Wentworth Institute of Technology, Inc. CIGNA DENTAL PREFERRED PROVIDER INSURANCE
EFFECTIVE DATE: January 1, 2012
This document printed in November, 2011 takes the place of any documents previously issued to you which described your benefits. Printed in U.S.A.
Table of Contents Important Information..................................................................................................................5 How To File Your Claim ...............................................................................................................7 Eligibility - Effective Date .............................................................................................................7 Employee Insurance ...............................................................................................................................................7 Dependent Insurance ..............................................................................................................................................7
CIGNA Dental Preferred Provider Insurance ............................................................................9 The Schedule ..........................................................................................................................................................9 Covered Dental Expense ......................................................................................................................................11 Dental PPO – Participating and Non-Participating Providers ..............................................................................11 Expenses Not Covered .........................................................................................................................................13
General Limitations .....................................................................................................................13 Coordination of Benefits..............................................................................................................13 Expenses For Which A Third Party May Be Responsible .......................................................15 Payment of Benefits .....................................................................................................................16 Termination of Insurance............................................................................................................17 Employees ............................................................................................................................................................17 Dependents ...........................................................................................................................................................17
Dental Benefits Extension............................................................................................................17 Federal Requirements .................................................................................................................17 Notice of Provider Directory/Networks................................................................................................................17 Qualified Medical Child Support Order (QMCSO) .............................................................................................18 Coverage of Students on Medically Necessary Leave of Absence.......................................................................18 Effect of Section 125 Tax Regulations on This Plan............................................................................................18 Eligibility for Coverage for Adopted Children.....................................................................................................19 Group Plan Coverage Instead of Medicaid...........................................................................................................19 Requirements of Medical Leave Act of 1993 (as amended) [FMLA]..................................................................19 Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA)....................................20 Claim Determination Procedures Under ERISA ..................................................................................................20 Dental - When You Have a Complaint or an Appeal ...........................................................................................21 COBRA Continuation Rights Under Federal Law ...............................................................................................22 ERISA Required Information...............................................................................................................................26
Important Information THIS IS NOT AN INSURED BENEFIT PLAN. THE BENEFITS DESCRIBED IN THIS BOOKLET OR ANY RIDER ATTACHED HERETO ARE SELF-INSURED BY WENTWORTH INSTITUTE OF TECHNOLOGY, INC. WHICH IS RESPONSIBLE FOR THEIR PAYMENT. CIGNA HEALTH AND LIFE INSURANCE COMPANY (CIGNA) PROVIDES CLAIM ADMINISTRATION SERVICES TO THE PLAN, BUT CIGNA DOES NOT INSURE THE BENEFITS DESCRIBED. THIS DOCUMENT MAY USE WORDS THAT DESCRIBE A PLAN INSURED BY CIGNA. BECAUSE THE PLAN IS NOT INSURED BY CIGNA, ALL REFERENCES TO INSURANCE SHALL BE READ TO INDICATE THAT THE PLAN IS SELF-INSURED. FOR EXAMPLE, REFERENCES TO "CIGNA," "INSURANCE COMPANY," AND "POLICYHOLDER" SHALL BE DEEMED TO MEAN YOUR "EMPLOYER" AND "POLICY" TO MEAN "PLAN" AND "INSURED" TO MEAN "COVERED" AND "INSURANCE" SHALL BE DEEMED TO MEAN "COVERAGE." HC-NOT1
Explanation of Terms You will find terms starting with capital letters throughout your certificate. To help you understand your benefits, most of these terms are defined in the Definitions section of your certificate. The Schedule The Schedule is a brief outline of your maximum benefits which may be payable under your insurance. For a full description of each benefit, refer to the appropriate section listed in the Table of Contents.
How To File Your Claim
you normally work at least 17.5 hours a week; and
There’s no paperwork for In-Network care. Just show your identification card and pay your share of the cost, if any; your provider will submit a claim to CIGNA for reimbursement. Out-of-Network claims can be submitted by the provider if the provider is able and willing to file on your behalf. If the provider is not submitting on your behalf, you must send your completed claim form and itemized bills to the claims address listed on the claim form.
you pay any required contribution.
You may get the required claim forms from the website listed on your identification card or by calling Member Services using the toll-free number on your identification card. CLAIM REMINDERS • BE SURE TO USE YOUR MEMBER ID AND ACCOUNT/GROUP NUMBER (3334070) WHEN YOU FILE CIGNA’s CLAIM FORMS, OR WHEN YOU CALL YOUR CIGNA CLAIM OFFICE.
Eligibility for Dependent Insurance You will become eligible for Dependent Insurance on the later of:
If you were previously insured and your insurance ceased, you must satisfy the Waiting Period to become insured again. If your insurance ceased because you were no longer employed in a Class of Eligible Employees, you are not required to satisfy any waiting period if you again become a member of a Class of Eligible Employees within one year after your insurance ceased.
Classes of Eligible Employees Each Employee, as reported to the insurance company by the Employer Effective Date of Employee Insurance You will become insured on the date you elect the insurance by signing an approved payroll deduction or enrollment form, as applicable, but no earlier than the date you become eligible.
Timely Filing of Out-of-Network Claims CIGNA will consider claims for coverage under our plans when proof of loss (a claim) is submitted within 180 days for Out-of-Network benefits after services are rendered. If services are rendered on consecutive days, such as for a Hospital Confinement, the limit will be counted from the last date of service. If claims are not submitted within 180 days for Out-of-Network benefits, the claim will not be considered valid and will be denied.
You will become insured on your first day of eligibility, following your election, if you are in Active Service on that date, or if you are not in Active Service on that date due to your health status. Late Entrant - Employee You are a Late Entrant if:
WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information; or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act.
Eligibility for Employee Insurance You will become eligible for insurance on the day you complete the waiting period if: you are an eligible, full-time Employee; and
you again elect it after you cancel your payroll deduction (if required).
Effective Date of Dependent Insurance Insurance for your Dependents will become effective on the date you elect it by signing an approved payroll deduction form (if required), but no earlier than the day you become eligible for Dependent Insurance. All of your Dependents as defined will be included.
This plan is offered to you as an Employee.
you elect the insurance more than 30 days after you become eligible; or
For your Dependents to be insured, you will have to pay the required contribution, if any, toward the cost of Dependent Insurance.
you are in a Class of Eligible Employees; and
Eligibility - Effective Date
the day you acquire your first Dependent.
A period of time as determined by the Employer
BE SURE TO FOLLOW THE INSTRUCTIONS LISTED ON THE BACK OF THE CLAIM FORM CAREFULLY WHEN SUBMITTING A CLAIM TO CIGNA.
the day you become eligible for yourself; or
YOUR MEMBER ID IS THE ID SHOWN ON YOUR BENEFIT IDENTIFICATION CARD. •
Your Dependents will be insured only if you are insured.
Late Entrant – Dependent You are a Late Entrant for Dependent Insurance if: •
you elect that insurance more than 30 days after you become eligible for it; or
you again elect it after you cancel your payroll deduction (if required).
CIGNA Dental Preferred Provider Insurance The Schedule For You and Your Dependents The Dental Benefits Plan offered by your Employer includes Participating and non-Participating Providers. If you select a Participating Provider, your cost will be less than if you select a non-Participating Provider. Emergency Services The Benefit Percentage payable for Emergency Services charges made by a non-Participating Provider is the same Benefit Percentage as for Participating Provider Charges. Dental Emergency services are required immediately to either alleviate pain or to treat the sudden onset of an acute dental condition. These are usually minor procedures performed in response to serious symptoms, which temporarily relieve significant pain, but do not effect a definitive cure, and which, if not rendered, will likely result in a more serious dental or medical complication. Deductibles Deductibles are expenses to be paid by you or your Dependent. Deductibles are in addition to any Coinsurance. Once the Deductible maximum in The Schedule has been reached you and your family need not satisfy any further dental deductible for the rest of that year. Participating Provider Payment Participating Provider services are paid based on the Contracted Fee agreed upon by the provider and the Insurance Company. Non-Participating Provider Payment Non-Participating Provider services are paid based on the Maximum Reimbursable Charge. For this plan, the Maximum Reimbursable Charge is calculated at the 90th percentile of all provider charges in the geographic area. Simultaneous Accumulation of Amounts Benefits paid for Participating and non-Participating Provider services will both be applied toward maximums shown in The Schedule below. Expenses incurred for either Participating or non-Participating Provider charges will be used to satisfy Deductibles shown in The Schedule below. . BENEFIT HIGHLIGHTS
Classes I, II, III Combined Calendar Year Maximum
Class IV Lifetime Maximum
Calendar Year Deductible Individual
$50 per person
$150 per family $100 per person
Lifetime Class IV Deductible
Class I Preventive Care
85% after plan deductible
85% after plan deductible
60% after plan deductible
60% after plan deductible
60% after separate Class IV deductible (plan deductible waived)
60% after separate Class IV deductible (plan deductible waived)
Class II Basic Restorative Class III Major Restorative Class IV Orthodontia .
Nomenclature, or by description and then submitted to CIGNA.
Covered Dental Expense Covered Dental Expense means that portion of a Dentist’s charge that is payable for a service delivered to a covered person provided:
the service is ordered or prescribed by a Dentist;
is essential for the Necessary care of teeth;
the service is within the scope of coverage limitations;
the deductible amount in The Schedule has been met;
Missing Teeth Limitation The amount payable for the replacement of teeth that are missing when a person first becomes insured is 50% of the amount payable for the replacement of teeth that are extracted after a person has dental coverage.
the maximum benefit in The Schedule has not been exceeded;
This payment limitation no longer applies after 24 months of continuous coverage.
the charge does not exceed the amount allowed under the Alternate Benefit Provision;
for Class I, II or III the service is started and completed while coverage is in effect, except for services described in the “Benefits Extension” section.
Dental PPO – Participating and NonParticipating Providers
Alternate Benefit Provision If more than one covered service will treat a dental condition, payment is limited to the least costly service provided it is a professionally accepted, necessary and appropriate treatment.
Plan payment for a covered service delivered by a Participating Provider is the Contracted Fee for that procedure, times the benefit percentage that applies to the class of service, as specified in the Schedule.
If the covered person requests or accepts a more costly covered service, he or she is responsible for expenses that exceed the amount covered for the least costly service. Therefore, CIGNA recommends Predetermination of Benefits before major treatment begins.
The covered person is responsible for the balance of the Contracted Fee. Plan payment for a covered service delivered by a nonParticipating Provider is the Maximum Reimbursable Charge for that procedure, times the benefit percentage that applies to the class of service, as specified in the Schedule.
Predetermination of Benefits Predetermination of Benefits is a voluntary review of a Dentist’s proposed treatment plan and expected charges. It is not preauthorization of service and is not required.
The covered person is responsible for the balance of the nonParticipating Provider’s actual charge. HC-DEN2
The treatment plan should include supporting pre-operative xrays and other diagnostic materials as requested by CIGNA's dental consultant. If there is a change in the treatment plan, a revised plan should be submitted.
Class I Services – Diagnostic and Preventive Clinical oral examination – Only 3 per person per calendar year.
CIGNA will determine covered dental expenses for the proposed treatment plan. If there is no Predetermination of Benefits, CIGNA will determine covered dental expenses when it receives a claim.
Palliative (emergency) treatment of dental pain, minor procedures, when no other definitive Dental Services are performed. (Any x-ray taken in connection with such treatment is a separate Dental Service.)
Review of proposed treatment is advised whenever extensive dental work is recommended when charges exceed $200.
X-rays – Complete series or Panoramic (Panorex) – Only one per person, including panoramic film, in any 3 calendar years.
Predetermination of Benefits is not a guarantee of a set payment. Payment is based on the services that are actually delivered and the coverage in force at the time services are completed.
Bitewing x-rays – Only 3 charges per person per calendar year. Prophylaxis (Cleaning), including Periodontal maintenance procedures (following active therapy) – Only 3 per person per calendar year.
Covered Services The following section lists covered dental services. CIGNA may agree to cover expenses for a service not listed. To be considered the service should be identified using the American Dental Association Uniform Code of Dental Procedures and
Topical application of fluoride (excluding prophylaxis) – Limited to persons less than 19 years old. Only Three per person per calendar year.
Topical application of sealant, per tooth, on a posterior tooth for a person less than 14 years old – Only 1 treatment per tooth in any 3 calendar years.
Class III Services - Major Restorations, Dentures and Bridgework Crowns
Space Maintainers, fixed unilateral – Limited to nonorthodontic treatment.
Note: Crown restorations are Dental Services only when the tooth, as a result of extensive caries or fracture, cannot be restored with amalgam, composite/resin, silicate, acrylic or plastic restoration.
Porcelain Fused to High Noble Metal
Class II Services – Basic Restorations, Endodontics, Periodontics, Prosthodontic Maintenance and Oral Surgery Amalgam Filling
Full Cast, High Noble Metal Three-Fourths Cast, Metallic Removable Appliances
Complete (Full) Dentures, Upper or Lower
Root Canal Therapy – Any x-ray, test, laboratory exam or follow-up care is part of the allowance for root canal therapy and not a separate Dental Service.
Osseous Surgery – Flap entry and closure is part of the allowance for osseous surgery and not a separate Dental Service.
Upper, Cast Metal Base with Resin Saddles (including any conventional clasps rests and teeth)
Lower, Cast Metal Base with Resin Saddles (including any conventional clasps, rests and teeth)
Periodontal Scaling and Root Planing – Entire Mouth
Bridge Pontics - Cast High Noble Metal
Adjustments – Complete Denture
Bridge Pontics - Porcelain Fused to High Noble Metal
Any adjustment of or repair to a denture within 6 months of its installation is not a separate Dental Service.
Bridge Pontics - Resin with High Noble Metal Retainer Crowns - Resin with High Noble Metal
Retainer Crowns - Porcelain Fused to High Noble Metal
Retainer Crowns - Full Cast High Noble Metal
Surgical Removal of Erupted Tooth Requiring Elevation of Mucoperiosteal Flap and Removal of Bone and/or Section of Tooth
Prosthesis Over Implant – A prosthetic device, supported by an implant or implant abutment is a Covered Expense. Replacement of any type of prosthesis with a prosthesis supported by an implant or implant abutment is only payable if the existing prosthesis is at least 5 calendar years old, is not serviceable and cannot be repaired.
Removal of Impacted Tooth, Soft Tissue Removal of Impacted Tooth, Partially Bony Removal of Impacted Tooth, Completely Bony Local anesthetic, analgesic and routine postoperative care for extractions and other oral surgery procedures are not separately reimbursed but are considered as part of the submitted fee for the global surgical procedure.
Class IV Services - Orthodontics Each month of active treatment is a separate Dental Service.
General Anesthesia – Paid as a separate benefit only when Medically Necessary (as determined by Cigna), and when administered in conjunction with complex oral surgical procedures which are covered under this plan.
Covered Expenses include: Orthodontic work-up including x-rays, diagnostic casts and treatment plan and the first month of active treatment including all active treatment and retention appliances.
IV Sedation – Paid as a separate benefit only when Medically Necessary (as determined by Cigna), and when administered in conjunction with complex oral surgical procedures which are covered under this plan. HC-DEN4
Continued active treatment after the first month. Fixed or Removable Appliances - Only one appliance per person for tooth guidance or to control harmful habits.
The total amount payable for all expenses incurred for Orthodontics during a person’s lifetime will not be more than the Orthodontia Maximum shown in the Schedule.
Payments for comprehensive full-banded Orthodontic treatment are made in installments. Benefit payments will be made every 3 months. The first payment is due when the appliance is installed. Later payments are due at the end of each 3-month period. The first installment is 25% of the charge for the entire course of treatment. The remainder of the charge is prorated over the estimated duration of treatment. Payments are only made for services provided while a person is insured. If insurance coverage ends or treatment ceases, payment for the last 3-month period will be prorated. HC-DEN6
services for which benefits are not payable according to the “General Limitations” section.
General Limitations No payment will be made for expenses incurred for you or any one of your Dependents: •
for or in connection with an Injury arising out of, or in the course of, any employment for wage or profit;
for or in connection with a Sickness which is covered under any workers' compensation or similar law;
for charges made by a Hospital;
services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared;
to the extent that payment is unlawful where the person resides when the expenses are incurred;
Expenses Not Covered Covered Expenses will not include, and no payment will be made for: •
services performed solely for cosmetic reasons;
replacement of a lost or stolen appliance;
replacement of a bridge, crown or denture within 5 years after the date it was originally installed unless: the replacement is made necessary by the placement of an original opposing full denture or the necessary extraction of natural teeth; or the bridge, crown or denture, while in the mouth, has been damaged beyond repair as a result of an injury received while a person is insured for these benefits;
for charges which the person is not legally required to pay;
for charges which would not have been made if the person had no insurance;
to the extent that billed charges exceed the rate of reimbursement as described in the Schedule;
for charges for unnecessary care, treatment or surgery;
any replacement of a bridge, crown or denture which is or can be made useable according to common dental standards;
procedures, appliances or restorations (except full dentures) whose main purpose is to: change vertical dimension; diagnose or treat conditions or dysfunction of the temporomandibular joint; stabilize periodontally involved teeth; or restore occlusion;
to the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid;
for or in connection with experimental procedures or treatment methods not approved by the American Dental Association or the appropriate dental specialty society.
porcelain or acrylic veneers of crowns or pontics on, or replacing the upper and lower first, second and third molars;
bite registrations; precision or semiprecision attachments; or splinting;
instruction for plaque control, oral hygiene and diet;
dental services that do not meet common dental standards;
services that are deemed to be medical services;
services and supplies received from a Hospital;
the surgical placement of an implant body or framework of any type; surgical procedures in anticipation of implant placement; any device, index, or surgical template guide used for implant surgery; treatment or repair of an existing implant; prefabricated or custom implant abutments; removal of an existing implant;
04-10 V3 M
Coordination of Benefits This section applies if you or any one of your Dependents is covered under more than one Plan and determines how benefits payable from all such Plans will be coordinated. You should file all claims with each Plan. Definitions For the purposes of this section, the following terms have the meanings set forth below: Plan Any of the following that provides benefits or services for medical or dental care or treatment: •
Group insurance and/or group-type coverage, whether insured or self-insured which neither can be purchased by
the general public, nor is individually underwritten, including closed panel coverage. •
Governmental benefits as permitted by law, excepting Medicaid, Medicare and Medicare supplement policies.
Medical benefits coverage of group, group-type, and individual automobile contracts.
because you did not comply with Plan provisions or because you did not use a preferred provider, the amount of the reduction is not an Allowable Expense. Such Plan provisions include second surgical opinions and precertification of admissions or services. Claim Determination Period A calendar year, but does not include any part of a year during which you are not covered under this policy or any date before this section or any similar provision takes effect.
Each Plan or part of a Plan which has the right to coordinate benefits will be considered a separate Plan. Closed Panel Plan A Plan that provides medical or dental benefits primarily in the form of services through a panel of employed or contracted providers, and that limits or excludes benefits provided by providers outside of the panel, except in the case of emergency or if referred by a provider within the panel.
Reasonable Cash Value An amount which a duly licensed provider of health care services usually charges patients and which is within the range of fees usually charged for the same service by other health care providers located within the immediate geographic area where the health care service is rendered under similar or comparable circumstances.
Primary Plan The Plan that determines and provides or pays benefits without taking into consideration the existence of any other Plan.
Order of Benefit Determination Rules A Plan that does not have a coordination of benefits rule consistent with this section shall always be the Primary Plan. If the Plan does have a coordination of benefits rule consistent with this section, the first of the following rules that applies to the situation is the one to use:
Secondary Plan A Plan that determines, and may reduce its benefits after taking into consideration, the benefits provided or paid by the Primary Plan. A Secondary Plan may also recover from the Primary Plan the Reasonable Cash Value of any services it provided to you. Allowable Expense A necessary, reasonable and customary service or expense, including deductibles, coinsurance or copayments, that is covered in full or in part by any Plan covering you. When a Plan provides benefits in the form of services, the Reasonable Cash Value of each service is the Allowable Expense and is a paid benefit.
The Plan that covers you as an enrollee or an employee shall be the Primary Plan and the Plan that covers you as a Dependent shall be the Secondary Plan;
If you are a Dependent child whose parents are not divorced or legally separated, the Primary Plan shall be the Plan which covers the parent whose birthday falls first in the calendar year as an enrollee or employee;
If you are the Dependent of divorced or separated parents, benefits for the Dependent shall be determined in the following order:
Examples of expenses or services that are not Allowable Expenses include, but are not limited to the following: •
An expense or service or a portion of an expense or service that is not covered by any of the Plans is not an Allowable Expense.
If you are covered by two or more Plans that provide services or supplies on the basis of reasonable and customary fees, any amount in excess of the highest reasonable and customary fee is not an Allowable Expense.
If you are covered by one Plan that provides services or supplies on the basis of reasonable and customary fees and one Plan that provides services and supplies on the basis of negotiated fees, the Primary Plan's fee arrangement shall be the Allowable Expense.
If your benefits are reduced under the Primary Plan (through the imposition of a higher copayment amount, higher coinsurance percentage, a deductible and/or a penalty)
first, if a court decree states that one parent is responsible for the child's healthcare expenses or health coverage and the Plan for that parent has actual knowledge of the terms of the order, but only from the time of actual knowledge;
then, the Plan of the parent with custody of the child;
then, the Plan of the spouse of the parent with custody of the child;
then, the Plan of the parent not having custody of the child; and
finally, the Plan of the spouse of the parent not having custody of the child.
The Plan that covers you as an active employee (or as that employee's Dependent) shall be the Primary Plan and the Plan that covers you as laid-off or retired employee (or as that employee's Dependent) shall be the secondary Plan. If the other Plan does not have a similar provision and, as a
CIGNA will have sole discretion to seek such recovery from any person to, or for whom, or with respect to whom, such services were provided or such payments made by any insurance company, healthcare plan or other organization. If we request, you must execute and deliver to us such instruments and documents as we determine are necessary to secure the right of recovery.
result, the Plans cannot agree on the order of benefit determination, this paragraph shall not apply. •
The Plan that covers you under a right of continuation which is provided by federal or state law shall be the Secondary Plan and the Plan that covers you as an active employee or retiree (or as that employee's Dependent) shall be the Primary Plan. If the other Plan does not have a similar provision and, as a result, the Plans cannot agree on the order of benefit determination, this paragraph shall not apply.
Right to Receive and Release Information CIGNA, without consent or notice to you, may obtain information from and release information to any other Plan with respect to you in order to coordinate your benefits pursuant to this section. You must provide us with any information we request in order to coordinate your benefits pursuant to this section. This request may occur in connection with a submitted claim; if so, you will be advised that the "other coverage" information, (including an Explanation of Benefits paid under the Primary Plan) is required before the claim will be processed for payment. If no response is received within 90 days of the request, the claim will be denied. If the requested information is subsequently received, the claim will be processed.
If one of the Plans that covers you is issued out of the state whose laws govern this Policy, and determines the order of benefits based upon the gender of a parent, and as a result, the Plans do not agree on the order of benefit determination, the Plan with the gender rules shall determine the order of benefits.
If none of the above rules determines the order of benefits, the Plan that has covered you for the longer period of time shall be primary. Effect on the Benefits of This Plan If this Plan is the Secondary Plan, this Plan may reduce benefits so that the total benefits paid by all Plans during a Claim Determination Period are not more than 100% of the total of all Allowable Expenses.
Expenses For Which A Third Party May Be Responsible
The difference between the amount that this Plan would have paid if this Plan had been the Primary Plan, and the benefit payments that this Plan had actually paid as the Secondary Plan, will be recorded as a benefit reserve for you. CIGNA will use this benefit reserve to pay any Allowable Expense not otherwise paid during the Claim Determination Period.
This plan does not cover:
As each claim is submitted, CIGNA will determine the following: •
CIGNA’s obligation to provide services and supplies under this policy;
whether a benefit reserve has been recorded for you; and
whether there are any unpaid Allowable Expenses during the Claims Determination Period.
If there is a benefit reserve, CIGNA will use the benefit reserve recorded for you to pay up to 100% of the total of all Allowable Expenses. At the end of the Claim Determination Period, your benefit reserve will return to zero and a new benefit reserve will be calculated for each new Claim Determination Period.
Expenses incurred by you or your Dependent (hereinafter individually and collectively referred to as a "Participant,") for which another party may be responsible as a result of having caused or contributed to an Injury or Sickness.
Expenses incurred by a Participant to the extent any payment is received for them either directly or indirectly from a third party tortfeasor or as a result of a settlement, judgment or arbitration award in connection with any automobile medical, automobile no-fault, uninsured or underinsured motorist, homeowners, workers' compensation, government insurance (other than Medicaid), or similar type of insurance or coverage.
Right Of Reimbursement If a Participant incurs a Covered Expense for which, in the opinion of the plan or its claim administrator, another party may be responsible or for which the Participant may receive payment as described above, the plan is granted a right of reimbursement, to the extent of the benefits provided by the plan, from the proceeds of any recovery whether by settlement, judgment, or otherwise.
Recovery of Excess Benefits If CIGNA pays charges for benefits that should have been paid by the Primary Plan, or if CIGNA pays charges in excess of those for which we are obligated to provide under the Policy, CIGNA will have the right to recover the actual payment made or the Reasonable Cash Value of any services.
Lien Of The Plan By accepting benefits under this plan, a Participant:
to future medical benefits hereunder until the Participant has fully complied with his reimbursement obligations hereunder, regardless of how those future medical benefits are incurred.
grants a lien and assigns to the plan an amount equal to the benefits paid under the plan against any recovery made by or on behalf of the Participant which is binding on any attorney or other party who represents the Participant whether or not an agent of the Participant or of any insurance company or other financially responsible party against whom a Participant may have a claim provided said attorney, insurance carrier or other party has been notified by the plan or its agents;
agrees that this lien shall constitute a charge against the proceeds of any recovery and the plan shall be entitled to assert a security interest thereon;
agrees to hold the proceeds of any recovery in trust for the benefit of the plan to the extent of any payment made by the plan.
Additional Terms • No adult Participant hereunder may assign any rights that it may have to recover medical expenses from any third party or other person or entity to any minor Dependent of said adult Participant without the prior express written consent of the plan. The plan’s right to recover shall apply to decedents’, minors’, and incompetent or disabled persons’ settlements or recoveries. •
No Participant shall make any settlement, which specifically reduces or excludes, or attempts to reduce or exclude, the benefits provided by the plan.
The plan’s right of recovery shall be a prior lien against any proceeds recovered by the Participant. This right of recovery shall not be defeated nor reduced by the application of any so-called “Made-Whole Doctrine”, “Rimes Doctrine”, or any other such doctrine purporting to defeat the plan’s recovery rights by allocating the proceeds exclusively to non-medical expense damages.
The plan shall recover the full amount of benefits provided hereunder without regard to any claim of fault on the part of any Participant, whether under comparative negligence or otherwise.
In the event that a Participant shall fail or refuse to honor its obligations hereunder, then the plan shall be entitled to recover any costs incurred in enforcing the terms hereof including, but not limited to, attorney’s fees, litigation, court costs, and other expenses. The plan shall also be entitled to offset the reimbursement obligation against any entitlement
Payment of Benefits To Whom Payable Dental Benefits are assignable to the provider. When you assign benefits to a provider, you have assigned the entire amount of the benefits due on that claim. If the provider is overpaid because of accepting a patient’s payment on the charge, it is the provider’s responsibility to reimburse the patient. Because of CIGNA's contracts with providers, all claims from contracted providers should be assigned. CIGNA may, at its option, make payment to you for the cost of any Covered Expenses from a Non-Participating Provider even if benefits have been assigned. When benefits are paid to you or your Dependent, you or your Dependents are responsible for reimbursing the provider. If any person to whom benefits are payable is a minor or, in the opinion of CIGNA is not able to give a valid receipt for any payment due him, such payment will be made to his legal guardian. If no request for payment has been made by his legal guardian, CIGNA may, at its option, make payment to the person or institution appearing to have assumed his custody and support.
No Participant hereunder shall incur any expenses on behalf of the plan in pursuit of the plan’s rights hereunder, specifically; no court costs, attorneys' fees or other representatives' fees may be deducted from the plan’s recovery without the prior express written consent of the plan. This right shall not be defeated by any so-called “Fund Doctrine”, “Common Fund Doctrine”, or “Attorney’s Fund Doctrine”.
Any reference to state law in any other provision of this plan shall not be applicable to this provision, if the plan is governed by ERISA. By acceptance of benefits under the plan, the Participant agrees that a breach hereof would cause irreparable and substantial harm and that no adequate remedy at law would exist. Further, the Plan shall be entitled to invoke such equitable remedies as may be necessary to enforce the terms of the plan, including, but not limited to, specific performance, restitution, the imposition of an equitable lien and/or constructive trust, as well as injunctive relief.
When one of our participants passes away, CIGNA may receive notice that an executor of the estate has been established. The executor has the same rights as our insured and benefit payments for unassigned claims should be made payable to the executor. Payment as described above will release CIGNA from all liability to the extent of any payment made. Recovery of Overpayment When an overpayment has been made by CIGNA, CIGNA will have the right at any time to: recover that overpayment from the person to whom or on whose behalf it was made; or
offset the amount of that overpayment from a future claim payment. HC-POB4
Dependents Your insurance for all of your Dependents will cease on the earliest date below:
Miscellaneous As a CIGNA Dental plan member, you may be eligible for various discounts, benefits, or other consideration for the purpose of promoting your general health and well being. Please visit our website at www.cigna.com for details.
the date your insurance ceases.
the date you cease to be eligible for Dependent Insurance.
the last day for which you have made any required contribution for the insurance.
the date Dependent Insurance is canceled.
The insurance for any one of your Dependents will cease on the date that Dependent no longer qualifies as a Dependent.
If you are a CIGNA Dental plan member you may be eligible for additional dental benefits during certain episodes of care. For example, certain frequency limitations for dental services may be relaxed for pregnant women, diabetics or those with cardiac disease. Please review your plan enrollment materials for details. HC-POB5
Dental Benefits Extension
An expense incurred in connection with a Dental Service that is completed after a person's benefits cease will be deemed to be incurred while he is insured if:
Termination of Insurance Employees
for fixed bridgework and full or partial dentures, the first impressions are taken and/or abutment teeth fully prepared while he is insured and the device installed or delivered to him within 3 calendar months after his insurance ceases.
for a crown, inlay or onlay, the tooth is prepared while he is insured and the crown, inlay or onlay installed within 3 calendar months after his insurance ceases.
for root canal therapy, the pulp chamber of the tooth is opened while he is insured and the treatment is completed within 3 calendar months after his insurance ceases.
Your insurance will cease on the earliest date below: •
the date you cease to be in a Class of Eligible Employees or cease to qualify for the insurance.
the last day for which you have made any required contribution for the insurance.
the date the policy is canceled.
the last day of the calendar month in which your Active Service ends except as described below.
There is no extension for any Dental Service not shown above.
Any continuation of insurance must be based on a plan which precludes individual selection.
Temporary Layoff or Leave of Absence If your Active Service ends due to temporary layoff or leave of absence, your benefits will be continued until the date your Employer cancels your insurance.
Federal Requirements The following pages explain your rights and responsibilities under federal laws and regulations. Some states may have similar requirements. If a similar provision appears elsewhere in this booklet, the provision which provides the better benefit will apply.
Injury or Sickness If your Active Service ends due to an Injury or Sickness, your insurance will be continued while you remain totally and continuously disabled as a result of the Injury or Sickness. However, your benefits will not continue past the date your Employer cancels your insurance.
Notice of Provider Directory/Networks
Retirement If your Active Service ends because you retire, your benefits will be continued until the date on which your Employer stops paying premium for you or otherwise cancels your insurance.
If your Plan utilizes a network of providers, a separate listing of providers who participate in the network is available to you by visiting www.cigna.com or mycigna.com; or by calling the toll-free telephone number on your ID card. Your Participating Provider network consists of a group of local dental practitioners of varied specialties as well as
general practice who are employed by, or contracted with, CIGNA HealthCare or CIGNA Dental Health. HC-FED2 M
address have been substituted for the name and address of the child. 10-10
Qualified Medical Child Support Order (QMCSO)
Coverage of Students on Medically Necessary Leave of Absence
Eligibility for Coverage Under a QMCSO If a Qualified Medical Child Support Order (QMCSO) is issued for your child, that child will be eligible for coverage as required by the order and you will not be considered a Late Entrant for Dependent Insurance.
If your Dependent child is covered by this plan as a student, as defined in the Definition of Dependent, coverage will remain active for that child if the child is on a medically necessary leave of absence from a postsecondary educational institution (such as a college, university or trade school.)
You must notify your Employer and elect coverage for that child, and yourself if you are not already enrolled, within 31 days of the QMCSO being issued.
Coverage will terminate on the earlier of: •
The date that is one year after the first day of the medically necessary leave of absence; or
Qualified Medical Child Support Order Defined A Qualified Medical Child Support Order is a judgment, decree or order (including approval of a settlement agreement) or administrative notice, which is issued pursuant to a state domestic relations law (including a community property law), or to an administrative process, which provides for child support or provides for health benefit coverage to such child and relates to benefits under the group health plan, and satisfies all of the following:
The date on which coverage would otherwise terminate under the terms of the plan.
the order recognizes or creates a child’s right to receive group health benefits for which a participant or beneficiary is eligible;
the order specifies your name and last known address, and the child’s name and last known address, except that the name and address of an official of a state or political subdivision may be substituted for the child’s mailing address;
the order provides a description of the coverage to be provided, or the manner in which the type of coverage is to be determined;
the order states the period to which it applies; and
if the order is a National Medical Support Notice completed in accordance with the Child Support Performance and Incentive Act of 1998, such Notice meets the requirements above.
The child must be a Dependent under the terms of the plan and must have been enrolled in the plan on the basis of being a student at a postsecondary educational institution immediately before the first day of the medically necessary leave of absence. The plan must receive written certification from the treating physician that the child is suffering from a serious illness or injury and that the leave of absence (or other change in enrollment) is medically necessary. A “medically necessary leave of absence” is a leave of absence from a postsecondary educational institution, or any other change in enrollment of the child at the institution that: starts while the child is suffering from a serious illness or condition; is medically necessary; and causes the child to lose student status under the terms of the plan. HC-FED31
Effect of Section 125 Tax Regulations on This Plan Your Employer has chosen to administer this Plan in accordance with Section 125 regulations of the Internal Revenue Code. Per this regulation, you may agree to a pretax salary reduction put toward the cost of your benefits. Otherwise, you will receive your taxable earnings as cash (salary).
The QMCSO may not require the health insurance policy to provide coverage for any type or form of benefit or option not otherwise provided under the policy, except that an order may require a plan to comply with State laws regarding health care coverage.
A. Coverage Elections Per Section 125 regulations, you are generally allowed to enroll for or change coverage only before each annual benefit period. However, exceptions are allowed if your Employer agrees and you enroll for or change coverage within 30 days of the date you meet the criteria shown in the following Sections B through F.
Payment of Benefits Any payment of benefits in reimbursement for Covered Expenses paid by the child, or the child’s custodial parent or legal guardian, shall be made to the child, the child’s custodial parent or legal guardian, or a state official whose name and 18
B. Change of Status A change in status is defined as:
Eligibility for Coverage for Adopted Children
change in legal marital status due to marriage, death of a spouse, divorce, annulment or legal separation;
change in number of Dependents due to birth, adoption, placement for adoption, or death of a Dependent;
change in employment status of Employee, spouse or Dependent due to termination or start of employment, strike, lockout, beginning or end of unpaid leave of absence, including under the Family and Medical Leave Act (FMLA), or change in worksite;
changes in employment status of Employee, spouse or Dependent resulting in eligibility or ineligibility for coverage;
change in residence of Employee, spouse or Dependent to a location outside of the Employer’s network service area; and
changes which cause a Dependent to become eligible or ineligible for coverage.
Any child under the age of 18 who is adopted by you, including a child who is placed with you for adoption, will be eligible for Dependent Insurance upon the date of placement with you. A child will be considered placed for adoption when you become legally obligated to support that child, totally or partially, prior to that child’s adoption. If a child placed for adoption is not adopted, all health coverage ceases when the placement ends, and will not be continued. HC-FED8 M
Group Plan Coverage Instead of Medicaid If your income and liquid resources do not exceed certain limits established by law, the state may decide to pay premiums for this coverage instead of for Medicaid, if it is cost effective. This includes premiums for continuation coverage required by federal law. HC-FED13
C. Court Order A change in coverage due to and consistent with a court order of the Employee or other person to cover a Dependent.
Requirements of Medical Leave Act of 1993 (as amended) [FMLA] Any provisions of the policy that provide for: continuation of insurance during a leave of absence; and reinstatement of insurance following a return to Active Service; are modified by the following provisions of the federal Family and Medical Leave Act of 1993, as amended, where applicable:
D. Medicare or Medicaid Eligibility/Entitlement The Employee, spouse or Dependent cancels or reduces coverage due to entitlement to Medicare or Medicaid, or enrolls or increases coverage due to loss of Medicare or Medicaid eligibility.
Continuation of Health Insurance During Leave Your health insurance will be continued during a leave of absence if:
E. Change in Cost of Coverage If the cost of benefits increases or decreases during a benefit period, your Employer may, in accordance with plan terms, automatically change your elective contribution. When the change in cost is significant, you may either increase your contribution or elect less-costly coverage. When a significant overall reduction is made to the benefit option you have elected, you may elect another available benefit option. When a new benefit option is added, you may change your election to the new benefit option.
that leave qualifies as a leave of absence under the Family and Medical Leave Act of 1993, as amended; and
you are an eligible Employee under the terms of that Act.
The cost of your health insurance during such leave must be paid, whether entirely by your Employer or in part by you and your Employer. Reinstatement of Canceled Insurance Following Leave Upon your return to Active Service following a leave of absence that qualifies under the Family and Medical Leave Act of 1993, as amended, any canceled insurance (health, life or disability) will be reinstated as of the date of your return.
F. Changes in Coverage of Spouse or Dependent Under Another Employer’s Plan You may make a coverage election change if the plan of your spouse or Dependent: incurs a change such as adding or deleting a benefit option; allows election changes due to Change in Status, Court Order or Medicare or Medicaid Eligibility/Entitlement; or this Plan and the other plan have different periods of coverage or open enrollment periods. HC-FED7
You will not be required to satisfy any eligibility or benefit waiting period or the requirements of any Pre-existing Condition limitation to the extent that they had been satisfied prior to the start of such leave of absence. Your Employer will give you detailed information about the Family and Medical Leave Act of 1993, as amended.
Uniformed Services Employment and ReEmployment Rights Act of 1994 (USERRA)
Claim Determination Procedures Under ERISA Procedures Regarding Medical Necessity Determinations In general, health services and benefits must be Medically Necessary to be covered under the plan. The procedures for determining Medical Necessity vary, according to the type of service or benefit requested, and the type of health plan.
The Uniformed Services Employment and Re-employment Rights Act of 1994 (USERRA) sets requirements for continuation of health coverage and re-employment in regard to an Employee’s military leave of absence. These requirements apply to medical and dental coverage for you and your Dependents.
You or your authorized representative (typically, your health care provider) must request Medical Necessity determinations according to the procedures described below, in the Certificate, and in your provider’s network participation documents as applicable.
Continuation of Coverage For leaves of less than 31 days, coverage will continue as described in the Termination section regarding Leave of Absence.
When services or benefits are determined to be not Medically Necessary, you or your representative will receive a written description of the adverse determination, and may appeal the determination. Appeal procedures are described in the Certificate, in your provider’s network participation documents, and in the determination notices.
For leaves of 31 days or more, you may continue coverage for yourself and your Dependents as follows: You may continue benefits by paying the required premium to your Employer, until the earliest of the following: •
24 months from the last day of employment with the Employer;
the day after you fail to return to work; and
the date the policy cancels.
Postservice Medical Necessity Determinations When you or your representative requests a Medical Necessity determination after services have been rendered, CIGNA will notify you or your representative of the determination within 30 days after receiving the request. However, if more time is needed to make a determination due to matters beyond CIGNA’s control CIGNA will notify you or your representative within 30 days after receiving the request. This notice will include the date a determination can be expected, which will be no more than 45 days after receipt of the request.
Your Employer may charge you and your Dependents up to 102% of the total premium. Following continuation of health coverage per USERRA requirements, you may convert to a plan of individual coverage according to any “Conversion Privilege” shown in your certificate. Reinstatement of Benefits (applicable to all coverages) If your coverage ends during the leave of absence because you do not elect USERRA or an available conversion plan at the expiration of USERRA and you are reemployed by your current Employer, coverage for you and your Dependents may be reinstated if you gave your Employer advance written or verbal notice of your military service leave, and the duration of all military leaves while you are employed with your current Employer does not exceed 5 years.
If more time is needed because necessary information is missing from the request, the notice will also specify what information is needed. The determination period will be suspended on the date CIGNA sends such a notice of missing information, and the determination period will resume on the date you or your representative responds to the notice. Postservice Claim Determinations When you or your representative requests payment for services which have been rendered, CIGNA will notify you of the claim payment determination within 30 days after receiving the request. However, if more time is needed to make a determination due to matters beyond CIGNA’s control, CIGNA will notify you or your representative within 30 days after receiving the request. This notice will include the date a determination can be expected, which will be no more than 45 days after receipt of the request. If more time is needed because necessary information is missing from the request, the notice will also specify what information is needed, and you or your representative must provide the specified information within 45 days after receiving the notice. The determination period will be suspended on the date CIGNA sends such a notice of missing information, and
You and your Dependents will be subject to only the balance of a Pre-Existing Condition Limitation (PCL) or waiting period that was not yet satisfied before the leave began. However, if an Injury or Sickness occurs or is aggravated during the military leave, full Plan limitations will apply. Any 63-day break in coverage rule regarding credit for time accrued toward a PCL waiting period will be waived. If your coverage under this plan terminates as a result of your eligibility for military medical and dental coverage and your order to active duty is canceled before your active duty service commences, these reinstatement rights will continue to apply. HC-FED18 M
resume on the date you or your representative responds to the notice.
any case within 30 days. If you are not satisfied with the results of a coverage decision, you may start the appeals procedure.
Notice of Adverse Determination Every notice of an adverse benefit determination will be provided in writing or electronically, and will include all of the following that pertain to the determination: •
the specific reason or reasons for the adverse determination;
reference to the specific plan provisions on which the determination is based;
a description of any additional material or information necessary to perfect the claim and an explanation of why such material or information is necessary;
a description of the plan’s review procedures and the time limits applicable, including a statement of a claimant’s rights to bring a civil action under section 502(a) of ERISA following an adverse benefit determination on appeal;
Appeals Procedure CIGNA has a two-step appeals procedure for coverage decisions. To initiate an appeal, you must submit a request for an appeal in writing to CIGNA within 365 days of receipt of a denial notice. You should state the reason why you feel your appeal should be approved and include any information supporting your appeal. If you are unable or choose not to write, you may ask CIGNA to register your appeal by telephone. Call or write us at the toll-free number on your Benefit Identification card, explanation of benefits, or claim form. Level-One Appeal Your appeal will be reviewed and the decision made by someone not involved in the initial decision. Appeals involving Medical Necessity or clinical appropriateness will be considered by a health care professional.
upon request and free of charge, a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon in making the adverse determination regarding your claim, and an explanation of the scientific or clinical judgment for a determination that is based on a Medical Necessity, experimental treatment or other similar exclusion or limit; and
For level-one appeals, we will respond in writing with a decision within 30 calendar days after we receive an appeal for a postservice coverage determination. If more time or information is needed to make the determination, we will notify you in writing to request an extension of up to 15 calendar days and to specify any additional information needed to complete the review.
in the case of a claim involving urgent care, a description of the expedited review process applicable to such claim.
Level-Two Appeal If you are dissatisfied with our level-one appeal decision, you may request a second review. To initiate a level-two appeal, follow the same process required for a level-one appeal.
Dental - When You Have a Complaint or an Appeal
Most requests for a second review will be conducted by the Committee, which consists of a minimum of three people. Anyone involved in the prior decision may not vote on the Committee. For appeals involving Medical Necessity or clinical appropriateness the Committee will consult with at least one Physician in the same or similar specialty as the care under consideration, as determined by CIGNA’s Physician reviewer. You may present your situation to the Committee in person or by conference call.
For the purposes of this section, any reference to “you,” “your,” or “Member” also refers to a representative or provider designated by you to act on your behalf, unless otherwise noted. “Physician Reviewers” are licensed Dentists depending on the care, service or treatment under review. We want you to be completely satisfied with the care you receive. That is why we have established a process for addressing your concerns and solving your problems.
For level-two appeals we will acknowledge in writing that we have received your request and schedule a Committee review. For post service claims, the Committee review will be completed within 30 calendar days. If more time or information is needed to make the determination, we will notify you in writing to request an extension of up to 15 calendar days and to specify any additional information needed by the Committee to complete the review. You will be notified in writing of the Committee’s decision within 5 business days after the Committee meeting, and within the Committee review time frames above if the Committee does not approve the requested coverage.
Start With Member Services We are here to listen and help. If you have a concern regarding a person, a service, the quality of care, or contractual benefits, you may call the toll-free number on your Benefit Identification card, explanation of benefits, or claim form and explain your concern to one of our Member Services representatives. You may also express that concern in writing. We will do our best to resolve the matter on your initial contact. If we need more time to review or investigate your concern, we will get back to you as soon as possible, but in
Department of Labor office and your State insurance regulatory agency. You may also contact the Plan Administrator.
Independent Review Procedure If you are not fully satisfied with the decision of CIGNA’s level-two appeal review regarding your Medical Necessity or clinical appropriateness issue, you may request that your appeal be referred to an Independent Review Organization. The Independent Review Organization is composed of persons who are not employed by CIGNA, or any of its affiliates. A decision to use the voluntary level of appeal will not affect the claimant’s rights to any other benefits under the plan.
Relevant Information Relevant information is any document, record or other information which: was relied upon in making the benefit determination; was submitted, considered or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination; demonstrates compliance with the administrative processes and safeguards required by federal law in making the benefit determination; or constitutes a statement of policy or guidance with respect to the plan concerning the denied treatment option or benefit for the claimant’s diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination.
There is no charge for you to initiate this Independent Review Process. CIGNA will abide by the decision of the Independent Review Organization. In order to request a referral to an Independent Review Organization, the reason for the denial must be based on a Medical Necessity or clinical appropriateness determination by CIGNA. Administrative, eligibility or benefit coverage limits or exclusions are not eligible for appeal under this process.
Legal Action If your plan is governed by ERISA, you have the right to bring a civil action under section 502(a) of ERISA if you are not satisfied with the outcome of the Appeals Procedure. In most instances, you may not initiate a legal action against CIGNA until you have completed the Level-One and Level-Two appeal processes. If your appeal is expedited, there is no need to complete the Level-Two process prior to bringing legal action.
To request a review, you must notify the Appeals Coordinator within 180 days of your receipt of CIGNA’s level-two appeal review denial. CIGNA will then forward the file to the Independent Review Organization. The Independent Review Organization will render an opinion within 30 days. When requested and when a delay would be detrimental to your medical condition, as determined by CIGNA’s Dentist reviewer, the review shall be completed within 3 days. The Independent Review Program is a voluntary program arranged by CIGNA.
COBRA Continuation Rights Under Federal Law
Notice of Benefit Determination on Appeal Every notice of a determination on appeal will be provided in writing or electronically and, if an adverse determination, will include: the specific reason or reasons for the adverse determination; reference to the specific plan provisions on which the determination is based; a statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to and copies of all documents, records, and other Relevant Information as defined; a statement describing any voluntary appeal procedures offered by the plan and the claimant’s right to bring an action under ERISA section 502(a); upon request and free of charge, a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon in making the adverse determination regarding your appeal, and an explanation of the scientific or clinical judgment for a determination that is based on a Medical Necessity, experimental treatment or other similar exclusion or limit.
For You and Your Dependents What is COBRA Continuation Coverage? Under federal law, you and/or your Dependents must be given the opportunity to continue health insurance when there is a “qualifying event” that would result in loss of coverage under the Plan. You and/or your Dependents will be permitted to continue the same coverage under which you or your Dependents were covered on the day before the qualifying event occurred, unless you move out of that plan’s coverage area or the plan is no longer available. You and/or your Dependents cannot change coverage options until the next open enrollment period. When is COBRA Continuation Available? For you and your Dependents, COBRA continuation is available for up to 18 months from the date of the following qualifying events if the event would result in a loss of coverage under the Plan:
You also have the right to bring a civil action under Section 502(a) of ERISA if you are not satisfied with the decision on review. You or your plan may have other voluntary alternative dispute resolution options such as Mediation. One way to find out what may be available is to contact your local U.S.
your termination of employment for any reason, other than gross misconduct, or
your reduction in work hours.
one of your Dependents is determined by the Social Security Administration (SSA) to be totally disabled under title II or XVI of the SSA, you and all of your Dependents who have elected COBRA continuation coverage may extend such continuation for an additional 11 months, for a maximum of 29 months from the initial qualifying event.
For your Dependents, COBRA continuation coverage is available for up to 36 months from the date of the following qualifying events if the event would result in a loss of coverage under the Plan: •
your divorce or legal separation; or
for a Dependent child, failure to continue to qualify as a Dependent under the Plan.
To qualify for the disability extension, all of the following requirements must be satisfied:
Who is Entitled to COBRA Continuation? Only a “qualified beneficiary” (as defined by federal law) may elect to continue health insurance coverage. A qualified beneficiary may include the following individuals who were covered by the Plan on the day the qualifying event occurred: you, your spouse, and your Dependent children. Each qualified beneficiary has their own right to elect or decline COBRA continuation coverage even if you decline or are not eligible for COBRA continuation.
SSA must determine that the disability occurred prior to or within 60 days after the disabled individual elected COBRA continuation coverage; and
A copy of the written SSA determination must be provided to the Plan Administrator within 60 calendar days after the date the SSA determination is made AND before the end of the initial 18-month continuation period.
If the SSA later determines that the individual is no longer disabled, you must notify the Plan Administrator within 30 days after the date the final determination is made by SSA. The 11-month disability extension will terminate for all covered persons on the first day of the month that is more than 30 days after the date the SSA makes a final determination that the disabled individual is no longer disabled.
The following individuals are not qualified beneficiaries for purposes of COBRA continuation: domestic partners, same sex spouses, grandchildren (unless adopted by you), stepchildren (unless adopted by you). Although these individuals do not have an independent right to elect COBRA continuation coverage, if you elect COBRA continuation coverage for yourself, you may also cover your Dependents even if they are not considered qualified beneficiaries under COBRA. However, such individuals’ coverage will terminate when your COBRA continuation coverage terminates. The sections titled “Secondary Qualifying Events” and “Medicare Extension For Your Dependents” are not applicable to these individuals.
All causes for “Termination of COBRA Continuation” listed below will also apply to the period of disability extension. Medicare Extension for Your Dependents When the qualifying event is your termination of employment or reduction in work hours and you became enrolled in Medicare (Part A, Part B or both) within the 18 months before the qualifying event, COBRA continuation coverage for your Dependents will last for up to 36 months after the date you became enrolled in Medicare. Your COBRA continuation coverage will last for up to 18 months from the date of your termination of employment or reduction in work hours.
Secondary Qualifying Events If, as a result of your termination of employment or reduction in work hours, your Dependent(s) have elected COBRA continuation coverage and one or more Dependents experience another COBRA qualifying event, the affected Dependent(s) may elect to extend their COBRA continuation coverage for an additional 18 months (7 months if the secondary event occurs within the disability extension period) for a maximum of 36 months from the initial qualifying event. The second qualifying event must occur before the end of the initial 18 months of COBRA continuation coverage or within the disability extension period discussed below. Under no circumstances will COBRA continuation coverage be available for more than 36 months from the initial qualifying event. Secondary qualifying events are: your death; your divorce or legal separation; or, for a Dependent child, failure to continue to qualify as a Dependent under the Plan.
Termination of COBRA Continuation COBRA continuation coverage will be terminated upon the occurrence of any of the following:
Disability Extension If, after electing COBRA continuation coverage due to your termination of employment or reduction in work hours, you or
the end of the COBRA continuation period of 18, 29 or 36 months, as applicable;
failure to pay the required premium within 30 calendar days after the due date;
cancellation of the Employer’s policy with CIGNA;
after electing COBRA continuation coverage, a qualified beneficiary enrolls in Medicare (Part A, Part B, or both);
after electing COBRA continuation coverage, a qualified beneficiary becomes covered under another group health plan, unless the qualified beneficiary has a condition for which the new plan limits or excludes coverage under a preexisting condition provision. In such case coverage will continue until the earliest of: the end of the applicable
maximum period; the date the pre-existing condition provision is no longer applicable; or the occurrence of an event described in one of the first three bullets above; •
Each qualified beneficiary has an independent right to elect COBRA continuation coverage. Continuation coverage may be elected for only one, several, or for all Dependents who are qualified beneficiaries. Parents may elect to continue coverage on behalf of their Dependent children. You or your spouse may elect continuation coverage on behalf of all the qualified beneficiaries. You are not required to elect COBRA continuation coverage in order for your Dependents to elect COBRA continuation.
any reason the Plan would terminate coverage of a participant or beneficiary who is not receiving continuation coverage (e.g., fraud).
Employer’s Notification Requirements Your Employer is required to provide you and/or your Dependents with the following notices: •
An initial notification of COBRA continuation rights must be provided within 90 days after your (or your spouse’s) coverage under the Plan begins (or the Plan first becomes subject to COBRA continuation requirements, if later). If you and/or your Dependents experience a qualifying event before the end of that 90-day period, the initial notice must be provided within the time frame required for the COBRA continuation coverage election notice as explained below.
A COBRA continuation coverage election notice must be provided to you and/or your Dependents within the following timeframes: •
if the Plan provides that COBRA continuation coverage and the period within which an Employer must notify the Plan Administrator of a qualifying event starts upon the loss of coverage, 44 days after loss of coverage under the Plan;
if the Plan provides that COBRA continuation coverage and the period within which an Employer must notify the Plan Administrator of a qualifying event starts upon the occurrence of a qualifying event, 44 days after the qualifying event occurs; or
How Much Does COBRA Continuation Coverage Cost? Each qualified beneficiary may be required to pay the entire cost of continuation coverage. The amount may not exceed 102% of the cost to the group health plan (including both Employer and Employee contributions) for coverage of a similarly situated active Employee or family member. The premium during the 11-month disability extension may not exceed 150% of the cost to the group health plan (including both employer and employee contributions) for coverage of a similarly situated active Employee or family member. For example: If the Employee alone elects COBRA continuation coverage, the Employee will be charged 102% (or 150%) of the active Employee premium. If the spouse or one Dependent child alone elects COBRA continuation coverage, they will be charged 102% (or 150%) of the active Employee premium. If more than one qualified beneficiary elects COBRA continuation coverage, they will be charged 102% (or 150%) of the applicable family premium. When and How to Pay COBRA Premiums First payment for COBRA continuation If you elect COBRA continuation coverage, you do not have to send any payment with the election form. However, you must make your first payment no later than 45 calendar days after the date of your election. (This is the date the Election Notice is postmarked, if mailed.) If you do not make your first payment within that 45 days, you will lose all COBRA continuation rights under the Plan.
in the case of a multi-employer plan, no later than 14 days after the end of the period in which Employers must provide notice of a qualifying event to the Plan Administrator.
How to Elect COBRA Continuation Coverage The COBRA coverage election notice will list the individuals who are eligible for COBRA continuation coverage and inform you of the applicable premium. The notice will also include instructions for electing COBRA continuation coverage. You must notify the Plan Administrator of your election no later than the due date stated on the COBRA election notice. If a written election notice is required, it must be post-marked no later than the due date stated on the COBRA election notice. If you do not make proper notification by the due date shown on the notice, you and your Dependents will lose the right to elect COBRA continuation coverage. If you reject COBRA continuation coverage before the due date, you may change your mind as long as you furnish a completed election form before the due date.
Subsequent payments After you make your first payment for COBRA continuation coverage, you will be required to make subsequent payments of the required premium for each additional month of coverage. Payment is due on the first day of each month. If you make a payment on or before its due date, your coverage under the Plan will continue for that coverage period without any break. Grace periods for subsequent payments Although subsequent payments are due by the first day of the month, you will be given a grace period of 30 days after the first day of the coverage period to make each monthly payment. Your COBRA continuation coverage will be provided for each coverage period as long as payment for that
coverage period is made before the end of the grace period for that payment. However, if your payment is received after the due date, your coverage under the Plan may be suspended during this time. Any providers who contact the Plan to confirm coverage during this time may be informed that coverage has been suspended. If payment is received before the end of the grace period, your coverage will be reinstated back to the beginning of the coverage period. This means that any claim you submit for benefits while your coverage is suspended may be denied and may have to be resubmitted once your coverage is reinstated. If you fail to make a payment before the end of the grace period for that coverage period, you will lose all rights to COBRA continuation coverage under the Plan.
COBRA Continuation for Retirees Following Employer’s Bankruptcy If you are covered as a retiree, and a proceeding in bankruptcy is filed with respect to the Employer under Title 11 of the United States Code, you may be entitled to COBRA continuation coverage. If the bankruptcy results in a loss of coverage for you, your Dependents or your surviving spouse within one year before or after such proceeding, you and your covered Dependents will become COBRA qualified beneficiaries with respect to the bankruptcy. You will be entitled to COBRA continuation coverage until your death. Your surviving spouse and covered Dependent children will be entitled to COBRA continuation coverage for up to 36 months following your death. However, COBRA continuation coverage will cease upon the occurrence of any of the events listed under “Termination of COBRA Continuation” above.
You Must Give Notice of Certain Qualifying Events If you or your Dependent(s) experience one of the following qualifying events, you must notify the Plan Administrator within 60 calendar days after the later of the date the qualifying event occurs or the date coverage would cease as a result of the qualifying event: •
Your divorce or legal separation; or
Your child ceases to qualify as a Dependent under the Plan.
The occurrence of a secondary qualifying event as discussed under “Secondary Qualifying Events” above (this notice must be received prior to the end of the initial 18- or 29month COBRA period).
Trade Act of 2002 The Trade Act of 2002 created a new tax credit for certain individuals who become eligible for trade adjustment assistance and for certain retired Employees who are receiving pension payments from the Pension Benefit Guaranty Corporation (PBGC) (eligible individuals). Under the new tax provisions, eligible individuals can either take a tax credit or get advance payment of 65% of premiums paid for qualified health insurance, including continuation coverage. If you have questions about these new tax provisions, you may call the Health Coverage Tax Credit Customer Contact Center toll-free at 1-866-628-4282. TDD/TYY callers may call toll-free at 1866-626-4282. More information about the Trade Act is also available at www.doleta.gov/tradeact/2002act_index.cfm.
(Also refer to the section titled “Disability Extension” for additional notice requirements.) Notice must be made in writing and must include: the name of the Plan, name and address of the Employee covered under the Plan, name and address(es) of the qualified beneficiaries affected by the qualifying event; the qualifying event; the date the qualifying event occurred; and supporting documentation (e.g., divorce decree, birth certificate, disability determination, etc.).
In addition, if you initially declined COBRA continuation coverage and, within 60 days after your loss of coverage under the Plan, you are deemed eligible by the U.S. Department of Labor or a state labor agency for trade adjustment assistance (TAA) benefits and the tax credit, you may be eligible for a special 60 day COBRA election period. The special election period begins on the first day of the month that you become TAA-eligible. If you elect COBRA coverage during this special election period, COBRA coverage will be effective on the first day of the special election period and will continue for 18 months, unless you experience one of the events discussed under “Termination of COBRA Continuation” above. Coverage will not be retroactive to the initial loss of coverage. If you receive a determination that you are TAA-eligible, you must notify the Plan Administrator immediately.
Newly Acquired Dependents If you acquire a new Dependent through marriage, birth, adoption or placement for adoption while your coverage is being continued, you may cover such Dependent under your COBRA continuation coverage. However, only your newborn or adopted Dependent child is a qualified beneficiary and may continue COBRA continuation coverage for the remainder of the coverage period following your early termination of COBRA coverage or due to a secondary qualifying event. COBRA coverage for your Dependent spouse and any Dependent children who are not your children (e.g., stepchildren or grandchildren) will cease on the date your COBRA coverage ceases and they are not eligible for a secondary qualifying event.
Interaction With Other Continuation Benefits You may be eligible for other continuation benefits under state law. Refer to the Termination section for any other continuation benefits. HC-FED24
the discretionary authority to perform a full and fair review, as required by ERISA, of each claim denial which has been appealed by the claimant or his duly authorized representative.
ERISA Required Information The name of the Plan is: Wentworth Institute of Technology, Inc.
Plan Modification, Amendment and Termination The Employer as Plan Sponsor reserves the right to, at any time, change or terminate benefits under the Plan, to change or terminate the eligibility of classes of employees to be covered by the Plan, to amend or eliminate any other plan term or condition, and to terminate the whole plan or any part of it. The procedure by which benefits may be changed or terminated, by which the eligibility of classes of employees may be changed or terminated, or by which part or all of the Plan may be terminated, is contained in the Employer’s Plan Document, which is available for inspection and copying from the Plan Administrator designated by the Employer. No consent of any participant is required to terminate, modify, amend or change the Plan.
The name, address, ZIP code and business telephone number of the sponsor of the Plan is: Wentworth Institute of Technology, Inc. 550 Huntington Ave. Boston, MA 02115 617-989-9010 Employer Identification Number (EIN)
The name, address, ZIP code and business telephone number of the Plan Administrator is: Employer named above
Termination of the Plan together with termination of the insurance policy(s) which funds the Plan benefits will have no adverse effect on any benefits to be paid under the policy(s) for any covered medical expenses incurred prior to the date that policy(s) terminates. Likewise, any extension of benefits under the policy(s) due to you or your Dependent’s total disability which began prior to and has continued beyond the date the policy(s) terminates will not be affected by the Plan termination. Rights to purchase limited amounts of life and medical insurance to replace part of the benefits lost because the policy(s) terminated may arise under the terms of the policy(s). A subsequent Plan termination will not affect the extension of benefits and rights under the policy(s).
The name, address and ZIP code of the person designated as agent for service of legal process is: Employer named above The office designated to consider the appeal of denied claims is: The CIGNA claim office responsible for this Plan The cost of the Plan is shared by Employee and Employer. The Plan’s fiscal year ends on 12/31. The preceding pages set forth the eligibility requirements and benefits provided for you under this Plan. Plan Trustees A list of any Trustees of the Plan, which includes name, title and address, is available upon request to the Plan Administrator.
Your coverage under the Plan’s insurance policy(s) will end on the earliest of the following dates:
Plan Type The plan is a health care benefit plan. Collective Bargaining Agreements You may contact the Plan Administrator to determine whether the Plan is maintained pursuant to one or more collective bargaining agreements and if a particular Employer is a sponsor. A copy is available for examination from the Plan Administrator upon written request.
the date you leave Active Service (or later as explained in the Termination Section;)
the date you are no longer in an eligible class;
if the Plan is contributory, the date you cease to contribute;
the date the policy(s) terminates.
See your Plan Administrator to determine if any extension of benefits or rights are available to you or your Dependents under this policy(s). No extension of benefits or rights will be available solely because the Plan terminates.
Discretionary Authority The Plan Administrator delegates to CIGNA the discretionary authority to interpret and apply plan terms and to make factual determinations in connection with its review of claims under the plan. Such discretionary authority is intended to include, but not limited to, the determination of the eligibility of persons desiring to enroll in or claim benefits under the plan, the determination of whether a person is entitled to benefits under the plan, and the computation of any and all benefit payments. The Plan Administrator also delegates to CIGNA
Statement of Rights As a participant in the plan you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to: Receive Information About Your Plan and Benefits examine, without charge, at the Plan Administrator’s office and at other specified locations, such as worksites and union
halls, all documents governing the plan, including insurance contracts and collective bargaining agreements and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure room of the Employee Benefits Security Administration. •
obtain, upon written request to the Plan Administrator, copies of documents governing the Plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies.
receive a summary of the Plan’s annual financial report. The Plan Administrator is required by law to furnish each person under the Plan with a copy of this summary financial report.
Enforce Your Rights Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the plan administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal court. In addition, if you disagree with the plan’s decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in federal court. If it should happen that plan fiduciaries misuse the plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example if it finds your claim is frivolous.
Continue Group Health Plan Coverage • continue health care coverage for yourself, your spouse or Dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your Dependents may have to pay for such coverage. Review this summary plan description and the documents governing the Plan on the rules governing your federal continuation coverage rights. •
reduction or elimination of exclusionary periods of coverage for preexisting conditions under your group health plan, if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage under the plan, when you become entitled to elect federal continuation coverage, when your federal continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a preexisting condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage.
Assistance with Your Questions If you have any questions about your plan, you should contact the plan administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the plan administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.
Prudent Actions by Plan Fiduciaries In addition to creating rights for plan participants, ERISA imposes duties upon the people responsible for the operation of the employee benefit plan. The people who operate your plan, called “fiduciaries” of the Plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer, your union, or any other person may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. If your claim for a welfare benefit is denied or ignored you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.
Definitions Active Service You will be considered in Active Service: •
on any of your Employer's scheduled work days if you are performing the regular duties of your work on a full-time basis on that day either at your Employer's place of business or at some location to which you are required to travel for your Employer's business.
on a day which is not one of your Employer's scheduled work days if you were in Active Service on the preceding scheduled work day.
No one may be considered as a Dependent of more than one Employee. HC-DFS126
04-10 V1 M
Employee The term Employee means a full-time employee of the Employer who is currently in Active Service. It also includes eligible retired Employees, as reported by the Employer. The term does not include employees who are part-time or temporary, or who normally work less than 17.5 hours a week for the Employer.
Contracted Fee The term Contracted Fee refers to the total compensation level that a provider has agreed to accept as payment for dental procedures and services performed on an Employee or Dependent, according to the Employee's dental benefit plan. HC-DFS123
Dentist The term Dentist means a person practicing dentistry or oral surgery within the scope of his license. It will also include a physician operating within the scope of his license when he performs any of the Dental Services described in the plan. HC-DFS125
Employer The term Employer means the plan sponsor self-insuring the benefits described in this booklet, on whose behalf CIGNA is providing claim administration services.
Dependent Dependents are:
Maximum Reimbursable Charge The Maximum Reimbursable Charge is the lesser of:
your lawful spouse; and
the provider’s normal charge for a similar service or supply; or
any child of yours who is
the policyholder-selected percentile of all charges made by providers of such service or supply in the geographic area where it is received.
less than 26 years old.
26 years old or older, primarily supported by you and incapable of self-sustaining employment by reason of mental or physical disability. Proof of the child's condition and dependence must be submitted to CIGNA within 31 days after the date the child ceases to qualify above. From time to time, but not more frequently than once a year, CIGNA may require proof of the continuation of such condition and dependence.
To determine if a charge exceeds the Maximum Reimbursable Charge, the nature and severity of the Injury or Sickness may be considered. CIGNA uses the Ingenix Prevailing Health Care System database to determine the charges made by providers in an area. The database is updated semiannually. The percentile used to determine the Maximum Reimbursable Charge is listed in the Schedule.
The term child means a child born to you or a child legally adopted by you. It also includes a stepchild who lives with you, a foster child, or a child for whom you are the legal guardian.
Additional information about the Maximum Reimbursable Charge is available upon request. HC-DFS130
Benefits for a Dependent child or student will continue until the last day of the calendar month in which the limiting age is reached.
Medicaid The term Medicaid means a state program of medical aid for needy persons established under Title XIX of the Social Security Act of 1965 as amended.
Anyone who is eligible as an Employee will not be considered as a Dependent.
Medicare The term Medicare means the program of medical care benefits provided under Title XVIII of the Social Security Act of 1965 as amended. HC-DFS17
Participating Provider The term Participating Provider means: A Dentist, or a professional corporation, professional association, partnership, or other entity which is entered into a contract with CIGNA to provide dental services at predetermined fees. The providers qualifying as Participating Providers may change from time to time. A list of the current Participating Providers will be provided by your Employer. HC-DFS136