Group Dental Insurance

For Your Employees and Their Families Underwritten By:

S11447 Rev. 06/2015


Insurance Overview SIHO understands that dental care is important to our members overall health and that comprehensive coverage should not be limited to just large employer groups. SIHO Dental is designed to provide dental coverage for smaller employers and their employees. SIHO Dental makes it easy to provide coverage:  Insurance coverage is offered on a voluntary basis with no cost to the employer. If an employer chooses to help pay for the cost of coverage, premium rates will be even lower!  The participation minimum is only two employees and is determined at the time of initial enrollment.  Participants are free to use their dentist of choice with SIHO Dental.  Employers and employees need complete only one application for both SIHO Health and SIHO Dental coverage.  SIHO will send just one bill to the employer for both health plan and dental coverage.  Participation in the SIHO health plan is not required.

Plan Options SIHO Dental offers three plan design options to meet the needs of any employer, the comprehensive Preferred Plan, mid-level Standard Plan, and lowest cost Value Plan.

General Information SIHO Dental is provided through a partnership with Security Life Insurance Company of America. Due to our relationship with Security Life employers do not have to worry about separate eligibility, coverage or premium payment rules for the dental coverage. The requirements for SIHO Dental are the same as SIHO Health coverage. Premiums, Renewability Applicable Premium Rates are guaranteed for each Participating Employer Unit for 12 months from date of issue. Thereafter, rates are subject to change in accordance with the Master Policy. Coverage is renewable as long as eligibility criteria are satisfied and premiums are paid when due. Participation Discount In the event the final dental employee participation reaches the greater of three employees or 50% of the eligible employees, your monthly premium rates charged may be reduced by 10%. Final approval of this discount is to be made by the insurance company. SIHO Vision Discount If the employer group offers SIHO Vision with SIHO Dental and participation requirements are met for both, the premium rates for both products will be reduced by 5%.

Insurance Designs Services

Preferred Plan

Standard Plan

Value Plan

Calendar Year Deductible

$50 Individual $150 Family Waived for Preventive & Diagnostic

$75 Individual $225 Family Waived for Preventive & Diagnostic

$100 Individual $300 Family Waived for Preventive & Diagnostic
























Not Covered

Calendar Year Benefit Maximum


Lifetime Orthodontia Maximum Calendar Year Maximum Preventive Services

    

Oral Exam every 6 Months Routine Cleanings every 6 Months Fluoride Treatment for Children every 6 Months Space Maintainers for Children Topical Sealants for unrestored molar teeth – 1 treatment for Children in a 3 year period

Diagnostic Services

 

Bitewing X-Rays – once every 12 months Full mouth - once every 3 years

Basic Services

    

Amalgam, Silicate & Composite Fillings+ Stainless Steel Crowns Simple Extractions Repairs of dentures, bridgework, crowns, etc. Periodontal Maintenance Cleanings

Major Services (12-month waiting period)*

      

Oral Surgery & Complex Extractions Periodontal Therapy Endodontic Therapy Full & Partial Dentures Implants Crowns Bridges

Orthodontia (for children under age 19) (12-month waiting period)*

! You may increase the Calendar Year Maximum Benefit per individual by either $500 or $1,000 for an additional monthly fee. + No limit on number of fillings per visit or per year.

 Does not apply if Employer Group is currently offering equivalent dental coverage. The plan reimburses at the above percentages for covered dental expenses based upon Reasonable and Customary (R & C) fees for those covered expenses.

Insurance Details Benefit Provisions, Limitations and Exclusions Eligible Expenses We will pay for Eligible Expenses You incur for Yourself or on behalf of Your insured Dependent. Expenses must be incurred while the Policy is in force and the person is covered by the Policy. The description of Eligible Expenses is shown in the Coverage Schedule. Expenses Incurred An Eligible Dental Expense is considered incurred on the following dates: For full and partial dentures the date the final impression is taken; for fixed bridges, crowns, inlays and onlays - the date the teeth are first prepared; for root canal therapy - on the date the pulp chamber is opened; for periodontal surgery - on the date surgery is performed; for all other services - the date the service is performed.

Deductible Amount The calendar year Deductible, if any, is shown in the Coverage Schedule. The Deductible is an amount of charges You must incur for yourself or on behalf of your insured Dependent before we start paying benefits. Dental Maximum Calendar Year Limit The maximum limit payable for all Eligible Expenses in any calendar year is shown in the Coverage Schedule. The Maximum Calendar Year Limit, if any, will apply to each person covered under the Policy.

Insurance Details Dental Pretreatment Review If the Dental Course of Treatment will exceed the amount shown in the Coverage Schedule, We will request prior review. We must be given the Dentist's treatment plan consisting of a description of the planned treatment with estimated charges and diagnostic x-rays.

Dental Alternate Benefit If: 1) We determine that a less

We will determine Eligible Expenses

expensive alternate procedure,

and state how much We will pay for

service or Course of Treatment

the treatment. Our determination may

can be performed in place of the

suggest an alternate less expensive

proposed treatment to correct a

Course of Treatment if it will produce

dental condition; and 2) the

professionally satisfactory results. If

alternative treatment will produce

You do not request a pretreatment

a professionally satisfactory result;

review We will pay for the least expen-

then the maximum We will allow

sive method of treatment regardless of

will be the charge for the less

the method actually used.

expensive treatment.

Insurance Details Missing Tooth When covered under your plan, benefits are provided for placement of dentures, fixed bridgework, implants or the addition of teeth to existing dentures only when the service includes replacement of a natural tooth extracted or lost while covered under this plan. This limitation ends after the individual receiving care has been covered under this plan for 36 consecutive months.

Insurance Details Dental Expenses NOT Covered The Policy, under which your certificate is issued, covers services and procedures as described in the Coverage Schedule. Your coverage, under the policy, does not cover any miscellaneous separate expense not considered a covered service or procedure. No benefits will be paid for expenses incurred: 1. for overdentures and associated procedures. 2. for charges in excess of those considered reasonable and customary. 3. for cosmetic procedures. 4. for the replacement of dentures, bridges, inlays, onlays or crowns that can be repaired or restored to normal function. 5. for replacement of lost or stolen appliances and for: a. replacement of retainers; b. athletic mouthguards; c. precision or semi-precision attachments; d. denture duplication; 6. for oral hygiene instructions; and for: a. plaque control; b. completion of a claim form; c. acid etch; d. broken appointments; e. prescription or take-home fluoride; or f. diagnostic photographs. 7. for services not completed by the end of the month in which coverage ends, unless continuation of coverage has been requested and accepted by us. 8. for procedures that are begun, but not completed. 9. for services and treatment provided without charge or for which there would be no charge in the absence of insurance. 10. for services in connection with war or any act of war, whether declared or undeclared, or condition contracted or accident occurring while on full-time active duty in the armed forces of any country or combination of countries. 11. for a condition covered under any Worker's Compensation Act or similar law. 12. that are applied toward satisfaction of a Deductible, if any. 13. that are generally considered by the dental profession as experimental or investigational. 14. for the treatment of cleft palate and anodontia. 15. for services or supplies payable under any medical expense plan. 16. for orthodontia, unless included by rider. 17. prior to the date the Insured is covered under the Policy. 18. for the diagnosis or treatment of Temporomandibular Joint Dysfunction (TMJD); 19. for hospital services. 20. for any dependent over the age of 26. 21. if You voluntarily end Your insurance, You will not be eligible to re-enroll for a period of 2 years after the date Your coverage first ended; 22. charges for infection control, sterilization, and waste disposal.

This provides a very brief description of some of the important features of the insurance policy. It is not the insurance policy and does not represent it. A full explanation of benefits, exceptions and limitations is contained in the Certificate of Insurance under Group Dental Policy Form GH-1112 (and any state specific). Premium rates may change upon renewal. This policy is renewable at the option of the Company. This product may not be available in all states and is subject to individual state regulations. Underwritten by Security Life Insurance Company of America. 10901 Red Circle Drive, Minnetonka, MN 55343.