not had Qualifying Prior Dental Coverage for the six (6) consecutive months prior
to enrollment in the Program are subject to a waiting period of six (6) months for Crowns, Inlays, Onlays, Fixed
Bridges and Removable Prosthetics. All Covered Persons are subject to a waiting period of twelve months for
Orthodontia services regardless of prior dental coverage.
CA−59657−HD SCP 6
19. DEFINITIONS
We shall apply the terms and meanings shown below wherever used in the Certificate to determine the intent and
administration of Insurance Benefits .
ACCIDENTAL INJURY
Accidental Injury means damage to the mouth, teeth, and supporting tissue, due directly to an accident.
Accidental Injury does not include damage to the teeth, appliances, or prosthetic devices which results from
chewing or biting food or other substances.
BENEFIT
Benefit means the amount payable in accordance with all of the provisions of this policy.
BENEFIT YEAR
Benefit Year means the 12−month period beginning January 1 of each year. It is the period during which Your
Deductible and plan Benefits are accumulated.
BODILY INJURY
Bodily Injury means injury due directly to an accident, independent of all other causes.
CARRIER
Carrier means any disability insurance company, health care service plan, nonprofit hospital service plan, or any
other entity that writes, issues, or administers group health benefit plans that cover the employees of small
employers.
CERTIFICATE
Certificate means this Certificate of Insurance.
COINSURANCE
Coinsurance means the percent of Covered Expenses payable as Benefits , after the Deductible is satisfied,
up to the Maximum Benefit . The applicable Coinsurance percentage rate is shown on the Schedule of Benefits.
COSMETIC DENTISTRY
Cosmetic Dentistry means those services provided by Dentists solely for the purpose of improving appearance
when the function is satisfactory and no pathologic conditions exist.
COVERAGE
Coverage means the state of being eligible to receive specified health Benefits under the terms of this health
Benefit plan.
CA−59657−HD 7
20. COVERED EXPENSE
Covered Expense means a Dentally Necessary Expense Incurred by the Covered Person for the actual fee
charged.
COVERED PERSON
Covered Person means the Enrolled Employee and/or the Enrolled Employee’s covered dependents.
CUSTOMARY, USUAL AND REASONABLE/MAXIMUM ALLOWABLE FEE
Customary, Usual and Reasonable/Maximum Allowable Fee means the lesser of:
1. The fee most often charged in the geographical area where the service was performed;
2. The fee most often charged by the provider;
3. The fee which is recognized as reasonable by a prudent person;
4. The fee determined by comparing charges for similar services to a national data base adjusted to the
geographical area where the services or procedures were performed; or
5. The fee that We have negotiated with a Qualified Practitioner for similar services provided as a Covered
Expense .
DEDUCTIBLE
Deductible means the amount of Covered Expense which You must incur and pay before Benefits become
payable by Us . It does not include services paid at 100%.
DENTALLY NECESSARY
Dentally Necessary means procedures, treatment or products which are considered necessary for the patient’s
dental health if they are not investigational and are necessary because:
1. They are appropriate and are provided in accordance with accepted dental care standards in the state of
California, and could not be omitted without adversely affecting the patient’s condition or the quality of dental
care rendered; and
2. If the proposed article or service is not commonly used, its application or proposed application has been
preceded by a thorough review and application of conventional therapies; and
3. The service or article has been demonstrated to be of significantly greater therapeutic value than other, less
expensive, services or articles;
To determine Dental Necessity, We may require preoperative dental x−rays and any other pertinent information
to help Us determine if Benefits are payable for the services submitted for consideration.
DENTIST
Dentist means a person who is validly licensed to practice dentistry and provide dental services and is acting
within the lawful scope of his/her license.
EMERGENCY CARE
Emergency Care means the necessary procedures for treatment of pain and/or injury. Services include
emergency procedures for treatment to the teeth and supporting structures.
CA−59657−HD 8
21. EMPLOYER PREMIUM
Employer Premium means the dollar amount owed each month by the Participating Employer to the Program ,
including Program participation fees, any required late fees, any required reinstatement fees, any required agent
or broker fees, and the sum of the individual premiums.
ENROLLED EMPLOYEE
Enrolled Employee means an employee of a Qualified Small Employer who is an eligible employee and is
enrolled in the Program .
EXPENSE INCURRED
Expense Incurred means the lesser of the Customary, Usual and Reasonable fee charge or the Maximum
Allowable Fee charge made for Dentally Necessary services and supplies.
EXPENSE INCURRED DATE
Expense Incurred Date means the date on which:
1. The teeth are prepared for fixed bridges, crowns, inlays or onlays;
2. The final impression is made for dentures or partials;
3. The pulp chamber of a tooth is opened for root canal therapy;
4. Periodontal surgery is performed;
5. The service is performed for Covered Expenses not listed under 1, 2, 3 or 4 above.
MAXIMUM BENEFIT
Maximum Benefit means the maximum amount that may be payable for each Covered Person , for Expenses
Incurred . The applicable Maximum Benefit is shown on the Schedule of Benefits. No further Benefits are
payable once the Maximum Benefit is reached.
MAXIMUM FAMILY DEDUCTIBLE
Maximum Family Deductible means the total Deductible applied to one family in a Benefit Year as defined on
the Schedule of Benefits.
PARTICIPATING EMPLOYER
Participating Employer means a Qualified Small Employer who has been accepted into the Program .
PROGRAM
Program means Pacific Health Advantage, also known as the Health Insurance Plan of California (HIPC).
QUALIFIED PRACTITIONER
Qualified Practitioner means a licensed Practitioner providing services within the scope of that license. A
Qualified Practitioner’s services are not covered if the practitioner resides in Your home or is Your family
member.
CA−59657−HD 9
22. QUALIFIED SMALL EMPLOYER
Qualified Small Employer means a small employer that has been determined to be in compliance with the
participation requirements of the Program .
QUALIFYING PRIOR DENTAL COVERAGE
Qualifying Prior Dental Coverage means:
1. Any individual or group policy, or contract, or program that is written or administered by a disability insurer,
nonprofit dental service plan, dental service plan, fraternal benefits society, self−insured employer dental plan,
or any other entity in this state or elsewhere, that arranges or provides dental coverage not designed to
supplement other private or governmental plans. The term includes continuation or conversion coverage, but
not does not include accident only, credit, disability income, Medicare supplement, long−term care, vision,
coverage issued as a supplement to liability insurance, insurance arising out of a workers’ compensation or
similar law, automobile medical payment insurance, or insurance under which benefits are payable with or
without regard to fault and that is statutorily required to be contained in any liability insurance policy or
equivalent self−insurance;
2. Any other publicly sponsored program, provided in this state or elsewhere, of dental care.
TREATMENT PLAN
Treatment Plan means a written report, on a form satisfactory to Us , and which is completed by the Dentist ,
which consists of:
1. A list of the services to be performed, using the American Dental Association Nomenclature and codes;
2. Your Dentist’s written description of the proposed treatment;
3. Supporting pretreatment x−rays showing Your dental needs;
4. Itemized cost of the proposed treatment; and
5. Any other appropriate diagnostic materials as requested by Us .
WE, US, AND OUR
We, Us, and Our means the Insurance Company as shown on the cover page of this Certificate .
YOU AND YOUR
You and Your means any Covered Person .
CA−59657−HD 10
23. CONTINUATION OF DENTAL COVERAGE
CAL−COBRA AND COBRA CONTINUATION
Employees eligible for coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) or under
Cal−COBRA shall be eligible to obtain such coverage upon written notification by the employer to the Program of
the employee’s intent to obtain such coverage.
CA−59657−HD 11
24. DENTAL BENEFITS FOR EMPLOYEE AND COVERED
DEPENDENTS
This section describes Benefits for Covered Expenses . Covered Expense means Dentally Necessary
Expense Incurred by You for the services stated herein. The expense must be incurred while You are insured
for that Benefit under this plan. Covered Expenses are payable, after satisfaction of the Deductible , on a
Customary, Usual and Reasonable or Maximum Allowable Fee basis at the Coinsurance percentages and up
to the Maximum Benefits shown on the Schedule of Benefits.
DEDUCTIBLE
The Deductible applies to each Covered Person . Only charges which would otherwise qualify as a Covered
Expense may be used to satisfy the Deductible . The amount of the Deductible is stated on the Schedule of
Benefits. The Deductible will be applied separately during each Benefit Year .
MAXIMUM FAMILY DEDUCTIBLE
The total Deductible applied to all Covered Persons in one family in a Benefit Year is subject to the Maximum
Family Deductible shown on the Schedule of Benefits.
COINSURANCE
After the Deductible is satisfied, Covered Expenses are payable at the applicable percentage rates shown on
the Schedule of Benefits, up to the Maximum Benefit .
ALTERNATE SERVICES
If two or more services are considered to be acceptable to correct the same dental condition, the Benefits
payable will be based on the Covered Expenses for the least expensive service which will produce a
professionally satisfactory result as determined by Us .
If You or Your Dentist decide on a more costly treatment than We have determined to be satisfactory for
treatment of the condition, payment will be limited to the lesser of the Customary, Usual and Reasonable fee
charge or Maximum Allowable Fee and are subject to any Deductible and Coinsurance for the least costly
treatment. The excess amount will not be paid by Us .
PREDETERMINATION OF BENEFITS
Whenever recommended dental treatment is expected to exceed $300, You or Your Dentist must submit a
dental Treatment Plan to Us for review prior to treatment. The dental Treatment Plan should consist of:
1. A list of the services to be performed, using the American Dental Association Nomenclature and codes;
2. Your Dentist’s written description of the proposed treatment;
3. Supporting pretreatment x−rays showing Your dental needs;
4. Itemized cost of the proposed treatment; and
5. Any other appropriate diagnostic materials as requested by Us .
Predetermination of Benefits is not a guarantee of what We will pay. It tells You and Your Dentist in advance,
Benefits payable for the Covered Dental Expenses named in the Treatment Plan .
CA−59657−HD 12
25. We will notify You and Your Dentist of the Benefits payable based upon the submitted Treatment Plan. In
determining the Benefits payable, consideration will be given to Alternate Services that may accomplish a
professionally satisfactory result. If You and Your Dentist decide on a more costly treatment than We have
determined to be satisfactory for treatment of the condition, payment will be limited to the lesser of the
Customary, Usual and Reasonable charge or Maximum Allowable Fee and are subject to any Deductible and
Coinsurance for the least costly treatment. The excess amount will not be paid by Us .
Subject to Your eligibility of Coverage under this plan, the Predetermination of Benefits is valid for 90 days after
the date We notify You and Your Dentist of the Benefits payable for the proposed Treatment Plan . If treatment
is to commence more than 90 days after the date We notify You and Your Dentist of the Benefits payable for the
proposed Treatment Plan , a new Treatment Plan must be submitted to Us .
Predetermination of Benefits is not necessary for Emergency Care .
COVERED EXPENSES
For all Covered Expenses , the following services will be considered an integral part of the entire dental service
rather than a separate service:
1. Bases
2. Pulp Caps
3. Temporary Dental Services
4. Treatment Plans
5. Occlusal Adjustments
The following are Covered Expenses for Dental Benefits :
Diagnostic and Preventive Benefits
1. Initial, periodic and emergency oral examinations, limited to one routine oral exam every six months per
Covered Person ;
2. Palliative treatment;
3. Consultations, including specialist consultations;
4. Roentgenology, limited as follows:
A. Bitewing x−rays in conjunction with periodic examinations are limited to one series of four films in any 12
consecutive month period;
B. Full mouth x−rays in conjunction with periodic examinations are limited to once every 60 consecutive
months;
C. Panoramic film x−rays are limited to once every 60 consecutive months;
D. Isolated bitewing or periapical films on an emergency or episodic basis;
5. Prophylaxis services, not to exceed once in a six month period;
6. Fluoride treatment, limited to:
A. Dental benefit plan enrollees under the age of 18;
B. One every 12 months;
CA−59657−HD 13
26. 7. Dental sealant treatments, limited to:
A. Dental plan enrollees under the age of 14;
B. Permanent first and second molars only;
C. One treatment per tooth in a 36 consecutive month period;
8. Space maintainers, limited to dental plan enrollees under the age of 14;
9. Preventive dental education and oral hygiene instruction;
10. Study models.
Restorative Dentistry
1. Restorations, limited as follows:
A. The covered dental Benefit is limited to the Benefit level for the least costly dentally appropriate
alternative. If a more costly alternative is chosen by the patient, the patient will be responsible for all
additional charges;
B. Replacement of a restoration is covered only when it is defective, as evidenced by conditions such as
recurrent caries or fracture, and necessary for the enrollee’s dental health;
2. Use of pins in conjunction with restoration.
Oral Surgery
1. Extractions, including surgical extractions;
2. Removal of impacted teeth, only when evidence of pathology exists;
3. Biopsy of oral tissues;
4. Alveolectomies;
5. Excision of cysts and neoplasms;
6. Treatment of palatal torus if interfering with a prosthesis;
7. Treatment of mandibular torus if interfering with a prosthesis;
8. Frenulectomy;
9. Incision and drainage of abscesses;
10. Post−operative exams, including suture removal and treatment of complications.
Endodontics
1. Direct pulp capping;
2. Therapeutic pulpotomy;
3. Apexification filling with calcium hydroxide;
4. Root amputation and hemisection;
5. Root canal therapy;
CA−59657−HD 14
27. 6. Apicoectomy;
7. Retrograde filling;
8. Vitality tests.
Periodontics
1. Periodontal scaling performed in the presence of gingival inflammation;
2. Periodontal scaling and root planing, gingival flap procedure, and subgingival curettage, limited to four
quadrant treatments in any 12 consecutive months;
3. Gingivectomy or gingivoplasty;
4. Osseous or muco−gingival surgery;
5. Correction of occlusion, limited to occlusal adjustment.
Crowns and Fixed Bridges
1. Crowns, limited to replacement of each unit once every 60 consecutive months, with the exception of
prefabricated stainless steel crowns;
2. Fixed bridges, limited as follows:
A. Fixed bridges are a covered Benefit when there are one or two missing teeth in any one quadrant;
B. Other than in A. above −fixed bridges will be covered only when a partial denture cannot satisfactorily
restore the case. If a fixed bridge is used when a partial could satisfactorily restore the case, Coverage
will be provided at the level it would have been for a partial denture;
C. Replacement of an existing fixed bridge is covered only when it cannot be made satisfactory by repair;
D. Replacement of bridge pontic and bridge abutment units is limited to once every 60 consecutive months;
3. Recementation of crowns or bridges;
4. Inlays and onlays, limited to replacement of each unit once every 60 consecutive months;
5. Prefabricated, cast or laboratory posts and cores for crowns or bridges;
6. Repair or replacement of crowns, abutments or pontics.
Removable Prosthetics
1. Dentures, full or partials, teeth and clasps, limited as follows:
A. Partial dentures are not to be replaced within 60 consecutive month, unless:
i. It is necessary due to natural tooth loss where the addition or replacement of teeth to the existing
partial is not feasible; or
ii. The denture is unsatisfactory and cannot be made satisfactory;
B. Full upper and/or lower dentures are not to be replaced within 60 consecutive months unless the existing
denture is unsatisfactory and cannot be made satisfactory;
C. The covered dental Benefit for complete dentures will be limited to the Benefit level for a standard
procedure. If a more personalized or specialized treatment is chosen by the patient and the Dentist , the
patient will be responsible for all additional charges;
CA−59657−HD 15
28. D. The covered dental Benefit for partial dentures will be limited to the charges for a cast chrome or acrylic
denture if this would satisfactorily restore an arch. If a more elaborate or precision appliance is chosen
by the patient and the Dentist , and is not necessary to satisfactorily restore an arch, the patient will be
responsible for all additional charges;
2. Office or laboratory relines or rebases, limited as follows:
A. One per arch in any 24 consecutive months for a standard procedure;
B. One per arch may be performed during the 6 consecutive months after an immediate procedure. After
this initial period, this Benefit is limited to one per arch in any 24 consecutive months;
3. Denture repair;
4. Denture adjustment;
5. Tissue conditioning.
Orthodontia
1. The basic Benefit shall cover a treatment program and shall include:
A. Start−up records, examination, consultation, x−rays, study models, photographs;
B. Final exam, x−rays, study models, photographs;
C. Post−treatment retention;
2. Interceptive orthodontic treatment shall be a Benefit if, in the opinion of the dental professional and the dental
Carrier alternative interceptive orthodontic treatment would be a more appropriate course of treatment for an
enrollee under the age of 18 than the customary orthodontic program described in (A) above;.
Other Dental Benefits
1. Local anesthetics;
2. Injection of antibiotic drugs.
CA−59657−HD 16
29. LIMITATIONS AND EXCLUSIONS
This policy does NOT provide Benefits and Covered Expenses do NOT include charges for:
1. Procedures, treatment or products which are not necessary for the patient’s dental health. Procedures,
treatments, or products are considered necessary for the patient’s dental health if they are not investigational
and are necessary because:
A. They are appropriate and are provided in accordance with accepted dental care standards in the state of
California, and could not be omitted without adversely affecting the patient’s condition or the quality of
dental care rendered; and
B. If the proposed article or service is not commonly used, its application or proposed application has been
preceded by a thorough review and application of conventional therapies; and
C. The service or article has been demonstrated to be of significantly greater therapeutic value than other,
less expensive, services or articles;
2. Any procedure, service, product, treatment or drug which is either:
A. Experimental or investigational or which is not recognized in accord with generally accepted dental care
standards as being safe and effective for use in the treatment in question; or
B. Outmoded or not efficacious;
3. Treatment for any dental condition arising from or sustained in the course of any occupation or employment
for compensation, profit or gain for which benefits are provided or payable under any Workers’ Compensation
benefit plan;
4. Services related to acts of war, or needed while in the service of the armed forces of any country;
5. Treatments or services provided by persons other than licensed Dentists or licensed dental professional
practicing under the supervision of a licensed Dentist ;
6. Dispensing of drugs which are not normally supplied in dental offices;
7. Hospital charges of any kind;
8. Treatment by any method of any condition of the temporomandibular joint;
9. Elective or Cosmetic Dentistry . This includes personalization or characterization of dentures, porcelain
veneers on molar teeth, and tooth color restorations on molar teeth, but does not include porcelain veneers
on other teeth and tooth color restorations on other teeth;
10. Oral surgery requiring the setting of fractures and dislocations;
11. Orthognathic surgery;
12. Removable orthodontic appliances, and fixed or removable orthodontic retainers, except as provided in the
retention phase of the orthodontia benefit;
13. The replacement of fixed prosthodontics and removable devices that are rendered nonfunctional due to
patient abuse, misuse, or neglect;
14. Replacement of prosthetic devices such as full or partial dentures due to loss or theft;
15. General anesthesia, intravenously administered conscious sedation, or other conscious sedation including
nitrous oxide;
16. Any procedure performed for the purpose of achieving full mouth occlusal equilibration to alter the bite;
CA−59657−HD 17
30. 17. Services or supplies solely to increase vertical dimension. These may include dentures, crowns, inlays and
onlays, fixed bridges or any other appliances or service;
18. Services related to or treatment of malignancies, with the exception of biopsies;
19. Treatment of congenital malformations;
20. Tooth replantation;
21. Supplies used for self−administered services or treatments which are related to dietary counseling, oral
hygiene, plaque control, chemical analysis or saliva;
22. Implants and the removal of implants are not covered Benefits . However, if implants are determined by Us
to be a less costly alternative to a covered Benefit by they may be provided. Removal of an implant provided
as a less costly alternative is a covered Benefit . Replacement of an implant provided as a less costly
alternative is limited to once every 60 consecutive months;
23. Restorations utilizing gold, porcelain, and restorative materials other than amalgam or like material are not
covered Benefits except as specified in Covered Services, Restorative Dentistry, 1.a.;
24. Grafting tissues from outside of the mouth to tissue inside the mouth;
25. Services which are Benefits under the medical insurance portion of the Program ;
26. All charges exceeding those considered usual, customary and reasonable.
EXCESS COVERAGE
No Benefits are payable for any Accidental Injury for which there is other insurance providing payments or
expense coverage, regardless of whether such other coverage is described as primary, excess or contingent.
If Your claim against the other insurer is denied or partially paid, We will process Your claim according to the
terms and conditions of this plan. If payment is made by Us on Your behalf, You agree to assign to Us any right
You have against the other insurer for Dental expenses We pay. Payments made by the other insurer will be
credited toward any applicable Coinsurance or Benefit Year Deductibles .
CA−59657−HD 18
31. COORDINATION OF BENEFITS
If You are covered under any Plans defined herein, Covered Expenses You incur under this Plan will be
coordinated with benefits payable under the other Plans defined herein.
BENEFITS SUBJECT TO THIS PROVISION
Dental Benefits described in this Certificate are coordinated with medical and dental Benefits provided by other
group insurance plans for which You are also covered. This is to prevent the problem of overinsurance and a
resulting increase in the cost of Dental Coverage .
DEFINITIONS
1. Plan
For this purpose a Plan is one which covers medical or dental expenses and provides Benefits or service for:
A. Group, franchise or blanket insurance coverage;
B. Hospital service prepayment plan on a group basis, medical service pre−payment plan on a group basis,
group practice or other pre−payment coverage on a group basis;
C. Any coverage under labor−management, employer plans, trustee plans, union welfare plans, employee
benefit organization plans; and
D. Any coverage under governmental programs, or any coverage mandated by state statute, or sponsored
or provided by an educational institution, if coverage is not otherwise excluded from the calculation of
Benefits under this plan. The term quot;Planquot; does not apply to any individual policies.
The term quot;Planquot; is construed separately with respect to each policy, contract, or other arrangement for Benefits
or services and separately with respect to that portion of any such policy, contract or other arrangement which
reserves the right to take the Benefits or services of other Plans into consideration in determining its Benefits
and that portion which does not.
2. Allowable Expense
Allowable Expense means any necessary, reasonable and customary item of expense at least a portion of
which is covered under at least one of the Plan(s) covering the person for whom claim is made. When a Plan
provides Benefits in the form of services rather than cash payments, the reasonable cash value of each
service rendered will be considered as both an Allowable Expense and a Benefit paid.
3. Claim Determination Period
Claim Determination Period means Benefit Year , except that if in any Benefit Year the person is not covered
under this plan for the full Benefit Year , the Claim Determination Period for that year will be that portion during
which he or she was covered under this plan.
EFFECTS ON BENEFITS
We will apply these provisions when You incur Allowable Expenses during a Claim Determination Period for which
Benefits are payable under any other Plan(s). The provisions will apply only when the sum of the Covered
Expenses under this plan and any other Plan(s) would, in the absence of these Coordination of Benefits
provisions or any similar provisions in the other Plan(s), exceed the Allowable Expenses.
CA−59657−HD 19
32. Benefits provided under this plan during a Claim Determination Period for Allowable Expenses incurred by You
will be determined as follows:
1. If Benefits under this plan are to be paid after Benefits are paid under any other Plan, the Benefits under this
plan will be reduced so that the sum of the Benefits so reduced plus the Benefits payable under all other
Plans will not exceed the total of the Allowable Expenses;
2. If Benefits under this plan are to be paid before Benefits paid under any other Plan, Benefits under this plan
will be paid without regard to the other Plan(s).
Covered Expenses under any other Plan include the Benefits that would have been payable had claim been
made.
Reimbursement will not exceed 100% of the total Allowable Expenses incurred under this plan and any other
Plans included under this provision.
ORDER OF BENEFITS DETERMINATION
For the purpose of the Effect of Benefits Provision above, the rules establishing the Order of Benefits
Determination are:
1. The Benefits of a Plan which covers the person on whose expenses claim is based other than as a
Dependent are determined before the Benefits of a Plan which covers such person as a Dependent .
2. The Benefits of a Plan which covers the person on whose expenses claim is based as a Dependent are
determined according to which parent’s birth date occurs first in a calendar year, excluding year of birth. If he
birth dates of both parents are the same, the Plan which has covered the person for the longer period of time
will be determined first, except if a claim is made for a Dependent child:
A. When parents are separated or divorced and the parent with custody of the child has not remarried, the
Benefits of a Plan which covers the child as a Dependent of the parent with custody of the child are
determined before the Benefits of a Plan which covers the child as a Dependent of the parent without
custody;
B. When parents are divorced and the parent with custody of the child has remarried, the Benefits of a Plan
which covers the child as a Dependent of the parent with custody are determined before the Benefits of
a Plan which covers that child as a Dependent of the step−parent, and the Benefits of a Plan which
covers that child as a Dependent of the step−parent are determined before the Benefits of a Plan which
covers that child as a Dependent of the parent without custody;
C. Notwithstanding provisions quot;Aquot; and quot;Bquot;, if there is a court decree which should otherwise establish
financial responsibility for the medical, dental or other health care expenses with respect to a child, the
Benefits of a Plan which covers the child as a Dependent of the parent with such financial responsibility
are determined before the Benefits of any other Plan which covers the child as a Dependent child.
3. When rules 1. and 2. do not establish an Order of Benefits Determination, the Benefits of a Plan which covers
the person on whose expense claim is based as a laid−off or retired Employee or as the Dependent of such
person are determined after the Benefits of a Plan which covers such person through present employment.
4. When rules 1., 2. and 3. do not establish an Order of Benefits Determination, the Benefits of a Plan which has
covered the person on whose expenses claim is based for the longer period of time are determined before the
Benefits of a Plan which has covered such person the shorter period of time.
5. If the provisions under the other Plan determining the effect of its Coordination of Benefits provision or
exclusion are irreconcilable with the above rules, this plan will waive application of the above rules and
incorporate the rules identical with those of the other Plan.
When these provisions reduce the total amount of Benefits otherwise payable to You under this plan during any
Claim Determination Period, each Benefit that would be payable in the absence of this provision is reduced
proportionately and such reduced amounts are charged against any applicable Benefit limit of this plan.
CA−59657−HD 20
33. RIGHT TO NECESSARY INFORMATION
We may require certain information in order to apply and coordinate these provisions with other Plans. To get the
needed information, We, without Your consent, will release or obtain from any insurance company, organization
or person information needed to implement this provision. You agree to furnish any information We need to apply
these provisions.
COORDINATION OF BENEFITS WITH MEDICARE
In all cases, Coordination of Benefits with Medicare will conform with Federal Statutes and Regulations.
If You are eligible for Medicare Benefits , but not necessarily enrolled, Your Benefits under this plan will be
coordinated to the extent Benefits otherwise would have been payable under Medicare as allowed by Federal
Statutes and Regulations.
Medicare means Title XVIII, Parts A and B of the Social Security Act, as enacted or amended.
FACILITY OF PAYMENT
Payments made under any other Plan which according to these provisions should have been made by Us will be
adjusted by Us . To do this, We reserve the sole right to pay the organization(s) which made such payments the
amount(s) the Company determines to be warranted. Any amount(s) so paid are regarded as Benefits paid
under this plan. We will be fully discharged from liability under this plan to the extent of any payment so made.
RIGHT OF RECOVERY
We reserve the right to recover Benefit payment made for an Allowable Expense under this plan in the amount
by which the payments exceed the maximum amount We are required to pay under these provisions. This right
of recovery applies to Us against:
1. Any person(s) to, for or respect to whom such payments were made; or
2. Any other insurance companies or organizations which according to these provisions owe Benefits for the
same Allowable Expense under any other Plan.
We alone shall determine against whom this right of recovery will be exercised.
CA−59657−HD 21
34. GENERAL PROVISIONS
HOW TO FILE YOUR CLAIM
You have received an identification (I.D.) card from Your Participating Employer which shows Your name, Your
I.D. number, and Your group number.
You must show Your I.D. card to Your Dentist . Request that Your bills be submitted to Us on any approved claim
form.
NOTICE OF CLAIM
Written notice of claim must be given to Us within 30 days after the Expense Incurred Date or as soon thereafter
as is reasonably possible. Notice must be given to Us at Our address shown on the Certificate cover page.
Notice must include the Enrolled Employee’s name, the name of the Covered Person who incurred the
expense, the Participating Employer’s name and group I.D. number. The notice must be signed and dated.
PROOFS OF LOSS
You must give written proof of loss to Us within 90 days after the Expense Incurred Date .
In order for Us to determine Benefits payable, We may require any of the following:
1. A complete dental chart showing:
A. Extractions;
B. Missing teeth;
C. Fillings;
D. Prosthesis;
E. Periodontal pocket depths;
F. The date of any work previously performed.
2. An itemized bill for all dental work.
3. The following exhibits:
A. X−rays;
B. Study models;
C. Laboratory and/or reports.
4. A dental examination at Our expense by a Dentist of Our choice.
5. Any additional information We need to determine Benefits .
Benefits will not be paid until We receive the information required. Your claim will not be reduced or denied if it
was not reasonably possible to give such proof within 90 days. In any event, written notice must be given within
one year after the date proof of loss is otherwise required, except if You were legally incapacitated.
CA−59657−HD 22
35. TIME OF BENEFIT PAYMENT
We will pay all Benefits due under this plan promptly upon receipt of written proof of loss.
PAYMENT OF BENEFITS
We may pay all or a portion of any Benefits provided for dental services to the provider, unless You direct
otherwise in writing at the time proof of loss is filed.
APPEAL PROCEDURE
If We partially or fully deny a claim for Benefits submitted by You , and You disagree or do not understand the
reasons for this denial, or, if You are dissatisfied with any action or inaction by Us . You may file an appeal. You
have the right to:
1. Request a review of the denial, action, or inaction;
2. Review pertinent plan documents; and
3. Submit in writing, any data, documents or comments which are relevant to Your appeal.
Your appeal must be submitted in writing within 60 days of the action or inaction or of receiving written notice of
denial. We will respond to You within 10 days and review all information and send written notification of Our
decision within 60 days of Your request.
If You are dissatisfied with any other decisions that are made relative to Your coverage, You need to notify Us in
writing of Your appeal. Upon written notification, persons superior to the individual rendering the original decision
will review all information pertinent to the decision and respond to You within 10 days. If We are unable to
adequately respond to you within 10 days due to the need to obtain additional information, We will send a written
notice informing You of the delay.
APPEALS THAT ARISE OUT OF PROGRAM DECISIONS ON ENROLLMENT, ELIGIBILITY OR PREMIUM
PAYMENT SHOULD BE ADDRESSED TO THE PROGRAM WITHIN 60 DAYS OF THE DECISION.
For information on how to file a written appeal, call Pacific Health Advantage toll free at 1−877−4PACADV or write
to:
Pacific Health Advantage
PO Box 619027
Roseville, CA 95661
RIGHT TO RECOVER OVERPAYMENTS
We reserve the right to recover any payments made by Us that were made in error or payments that are greater
than You are entitled to under this Coverage .
LEGAL ACTIONS
You cannot bring an action at law or equity to recover a claim until 60 days after the date written proof of loss is
made. No action may be brought more than three years after such proof of loss is made.
WORKERS’ COMPENSATION NOT AFFECTED
This plan is not issued in lieu of, nor does it affect any requirement for coverage by any Workers’ Compensation
or Occupational Disease Act or Law.
CA−59657−HD 23
36. WORKERS’ COMPENSATION
This plan contains a limitation which states that no Benefits are payable for any expense arising from or
sustained in the course of any occupation or employment for compensation, profit or gain.
If Benefits are paid by Us and We determine You received Workers’ Compensation for the same incident, We
have the right to recover as described under the quot;Recovery Rightsquot; provision. We will exercise Our right to
recover against You .
CA−59657−HD 24
37. RECOVERY RIGHTS
RIGHT OF REIMBURSEMENT
If Benefits are paid under this plan and You or Your covered dependent recovers from a responsible third party
by settlement, judgment or otherwise, We have a right to recover from You or Your covered dependent an
amount equal to the amount We paid.
ASSIGNMENT OF RECOVERY RIGHTS
If You file a claim against another insurer for Dental Payment/Expense coverage provided or payable under any
automobile, homeowner’s premises or other similar coverage and Your claim against the other insurer is denied
or partially paid, We will process Your claim according to the terms and conditions of this plan. If payment is made
by Us on Your behalf, You agree to assign to Us any right You have against the other insurer for dental expenses
We pay.
CA−59657−HD 25
39. PREFERRED PROVIDER ORGANIZATION RIDER
This Rider amends the Certificate. The effective date of this change is the effective date of the Certificate. Except
as modified below, all Policy terms, conditions and limitations apply.
DEFINITIONS
Customary, Usual and Reasonable/Maximum Allowable Fee is removed in its entirety and replaced with the
following:
MAXIMUM ALLOWABLE FEE
Maximum Allowable Fee means the predetermined level agreed to by Participating Preferred Dentists.
Wherever Customary, Usual and Reasonable/Maximum Allowable Fee appears in this Certificate, it is
removed and replaced with Maximum Allowable Fee, as defined above.
PREFERRED PROVIDER ORGANIZATION
PROVISIONS
WHAT IS A PREFERRED PROVIDER ORGANIZATION?
Preferred Provider Organization (PPO) are networks of Dentists that are contracted to furnish, at negotiated fees,
dental services for Enrolled Employees (and their covered Dependents ) of Participating Employers .
REASONS TO USE A PPO PROVIDER
1. We negotiate fees for dental services. The negotiated fees lower costs for You when You use Dentists in the
PPO.
2. In addition, You may receive a better benefit and Your out−of−pocket expenses will be minimized.
3. You will have a wide variety of selected Dentists in the PPO to help You with Your dental care needs.
In order to avoid reduced Benefit payments, obtain Your dental care from Preferred Providers whenever
possible. However, the choice of provider is Yours.
HOW TO SELECT A PROVIDER
A list of the participating Dentists in Your PPO will be given to You at the time Your coverage becomes effective.
This list is subject to change. To confirm that Your Dentist is a current participant in Your PPO, You must call the
number listed on the back of Your dental identification card.
If You are traveling or need emergency care and care unable to access care from Your PPO provider, Benefits
will be paid at the Non−Preferred Provider level.
GERALD L. GANONI
PRESIDENT
CA−59657−HD NEG PPO 27
43. Notices
The following pages contain important information about Humana’s
claims procedures and certain federal laws
This section includes notices about:
Claims Procedures
Discretionary Authority
Appeals of Adverse Determinations
Medical Child Support Orders
Consolidated Omnibus Budget Reconciliation Act (COBRA)
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)
Family and Medical Leave Act (FMLA)
Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA)
44. CLAIMS PROCEDURES
Notwithstanding any provisions in the group insurance policy, HMO contract or certificate of coverage, the
following are the minimum claims procedures employed by Humana with respect to plans governed by the
Employee Retirement Income Security Act of 1974, as amended (quot;ERISAquot;). Covered persons in insured plans
subject to ERISA should also consult their insurance benefit plan documents (e.g., the Certificate of Insurance or
Evidence of Coverage). Humana will comply with the requirements set forth in any such benefit plan document
issued by it with respect to the plan unless doing so would prevent compliance with the requirements of the
federal ERISA statute and the regulations issued thereunder. The following claims procedures are intended to
comply with the ERISA claims regulation, and should be interpreted consistent with the minimum requirements of
that regulation. Covered persons in plans not subject to ERISA should consult their benefit plan documents for
the applicable claims and appeals procedures.
DISCRETIONARY AUTHORITY
With respect to paying claims for benefits or determining eligibility for coverage under a policy issued by Humana,
Humana as administrator for claims determinations and as ERISA claims review fiduciary, shall have full and
exclusive discretionary authority to: 1) interpret plan provisions, 2) make decisions regarding eligibility for
coverage and benefits, and 3) resolve factual questions relating to coverage and benefits.
CLAIMS PROCEDURES
Definitions
Claimant: A covered person (or authorized representative) who files a claim.
Concurrent−care Decision: A decision by the plan to reduce or terminate benefits otherwise payable for a
course of treatment that has been approved by the plan (other than by plan amendment or termination) or a
decision with respect to a request by a Claimant to extend a course of treatment beyond the period of time or
number of treatments that has been approved by the plan.
Group health plan: an employee welfare benefit plan to the extent the plan provides dental care to employees
or their dependents directly (self insured) or through insurance (including HMO plans), reimbursement or
otherwise.
Health insurance issuer: the offering company listed on the face page of your Certificate of Insurance or
Certificate of Coverage and referred to in this document as quot;Humana.quot;
Post−service Claim: Any claim for a benefit under a group health plan that is not a Pre−service Claim.
Pre−service Claim: A request for authorization of a benefit for which the plan conditions receipt of the benefit,
in whole or in part, on advance approval.
Urgent−care Claim (expedited review): A claim for covered services to which the application of the time
periods for making non−urgent care determinations:
could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain
maximum function; or
in the opinion of a physician with knowledge of the covered person’s medical condition, would subject the
covered person to severe pain that cannot be adequately managed without the service that is the subject of
the claim.
Humana will make a determination of whether a claim is an Urgent−care Claim. However, any claim a
physician, with knowledge of a covered person’s medical condition, determines is a quot;Urgent−care Claimquot; will
be treated as a quot;claim involving urgent care.quot;
2
45. Submitting a Claim
This section describes how a Claimant files a claim for plan benefits.
A claim must be filed in writing and delivered by mail, postage prepaid, by FAX or e−mail. A request for
pre−authorization may be filed by telephone. The claim or request for pre−authorization must be submitted to
Humana or to Humana’s designee at the address indicated in the covered person’s benefit plan document or
identification card. Claims will be not be deemed submitted for purposes of these procedures unless and until
received at the correct address.
Claims submissions must be in a format acceptable to Humana and compliant with any legal requirements.
Claims not submitted in accordance with the requirements of applicable federal law respecting privacy of
protected health information and/or electronic claims standards will not be accepted by Humana.
Claims submissions must be timely. Claims must be filed as soon as reasonably possible after they are incurred,
and in no event later than the period of time described in the benefit plan document.
Claims submissions must be complete and delivered to the designated address. At a minimum they must include:
Name of the covered person who incurred the covered expense.
Name and address of the provider
Diagnosis
Procedure or nature of the treatment
Place of service
Date of service
Billed amount
A general request for an interpretation of plan provisions will not be considered a claim. Requests of this type,
such as a request for an interpretation of the eligibility provisions of the plan, should be directed to the plan
administrator.
Procedural Defects
If a Pre−service Claim submission is not made in accordance with the plan’s requirements, Humana will notify the
Claimant of the problem and how it may be remedied within five (5) days (or within 24 hours, in the case of an
Urgent−care Claim). If a Post−service Claim is not made in accordance with the plan’s requirement, it will be
returned to the submitter.
Authorized Representatives
A covered person may designate an authorized representative to act on his or her behalf in pursuing a benefit
claim or appeal. The authorization must be in writing and authorize disclosure of health information. If a
document is not sufficient to constitute designation of an authorized representative, as determined by Humana,
the plan will not consider a designation to have been made. An assignment of benefits does not constitute
designation of an authorized representative.
3
46. Any document designating an authorized representative must be submitted to Humana in advance or at the
time an authorized representative commences a course of action on behalf of the covered person. Humana
may verify the designation with the covered person prior to recognizing authorized representative status.
In any event, a health care provider with knowledge of a covered person’s medical condition acting in
connection with an Urgent−care Claim will be recognized by the plan as the covered person’s authorized
representative.
Covered persons should carefully consider whether to designate an authorized representative. Circumstances
may arise under which an authorized representative may make decisions independent of the covered person,
such as whether and how to appeal a claim denial.
Claims Decisions
After a determination on a claim is made, Humana will notify the Claimant within a reasonable time, as follows:
Pre−service Claims
Humana will provide notice of a favorable or adverse determination within a reasonable time appropriate to the
medical circumstances but no later than 15 days after the plan receives the claim.
This period may be extended by an additional 15 days , if Humana determines the extension is necessary due to
matters beyond the control of the plan. Before the end of the initial 15−day period, Humana will notify the Claimant
of the circumstances requiring the extension and the date by which Humana expects to make a decision.
If the reason for the extension is because Humana does not have enough information to decide the claim, the
notice of extension will describe the required information, and the Claimant will have at least 45 days from the date
the notice is received to provide the necessary information.
Urgent−care Claims (expedited review)
Humana will determine whether a particular claim is an Urgent−care Claim. This determination will be based on
information furnished by or on behalf of a covered person. Humana will exercise its judgment when making the
determination with deference to the judgment of a physician with knowledge of the covered person’s condition.
Humana may require a Claimant to clarify the medical urgency and circumstances supporting the Urgent−care
Claim for expedited decision−making.
Notice of a favorable or adverse determination will be made by Humana as soon as possible, taking into account
the medical urgency particular to the covered person’s situation, but not later than 72 hours after receiving the
Urgent−care Claim.
If a claim does not provide sufficient information to determine whether, or to what extent, services are covered
under the plan, Humana will notify the Claimant as soon as possible, but not more than 24 hours after receiving
the Urgent−care Claim. The notice will describe the specific information necessary to complete the claim. The
Claimant will have a reasonable amount of time, taking into account the covered person’s circumstances, to
provide the necessary information −but not less than 48 hours .
Humana will provide notice of the plan’s Urgent−care Claim determination as soon as possible but no more than
48 hours after the earlier of:
The plan receives the specified information; or
The end of the period afforded the Claimant to provide the specified additional information.
4
47. Concurrent−care Decisions
Humana will notify a Claimant of a Concurrent−care Decision involving a reduction or termination of pre−authorized
benefits sufficiently in advance of the reduction or termination to allow the Claimant to appeal and obtain a
determination.
Humana will decide Urgent−care Claims involving an extension of a course of treatment as soon as possible
taking into account medical circumstances. Humana will notify a Claimant of the benefit determination, whether
adverse or not, within 24 hours after the plan receives the claim, provided the claim is submitted to the plan 24
hours prior to the expiration of the prescribed period of time or number of treatments.
Post−service Claims
Humana will provide notice of a favorable or adverse determination within a reasonable time appropriate to the
medical circumstances but no later than 30 days after the plan receives the claim.
This period may be extended an additional 15 days , if Humana determines the extension is necessary due to
matters beyond the plan’s control. Before the end of the initial 30−day period, Humana will notify the affected
Claimant of the extension, the circumstances requiring the extension and the date by which the plan expects to
make a decision.
If the reason for the extension is because Humana does not have enough information to decide the claim, the
notice of extension will describe the required information, and the Claimant will have at least 45 days from the date
the notice is received to provide the specified information. Humana will make a decision on the earlier of the date
on which the Claimant responds or the expiration of the time allowed for submission of the requested information.
Initial Denial Notices
Notice of a claim denial (including a partial denial) will be provided to Claimants by mail, postage prepaid, by FAX
or by e−mail, as appropriate, within the time frames noted above. With respect to adverse decisions involving
Urgent−care Claims, notice may be provided to Claimants orally within the time frames noted above. If oral notice
is given, written notification must be provided no later than 3 days after oral notification.
A claims denial notice will convey the specific reason for the adverse determination and the specific plan
provisions upon which the determination is based. The notice will also include a description of any additional
information necessary to perfect the claim and an explanation of why such information is necessary. The notice
will disclose if any internal plan rule, protocol or similar criterion was relied upon to deny the claim. A copy of the
rule, protocol or similar criterion will be provided to Claimants, free of charge, upon request.
The notice will describe the plan’s review procedures and the time limits applicable to such procedures, including
a statement of the Claimant’s right to bring a civil action under ERISA Section 502(a) following an adverse benefit
determination on review.
If an adverse determination is based on medical necessity, experimental treatment or similar exclusion or
limitation, the notice will state that an explanation of the scientific or clinical basis for the determination will be
provided, free of charge, upon request. The explanation will apply the terms of the plan to the covered person’s
medical circumstances.
In the case of an adverse decision of an Urgent−care Claim, the notice will provide a description of the plan’s
expedited review procedures.
5
48. APPEALS OF ADVERSE DETERMINATIONS
A Claimant must appeal an adverse determination within 180 days after receiving written notice of the denial (or
partial denial). An appeal may be made by a Claimant by means of written application to Humana, in person, or
by mail, postage prepaid.
A Claimant, on appeal, may request an expedited appeal of an adverse Urgent−care Claim decision orally or in
writing. In such case, all necessary information, including the plan’s benefit determination on review, will be
transmitted between the plan and the Claimant by telephone, facsimile, or other available similarly expeditious
method, to the extent permitted by applicable law.
Determination of appeals of denied claims will be conducted promptly, will not defer to the initial determination and
will not be made by the person who made the initial adverse claim determination or a subordinate of that person.
The determination will take into account all comments, documents, records, and other information submitted by
the Claimant relating to the claim.
On appeal, a Claimant may review relevant documents and may submit issues and comments in writing. A
Claimant on appeal may, upon request, discover the identity of medical or vocational experts whose advice was
obtained on behalf of the plan in connection with the adverse determination being appealed, as permitted under
applicable law.
If the claims denial is based in whole, or in part, upon a medical judgment, including determinations as to whether
a particular treatment, or other service is experimental, investigational, or not medically necessary or appropriate,
the person deciding the appeal will consult with a health care professional who has appropriate training and
experience in the field of medicine involved in the medical judgment. The consulting health care professional will
not be the same person who decided the initial appeal or a subordinate of that person.
Time Periods for Decisions on Appeal
Appeals of claims denials will be decided and notice of the decision provided as follows:
Urgent−care Claims As soon as possible but no later than 72 hours after Humana receives the appeal
request.
Pre−service Claims Within a reasonable period but no later than 30 days after Humana receives the
appeal request.
Post−service Claims Within a reasonable period but no later than 60 days after Humana receives the
appeal request
Concurrent−care Within the time periods specified above depending on the type of claim involved.
Decisions
Appeals Denial Notices
Notice of a claim denial (including a partial denial) will be provided to Claimants by mail, postage prepaid, by FAX
or by e−mail, as appropriate, within the time periods noted above.
A notice that a claim appeal has been denied will include:
The specific reason or reasons for the adverse determination.
Reference to the specific plan provision upon which the determination is based.
If any internal plan rule, protocol or similar criterion was relied upon to deny the claim. A copy of the rule,
protocol or similar criterion will be provided to the Claimant, free of charge, upon request.
6
49. A statement describing any voluntary appeal procedures offered by the plan and the claimant’s right to obtain
the information about such procedures, and a statement about the Claimant’s right to bring an action under
section 502(a) of ERISA.
If an adverse determination is based on medical necessity, experimental treatment or similar exclusion or
limitation, the notice will state that an explanation of the scientific or clinical basis for the determination will be
provided, free of charge, upon request. The explanation will apply the terms of the plan to the covered
person’s medical circumstances.
In the event an appealed claim is denied, the Claimant, will be entitled to receive without charge reasonable
access to, and copies of, any documents, records or other information that:
Was relied upon in making the 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 in making the
determination.
Constitutes a statement of policy or guidance with respect to the plan concerning the denied treatment option
or benefit for the claimant’s diagnosis, without regard to whether the statement was relied on in making the
benefit determination.
EXHAUSTION
Upon completion of the appeals process under this section, a Claimant will have exhausted his or her
administrative remedies under the plan. If Humana fails to complete a claim determination or appeal within the
time limits set forth above, the claim shall be deemed to have been denied and the Claimant may proceed to the
next level in the review process.
After exhaustion, a Claimant may pursue any other legal remedies available, which may include bringing civil
action under ERISA section 502(a) for judicial review of the plan’s determination. Additional information may be
available from the local U.S. Department of Labor Office.
LEGAL ACTIONS AND LIMITATIONS
No lawsuit may be brought with respect to plan benefits until all remedies under the plan have been exhausted.
No lawsuit with respect to plan benefits may be brought after the expiration of the applicable limitations period
stated in the benefit plan document. If no limitation is stated in the benefit plan document, then no such suit may
be brought after the expiration of the applicable limitations under applicable law.
7
50. MEDICAL CHILD SUPPORT ORDERS
An individual who is a child of a covered employee shall be enrolled for coverage under the group health plan in
accordance with the direction of a Qualified Medical Child Support Order (QMCSO) or a National Medical Support
Notice (NMSO).
A QMCSO is a state−court order or judgment, including approval of a settlement agreement that: (a) provides for
support of a covered employee’s child; (b) provides for health care coverage for that child; (c) is made under state
domestic relations law (including a community property law); (d) relates to benefits under the group health plan;
and (e) is quot;qualified,quot; i.e., it meets the technical requirements of ERISA or applicable state law. QMCSO also
means a state court order or judgment enforcing state Medicaid law regarding medical child support required by
the Social Security Act section 1908 (as added by Omnibus Budget Reconciliation Act of 1993).
An NMSO is a notice issued by an appropriate agency of a state or local government that is similar to a QMCSO
requiring coverage under the group health plan for a dependent child of a non−custodial parent who is (or will
become) a covered person by a domestic relations order providing for health care coverage.
Procedures for determining the qualified status of medical child support orders are available at no cost upon
request from the plan administrator.
CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT OF 1985 (COBRA)
On April 7, 1986, the Consolidated Omnibus Budget Reconciliation Act (COBRA) was signed into law. This
federal law applies to employers with 20 or more employees. The law requires employers offer qualified
beneficiaries temporary continuation of medical and dental coverage at group rates in certain instances where
there is a loss of group health insurance coverage due to a qualifying event.
A qualified beneficiary is an employee, employee’s spouse, or dependent child covered under the group health
plan on the day before the qualifying event. A former employee who is covered under the group health plan may
be a qualified beneficiary if coverage is provided in whole or in part because of his or her previous employment.
A child born to the covered employee or placed for adoption with the covered employee during the COBRA
continuation period may also be a qualified beneficiary.
Qualifying Events
Covered employees can elect to continue coverage if coverage is lost due to any of the following qualifying
events:
Termination of the employee’s employment for reasons other than gross misconduct;
Reduction in the employee’s hours of employment with the employer; or,
For a covered employee who is retired, the employer’s bankruptcy (Title 11).
A covered spouse of a covered employee can elect continuation if coverage is lost due to any of the following
qualifying events:
Death of the employee;
Termination of the employee’s employment for reasons other than gross misconduct;
Reduction in the employee’s hours of employment with the employer;
Divorce or legal separation from the employee;
Coverage of the employee under Medicare becoming effective; or,
For the spouse of a covered employee who is retired, the employer’s bankruptcy (Title 11).
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51. A covered dependent child has the right to elect continuation if coverage is lost due to any of the following
qualifying events:
Death of the employee parent;
Termination of the employee parent’s employment for reasons other than gross misconduct;
Reduction in the employee’s hours of employment with the employer;
Parent’s divorce or legal separation;
Coverage of the employee parent under Medicare becoming effective;
The dependent ceasing to be a quot;dependent childquot; under the terms of the Group Health Plan; or,
For the dependent of a covered employee who is retired, the employer’s bankruptcy (Title 11).
Loss of Coverage
As used in this provision, quot;loss of coveragequot; means a covered employee, spouse, or dependent child ceases to
be covered under the same group health plan terms and conditions as were in effect immediately before the
qualifying event. Loss of coverage includes any increase in the premium or contribution that must be paid for
employee, spouse, or dependent child coverage under the Group Health Plan as a result of the occurrence of a
qualifying event.
If the qualifying event is bankruptcy of the employer, quot;loss of coveragequot; also means any substantial elimination of
coverage under the employer−sponsored health plan, occurring within 12 months before or after the date the
bankruptcy proceeding commences. This applies to a covered employee who has retired on or before the date
of the substantial elimination of group health plan coverage.
If coverage is reduced or eliminated in anticipation of an event (for example, an employer’s eliminating an
employee’s coverage in anticipation of the termination of the employee’s employment, or an employee’s
eliminating the coverage of his or her spouse in anticipation of a divorce or legal separation), the reduction or
elimination is disregarded in determining whether the event causes a loss of coverage. If an employee
discontinues the coverage of a spouse in anticipation of a divorce or legal separation, the actual divorce or
separation will be considered a qualifying event.
A loss of coverage need not occur immediately after the event, so long as it occurs before the end of the
maximum coverage period.
Notification and Election
Each covered employee or other qualified beneficiary has the responsibility to inform the plan administrator of a
divorce, legal separation, or a child losing dependent status under the group health plan. The covered employee
or qualified beneficiary must give this notice within 60 days from the later of the date of the qualifying event or the
date coverage would be lost under the terms of the group health plan. If this notice is not given in a timely manner
the option of electing continuation coverage is forfeited. Under the COBRA statute, the employer is required to
notify the plan administrator of qualifying events that are terminations or reduction in hours, death, Medicare
entitlement and bankruptcy.
If, during the COBRA continuation period, a child is born or placed for adoption, the child is considered a qualified
beneficiary. The covered employee on continuation or other guardian may elect continuation coverage for the
child provided the child satisfies the otherwise applicable group health plan eligibility requirements (for example:
age). The covered employee or qualified beneficiary must notify the plan administrator within 31 days of the birth
or placement to enroll the child. Failure to do so may result in the loss of the right to cover the child under
continuation coverage.
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52. Upon timely notification of the qualifying event, the plan administrator is obligated under the COBRA statute to
notify qualified beneficiaries of the right to elect COBRA continuation coverage. A qualified beneficiary must take
action to become entitled to continuation of coverage. The qualified beneficiary must elect continuation coverage
within 60 days of the later of:
The date coverage is lost; or,
The date that notice of COBRA continuation rights is sent to the qualified beneficiary.
Qualified beneficiaries not electing continuation coverage within the 60−day election period lose the right to
continue coverage under COBRA. An election is considered to be made on the date the election is sent to the
plan administrator.
Each qualified beneficiary has an independent right to elect COBRA continuation coverage. However, a covered
employee or the covered employee’s spouse may elect continuation coverage on behalf of another qualified
beneficiary. An election on behalf of a minor child can be made by the child’s parent or legal guardian.
Premium and Coverage
If continuation coverage is elected and the applicable premium is paid, the continuation coverage will be identical
to the coverage provided under the group health plan to similarly situated active employees and/or their covered
dependents. If coverage is changed or modified for active employees, then continuation coverage will be
changed or modified for individuals on continuation. Additionally, qualified beneficiaries have the same open
enrollment and special enrollment rights as similarly situated active employees.
New family members, other than newborn children or children placed for adoption, added to the coverage by the
qualified beneficiary on or after the date of the qualifying event do not themselves become qualified beneficiaries.
As such, coverage for these family members is generally dependent upon the coverage selection activity of the
qualified beneficiary.
If the qualified beneficiary is covered by an employer−sponsored medical plan and an employer−sponsored dental
plan, s/he may elect continuation under one plan or both plans.
If the qualified beneficiary is participating in a region−specific benefit plan, and moves outside of the service area
for the region−specific coverage, the qualified beneficiary will have the opportunity to elect alternative coverage
made available by the employer, if such coverage is available to active employees.
The individual continuing COBRA coverage is responsible for ensuring the timely payment of COBRA premiums.
In addition to the applicable premium, a 2% administration fee may be charged. Information regarding premium
amounts and payment responsibilities can be obtained from the plan administrator.
The initial premium payment is due by the 45 th day after the date continuation coverage is elected. The initial
premium payment must include charges back to the date continuation coverage began (the date of loss of
coverage). Subsequent premiums are due monthly on the first day of each month for which premium is payable,
subject to a 31 day grace period.
Duration of Coverage
The maximum coverage period for a spouse and dependent children is 36 months from the date of the qualifying
event if coverage is lost due to:
The death of the covered employee;
Divorce or legal separation;
Coverage of the employee under Medicare becoming effective; or,
The loss of dependent status under the group health plan.
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53. If coverage is lost due to the covered employee’s termination of employment for reasons other than gross
misconduct or reduction in hours, the maximum continuation period for the employee, spouse and dependent
children is 18 months from the date of the qualifying event. There are two exceptions to this 18−month
continuation period:
If a qualified beneficiary is determined under the Social Security Act to have been disabled at any time during
the first 60 days of continuation, the continuation period for all qualified beneficiaries is 29 months from the
date of the qualifying event. For the 29 month continuation period to apply, notice of the determination of
disability under the Social Security Act must be provided by the disabled individual to the plan administrator
within the initial 18 month continuation period but no later than 60 days after the date of the determination.
During the extended period of continuation (11 months), up to 150% of the applicable premium may be
charged.
If a second qualifying event, such as the death of the employee, occurs within the 18 month or 29 month
continuation period, the maximum coverage period becomes 36 months from the date of the initial
termination or reduction in hours for those individuals who:
* Were qualified beneficiaries under the group health plan in connection with the initial qualifying event;
and,
* Are still qualified beneficiaries at the time of the second qualifying event.
There is a special rule when coverage of the covered employee under Medicare becomes effective prior to an
initial qualifying event that is termination of employment or reduction of hours. If coverage of the employee under
Medicare is effective prior to the initial qualifying event, the period of continuation for other qualified beneficiaries
is the later of:
36 months from the effective date of the employee’s Medicare coverage;
18 months from the date of the qualifying event; or,
29 months from the date of the qualifying event if the continuation coverage is subject to a disability extension.
If coverage of the covered employee under Medicare becomes effective within the initial continuation period
following an initial qualifying event, the other qualified beneficiaries may be entitled to continuation not to exceed
36 months from the date of the initial qualifying event.
If the qualifying event for continued coverage is the bankruptcy of the employer, the maximum coverage period for
a qualified beneficiary who is the retired covered employee ends on the date of the retired covered employee’s
death. The maximum coverage period for a qualified beneficiary who is the spouse, surviving spouse, or
dependent child of the retired covered employee ends on the earlier of:
The date of the qualified beneficiary’s death; or,
The date that is 36 months after the death of the retired covered employee.
If the qualified beneficiary is a newborn child or a child placed for adoption during the continuation period, the
qualifying event for that child is the event that initiated the parent’s COBRA continuation during which the child was
born or placed for adoption. The maximum coverage period for the child is measured from the date of the
qualifying event that initiated COBRA continuation.
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54. Termination of COBRA Continuation Coverage
COBRA continuation coverage may be terminated prior to the end of the maximum continuation period when:
Premiums are not paid timely;
The employer ceases to maintain a group health plan;
The qualified beneficiary obtains coverage under another group health plan:
* That does not contain any exclusion or limitation with respect to any pre−existing condition the individual
has; or,
* When the exclusion or limitation no longer applies, if such plan has an applicable exclusion or limitation.
(An exclusion or limitation of the new plan may not apply at all depending on the length of the individual’s
prior creditable coverage under the previous plan(s). Federal law requires that once an individual obtains
creditable health insurance, evidence of this coverage can be used to reduce or eliminate any
pre−existing medical condition exclusion or limitation period that might otherwise apply under the new
health insurance coverage.);
Coverage of the qualified beneficiary under Medicare becomes effective (even if entitlement is based on end
stage renal disease);
Coverage has been extended due to disability and the qualified beneficiary is no longer disabled as
determined by the Social Security Administration. COBRA coverage for all qualified beneficiaries covered
under the disability extension will terminate on the later of:
* The first day of the month that is more than 30 days after the date of the final agency determination that
the qualified beneficiary is no longer disabled; or,
* The end of the coverage period that applies without regard to the disability extension.
Any event occurs that would permit termination of coverage for cause under the Group Health Plan, such as
submission of a fraudulent claim.
Other Information
Please contact the plan administrator for any questions regarding COBRA continuation. Notify the plan
administrator of any change in marital status, or a change of address.
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55. IMPORTANT NOTICE FOR INDIVIDUALS ENTITLED TO MEDICARE TAX EQUITY AND FISCAL
RESPONSIBILITY ACT OF 1982 (TEFRA) OPTIONS
Where an employer employs more than 20 people, the Tax Equity And Fiscal Responsibility Act of 1982 (TEFRA)
allows covered employees in active service who are age 65 or older and their covered spouses who are eligible
for Medicare to choose one of the following options.
OPTION 1 − The benefits of their group health plan will be payable first and the benefits of Medicare will be
payable second.
OPTION 2 − Medicare benefits only. The employee and his or her dependents, if any, will not be insured by the
group health plan.
The employer must provide each covered employee and each covered spouse with the choice to elect one of
these options at least one month before the covered employee or the insured spouse becomes age 65. All new
covered employees and newly covered spouses age 65 or older must be offered these options. If Option 1 is
chosen, its issue is subject to the same requirements as for an employee or dependent that is under age 65.
Under TEFRA regulations, there are two categories of persons eligible for Medicare. The calculation and payment
of benefits by the group health plan differs for each category.
Category 1 Medicare eligibles are:
Covered employees in active service who are age 65 or older who choose Option 1;
Age 65 or older covered spouses; and
Age 65 or older covered spouses of employees in active service who are either under age 65 or age 70 or
older;
Category 2 Medicare eligibles are any other covered persons entitled to Medicare, whether or not they enrolled.
This category includes, but is not limited to:
Retired employees and their spouses; or
Covered dependents of a covered employee, other than his or her spouse.
Calculation and Payment of Benefits
For covered persons in Category 1, benefits are payable by the policy without regard to any benefits payable by
Medicare. Medicare will then determine its benefits.
For covered persons in Category 2, Medicare benefits are payable before any benefits are payable by the policy.
The benefits of the policy will then be reduced by the full amount of all Medicare benefits the covered person is
entitled to receive, whether or not the eligible individual is actually enrolled for Medicare Benefits.
FAMILY AND MEDICAL LEAVE ACT (FMLA)
If an employee is granted a leave of absence (Leave) by the employer as required by the Federal Family and
Medical Leave Act, s/he may continue to be covered under the plan for the duration of the Leave under the same
conditions as other employees who are currently employed and covered by the plan. If the employee chooses to
terminate coverage during the Leave, or if coverage terminates as a result of nonpayment of any required
contribution, coverage may be reinstated on the date the employee returns to work immediately following the end
of the Leave. Charges incurred after the date of reinstatement will be paid as if the employee had been
continuously covered.
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56. UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT OF 1994 (USERRA)
Continuation of Benefits
Effective October 13, 1994, federal law requires health plans offer to continue coverage for employees that are
absent due to service in the uniformed services and/or dependents.
Eligibility
An employee is eligible for continuation under USERRA if he or she is absent from employment because of
voluntary or involuntary performance of duty in the Armed Forces, Army National Guard, Air National Guard, or
commissioned corps of the Public Health Service. Duty includes absence for active duty, active duty for training,
initial active duty for training, inactive duty training and for the purpose of an examination to determine fitness for
duty.
An employee’s dependents that have coverage under the plan immediately prior to the date of the employee’s
covered absence are eligible to elect continuation under USERRA.
If continuation of Plan coverage is elected under USERRA, the employee or dependent is responsible for
payment of the applicable cost of coverage. If the employee is absent for not longer than 31 days, the cost will be
the amount the employee would otherwise pay for coverage. For absences exceeding 31 days, the cost may be
up to 102% of the cost of coverage under the plan. This includes the employee’s share and any portion previously
paid by the employer.
Duration of Coverage
Of elected, continuation coverage under USERRA will continue until the earlier of:
1. Eighteen months beginning the first day of absence from employment due to service in the uniformed
services; or
2. The day after the employee fails to apply for a return to employment as required by USERRA, after the
completion of a period of service.
Under federal law, the period coverage available under USERRA shall run concurrently with the COBRA period
available to an employee and/or eligible dependent.
Other Information
Employees should contact their employer with any questions regarding coverage normally available during a
military leave of absence or continuation coverage and notify the employer of any changes in marital status, or
change of address.
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