Coventry Health and Life Insurance Company. Dental Insurance Rider

Coventry Health and Life Insurance Company Dental Insurance Rider This Rider is issued in consideration of the required Premium and amends the Policy ...
Author: Erin Ward
2 downloads 0 Views 41KB Size
Coventry Health and Life Insurance Company Dental Insurance Rider This Rider is issued in consideration of the required Premium and amends the Policy to which it is attached. All definitions, provisions, terms, Limitations, Exclusions, and conditions of the Policy apply to this Rider except to the extent such terms and conditions are explicitly superseded or modified by this Rider. The Effective Date of this Rider shall be consistent with the effective date of Your Policy. Services Performed Outside the United States of America Any claim submitted for procedures performed outside the U.S.A. must: (1) be for a Covered Service; (2) be supplied in English; and (3) use American Dental Association (ADA) codes or provide a narrative of the services received. Reimbursement will be based on the Maximum Allowable Charge for Your zip code. Covered Percentage and Deductibles The Covered Percentage and Deductible amounts are listed in Your Dental Schedule of Payments, attached hereto. We will pay the Covered Percentage amount, calculated using a fixed percentage, each time You receive Covered Dental Services. The Deductible is the dollar amount of dental expenses for Covered Dental Services that You must incur before benefits subject to the Deductible are payable under this Rider. Annual Maximum The Annual Maximum payable per Insured is listed in the Dental Schedule of Payments. The benefits paid for In-Network and for Out-of-Network Dental Services are combined to determine when the Annual Maximum is reached. SECTION 1 COVERED PREVENTIVE AND DIAGNOSTIC SERVICES This Rider covers only those Dental Services that are (1) listed below; (2) determined to be Medically Necessary; and (3) not excluded under the Exclusions and Limitations set forth in Section 2. You must be Covered under the Rider on the date the service is provided, except as described in the Extension of Benefits provision. Your payment responsibility for Covered Dental Services is listed in the Dental Schedule of Payments. • • • •

Periodic Oral Evaluation – two per Contract Year Comprehensive Oral Evaluation – one evaluation with new Dentist Prophylaxis - Adult – two per Contract Year Prophylaxis - Dependent Child – two per Contract Year

CHL(MD) 809.1

1 of 6

Individual Dental Rider 05/09 CHDE 4259M

SECTION 2 LIMITATIONS AND EXCLUSIONS All Benefits are subject to the following exclusions and limitations and frequency limits: 1. Coverage is limited to those services set forth in Section 1 - Covered Preventive and Diagnostic Services. If a service is not listed, it is not included and is not Covered. 2. Services furnished solely for cosmetic reasons are not Covered. 3. Fees related to broken appointments, preparing or copying dental reports, duplication of x-rays, itemized bills or claim forms are not Covered. 4. Treatment for injuries or conditions covered by Workers’ Compensation or employer liability laws, and treatment provided without cost to the Insured by any municipality, county, or other political subdivision is not covered. This exclusion does not apply to any treatment covered by Medicaid or Medicare. 5. Treatment as a result of, civil insurrection, duty as a member of the armed forces of any state or country, engaging in an act of declared or undeclared war, intentional or unintentional nuclear explosion or other release of nuclear energy, whether in peacetime or wartime is not Covered except if the intentional or unintentional nuclear explosion was the result of a crime. 6. Treatment of congenital or developmental malformations or the replacement of congenitally missing teeth is not Covered. 7. Examination, evaluation and treatment of temporomandibular joint (TMJ) pain dysfunction is not Covered unless otherwise provided for in the Policy to which this Rider is attached. 8. Treatment of jaw fractures or orthognathic surgery is not Covered 9. Consultations and/or evaluation for non-covered services is not Covered 10. Analgesia, anxiolysis, inhalation of nitrous oxide or non-intravenous sedation is not Covered. 11. Any procedure or treatment method which does not meet professionally recognized standards of dental practice or which is considered to be experimental in nature is not Covered. 12. Any outpatient facility, surgicenter facility, or inpatient hospital facility and associated facility charges, services and supplies is not Covered 13. House, extended care facility calls, hospital calls, office visits for observation (during regularly scheduled hours) when no other services are provided, office visits after regularly scheduled hours or case presentations is not Covered. 14. Drugs obtainable with or without a prescription are not Covered. 15. Fees for equipment sterilization, OSHA or other regulatory agency requirements or mandates, infection control, and medical waste disposal is not Covered 16. Treatment that is not described by the most recent (current edition) of the American CHL(MD) 809.1

2 of 6

Individual Dental Rider 05/09 CHDE 4259M

Dental Association (ADA) CDT (current dental terminology) book is not Covered. SECTION 3 RIDER TERMINATION 3.1


This Rider will terminate on the earliest of the following: 1. The date the Policy terminates; 2. The date the premium for this Rider is not paid, subject to the Policy’s “Grace Period” provision; 3. The date the Subscriber sends a notice to Us to terminate this Rider subject to the Policy’s “Termination by Subscriber” provision. 3.2


If the Policy is reinstated at the same time, We will reinstate this Rider subject to the “Reinstatement” provision in the Policy. Except for the above and any new provisions We may require for reinstatement, Your rights and Our rights under this Rider will be the same as just before the Rider lapsed.

SECTION 4 DEFINITIONS Any capitalized terms listed in this Section shall have the meaning set forth below whenever the capitalized term is used in this Rider. 4.1

Dental Care Provider

A Dentist, Dental Hygienist, Physician or Nurse as those terms are specifically defined in this section. 4.2

Dental Hygienist

A person trained and licensed to perform dental hygiene services, such as prophylaxis (cleaning of teeth), under the direction of a licensed Dentist. 4.3

Dental Services

The services or supplies provided to You for which We will make payment, as described in this Rider.

CHL(MD) 809.1

3 of 6

Individual Dental Rider 05/09 CHDE 4259M



A person acting within the scope of his/her license, holding the degree of Doctor of Medicine (M.D.), Doctor of Dental Surgery (D.D.S.) or Doctor of Dental Medicine (D.M.D.), and who is legally entitled to practice dentistry in all its branches under the laws of the state or jurisdiction where the services are rendered. 4.5

Maximum Allowable Charge

Benefits are calculated using a Maximum Allowable Charge. The Maximum Allowable Charge is a rate established by us based upon data provided by Ingenix. You may call customer service at the telephone number listed on your identification card to find out the Maximum Allowable Charge for a particular dental procedure code. 4.6

Non-participating Dental Care Provider

A Dental Care Provider who has no direct or indirect written agreement with Us to provide Covered Dental Services to Insureds. 4.7


A person acting within the scope of his/her license and holding the degree of Registered Graduate Nurse (R.N.) or Licensed Practical Nurse (L.P.N.). 4.8

Participating Dental Care Provider

A Provider who has entered into a direct or indirect written agreement with Us to provide Covered Dental Services to Insureds. The participation status of Dental Care Providers may change from time to time. 4.9


With respect to the term Participating Provider, as defined in the Policy, with respect to Covered Dental Services, Participating Provider shall also include Participating Dental Care Providers. 4.10

Out-of-Network Rate

For purposes of Covered Dental Services provided by Out-of-Network Dental Care Providers, the Out-of-Network Rate shall be the Maximum Allowable Charge. 4.11

We, Us or Our

Coventry Health and Life Insurance Company

CHL(MD) 809.1

4 of 6

Individual Dental Rider 05/09 CHDE 4259M


You or Your(s)

The Member Extension of Benefits Pursuant to Maryland law, covered benefits shall be provided, in accordance with the policy in effect at the time the individual's coverage terminates, for a course of treatment for at least 90 days after the date coverage terminates if the treatment: (i) begins before the date coverage terminates; and (ii) requires two or more visits on separate days to a dentist's office. Additionally, if orthodontic coverage is provided, coverage for orthodontics shall provide covered benefits, in accordance with the policy in effect at the time the individual's coverage terminates, for orthodontics: (i) for 60 days after the date coverage terminates if the orthodontist has agreed to or is receiving monthly payments; or (ii) until the later of 60 days after the date coverage terminates or the end of the quarter in progress, if the orthodontist has agreed to accept or is receiving payments on a quarterly basis. DENTAL SCHEDULE OF PAYMENTS

Covered Percentage Deductible Your Reimbursement Annual Maximum

CHL(MD) 809.1

In-Network Out-of-Network 100% of Maximum Allowable 100% of the Maximum Charge Allowable Charge $0 $0 Maximum Allowable Charge Maximum Allowable Charge $500

5 of 6

Individual Dental Rider 05/09 CHDE 4259M

*Your CoventryOne PPO benefit plan provides coverage for out-of-network services. Many out-of-

network services are covered ONLY if they are prior authorized. You are responsible for making sure that any services you receive from a non-participating provider are prior authorized. When you receive out-of-network covered services from a non-participating provider, you must pay applicable copayments, coinsurance, and deductibles. In addition, in most cases, the non-participating

providers may bill you for charges that exceed our out-of-network rate. This amount could be substantial. Balances above the Out-of-Network Rate do NOT apply to your out-of-pocket maximum. The Out-of-Network Rate is the maximum amount covered by Us for approved out-of-network services. This rate will be derived from either • a Medicare based fee schedule, or • a percent of billed charges as determined by Us. We will base the development of the rate on the following: •

Non-Participating Physicians Fees. The Out-of-Network Rate is equivalent to 125% of the then-current Participating Provider Fee-Schedule, based on geographic region.

Non-Participating Facility Fees. • Inpatient facility services will be paid at the rate approved by the Health Services Cost Review Commission. • Outpatient services rendered in a non-Hospital facility are paid at either • Our Non-Participating non-Hospital fee schedule, which results in approximately 72% of the 2004 Medicare reimbursement schedule for ASC’s (“Ambulatory Surgical Centers”). For a copy of this fee schedule, please contact Customer Services; or • If Medicare has not yet priced a particular code, 60% of billed charges for such code. When We determine the Out-of-Network fee schedule, We reserve the right to apply • • •

proprietary reimbursement guidelines, claim adjudication procedures, and billing instructions.

This is not a contract or a definitive statement of benefits. It is intended solely to provide you with an overview of the proposed CoventryOne benefits. Complete details of benefits, terms and exclusions are governed by your CoventryOne Certificate of Insurance. The CoventryOne Certificate of Insurance may not cover all your health care expenses. Read your Certificate of Insurance carefully to determine which health care services are covered. If you have questions call us toll free at 1-800833-7423.

CHL(MD) 809.1

6 of 6

Individual Dental Rider 05/09 CHDE 4259M

Suggest Documents