Optional Dental Benefits For Employees Table of Contents Table of Contents Participation Requirements/Enrollment Procedures........................................................................... 2 Eligibility Requirements......................................................................................................................... 3 Dental 3000 Prepaid Benefit Summary................................................................................................ 4 by SmileSaverSM Dental 1000 Prepaid Benefit Summary................................................................................................ 5 by SmileSaverSM Prepaid Dental 3000 & 1000.................................................................................................................. 6 Exclusions & Limitations Dental EPO 3000 & 3500, PPO 4000 & 5000 Benefit Summaries...................................................7-8 by Ameritas Group Dental EPO 3000 & 3500, PPO 4000 & 5000........................................................................................ 9 Exclusions & Limitations Participation Requirements/Enrollment Procedures This guide explains the various dental benefit designs that are available through HSA California. Please ask your health plan administrator which plans are available at your company. Optional Dental Sections: Prepaid Dental Plan 3000 by SmileSaverSM Prepaid Dental Plan 1000 by SmileSaverSM EPO Dental Plan 3000 by Ameritas Group EPO Dental Plan 3500 by Ameritas Group PPO Dental Plan 4000 by Ameritas Group PPO Dental Plan 5000 by Ameritas Group Participation Requirements Prepaid Dental Plans 3000 & 1000, EPO Plan 3000 & 3500 and PPO Dental Plans 4000 & 5000 These benefit designs must be offered through your company. You will be responsible for any supplemental premiums, as well as member copays that apply to listed services. Enrollment Procedures 1. Ask your health plan administrator for a list of available plans. 2. Complete the Dental Coverage Section of your enrollment application. 3. Return the completed Application to your health plan administrator. *Does not qualify as comparable dental coverage and will not count toward prior credit. 2 Eligibility Requirements Eligibility Requirements To qualify for dental coverage in the Prepaid Dental Plan 3000 & 1000, EPO 3000 & 3500 and PPO 4000 & 5000 through HSA California, the following conditions must be met: Employee 1. Employees must work the minimum number of hours required to be considered eligible for benefits as determined by the employer. (Employees working less than 20 hours per week, as well as inactive owners, contracted (1099), temporary, permanent employees who are eligible for medical healthcare coverage by or through a union, seasonal or substitute workers are not eligible). 2. You have to be employed by your company for a pre-established length of time or waiting period. If you are enrolled and have a spouse and/or children, they may also qualify for coverage under your plan. Dependents SPOUSE must be legally married to you in order to be eligible. Children For Prepaid Dental Plan 1000, 3000: Born to, a step-child or legal ward of, or adopted by eligible employee, employee spouse or domestic partner Under age 26 (unless disabled, disability diagnosed prior to age 26) For Dental Plan EPO 3000, EPO 3500, PPO 4000 and PPO 5000: Born to, a step-child or legal ward of, or adopted by eligible employee, employee spouse or domestic partner Financially dependent upon the employee per IRS guidelines Unmarried or not involved in a domestic partnership. Under age 26 (unless disabled, disability diagnosed prior to age 26) Disabled Dependents: Dependents who are incapable of self-support because of continuous mental or physical disability that existed before the age limit are eligible for coverage until the incapacity ends. Documentation of disability will be requested. Once the child reaches the age limit for coverage, verification of eligibility will occur annually at the child’s birthday You are not required to extend coverage to your spouse or dependent children. To decline coverage on their behalf, you must complete and sign the waiver section of the enrollment application. Enrollment for spouse and children is contingent upon employee enrollment. The dependent makeup for dental and medical coverage must be the same. However, if your dependents are not enrolled in medical, any dependent makeup for dental is acceptable. Domestic Partner Coverage Requirements: At time of employee eligibility for enrollment, the employee and partner must fall into all of the following categories: Share a common residence Neither is married under either statutory, common law or part of another domestic partnership Both be 18 years of age or older Share an intimate and committed relationship Agree to be jointly responsible for each other’s basic living expenses incurred during the domestic relationship Both be mentally competent Not related by blood to a degree of closeness that would prohibit marriage in this state Agree to notify HSA California immediately upon termination of domestic partnership Members who are in a same sex partnership or are over the age of 62 are required to submit a statestamped Certificate of Registration of Domestic Partnership from a state or local government agency authorized to perform such registrations within 30 days of issue; all others must submit a signed Affidavit of Domestic Partnership. 3 Dental 3000 Prepaid Benefit Summary Dental Plan 3000 by SmileSaverSM - Prepaid Dental Plan (Also available as a Voluntary Plan) This is a summary of benefits for the Dental Plan 3000, a prepaid dental plan offered through HSA California. To be eligible, your employer must be located within the plan service area shown below. If you are enrolled in the Dental Plan 3000, you need to choose a participating dentist from the SmileSaverSM network (You can look up a dentist through the Online Provider Directory at www.hsacalifornia.com). These dentists will provide dental care for any employee and dependents who are enrolled in the plan. Summary of Benefits and Member Copays Office Visits During regular hours ...................................................... No charge Emergency office visit (After regular hours )....................... $ 30.00 Diagnostic Comprehensive oral exam.............................................. No charge Periodic oral exam........................................................... No charge Oral hygiene instruction................................................. No charge X-rays, complete series................................................... No charge Bitewing X-rays................................................................ No charge Preventive Teeth cleaning - adult (1 every 6 months)..................... No charge Teeth cleaning - child (1 every 6 months)..................... No charge Restorative Amalgam Restorations Primary teeth Cavities - 1 surface.................................................................. $ 9.00 Cavities - 2 surfaces............................................................... $ 14.00 Cavities - 3 surfaces .............................................................. $ 22.00 Cavities - 4 or more surfaces................................................ $ 25.00 Amalgam Restorations Permanent teeth Cavities - 1 surface ................................................................. $ 9.00 Cavities - 2 surfaces............................................................... $ 14.00 Cavities - 3 surfaces .............................................................. $ 22.00 Cavities - 4 or more surfaces................................................ $ 25.00 Resin Restorations Permanent teeth Composite resin - 1 surface, anterior tooth........................ $ 25.00 Composite resin - 2 surfaces, anterior tooth...................... $ 35.00 Composite resin - 1 surface, posterior tooth...................... $ 60.00 Composite resin - 2 surfaces, posterior tooth.................... $ 85.00 Periodontics Gingivectomy/gingivoplasty, per quadrant........................ $ 85.00 Periodontal scaling/root planing - per quadrant............... $ 26.00 Prepaid Dental Plan 3000 Service Area Dental coverage is available throughout these counties: Alameda Contra Costa Fresno Imperial Kern Los Angeles Marin Monterey Napa Orange Riverside Sacramento SanBernardino San Diego San Francisco San Joaquin San Luis Obispo San Mateo Santa Barbara Santa Clara Santa Cruz Sonoma Tulare Ventura Crowns* Crown - porcelain with metal (anterior)............................. $ 120.00 Crown - porcelain with metal (posterior)........................... $ 225.00 Crown - full cast metal........................................................$ 115.00 Crown - stainless steel (primary or permanent)................$ 40.00 Endodontics Single root canal therapy (anterior)................................... $ 100.00 Bi-root canal (bicuspid)....................................................... $ 135.00 Molar root canal.................................................................. $ 185.00 Dentures and Partials Complete upper or lower denture.................................... $ 120.00. Immediate upper or lower denture................................... $ 175.00 Partial upper or lower, acrylic base (including conventional clasps and rests)........................................... $ 110.00 Oral Surgery (extractions) Single tooth............................................................................ $ 10.00 Each additional tooth............................................................ $ 10.00 Surgical removal of erupted tooth...................................... $ 25.00 Soft tissue impaction............................................................. $ 35.00 Partial bony impaction.......................................................... $ 50.00 Orthodontics** Orthodontics - adult full upper and lower banded case.................................. $ 1,950.00 Orthodontics - child (Up to age 19) full upper and lower banded case.................................. $ 1,600.00 *Cost of high noble metal (gold, etc.) may be charged extra when used. Not to exceed actual laboratory cost of metal. ** 24 month treatment And within the following zip codes in these counties: Amador: 95654 Madera: 93637, 93638 Butte: 95914, 95917, 95948 Mariposa: 95338 Colusa: 95950 Mendocino: 95427, 95482 El Dorado: 95630, 95667, 95682 Merced: 95301, 95303, 95312, 95315, 95317, 95333, 95334, 95339, 95340, 95341, 95342, 95343, 95344, 95348, 95365 Humboldt: 95501, 95502, 95521, 95525, 95534, 95536, 95537, 95540, 95547, 95549, 95550, 95551, 95556 Kings: 93230, 93291 Placer: 95603, 95616, 95650, 95661, 95677, 95678, 96145 San Benito: 95023, 95024, 95043, 95045 Shasta: 96001, 96002, 96003, 96007, 96019, 96022, 96033, 96047, 96062, 96073, 96079, 96087, 96089, 96095 Solano: 94510, 94533, 94535, 94585, 94589, 94590, 94591, 95620, 95687, 95688 Yolo: 95605, 95616, 95691, 95695 Yuba: 95369, 95692, 95901, 95918, 95919, 95961 Stanislaus: 95307, 95319, 95328, 95350, 95352, 95353, 95354, 95355, 95356, 95361, 95367, 95368, 95380, 95381, 95384 Sutter: 95659, 95668, 95674, 95676, 95953, 95957, 95982, 95991 4 Dental 1000 Prepaid Benefit Summary Dental Plan 1000 by SmileSaverSM - Prepaid Dental Plan This is a summary of benefits for the Dental Plan 1000, a prepaid dental plan offered through HSA California. To be eligible, your employer must be located within the plan service area shown below. If you are enrolled in the Dental Plan 1000, you need to choose a participating dentist from the SmileSaverSM network (You can look up a dentist through the Online Provider Directory at www.hsacalifornia.com). These dentists will provide dental care for any employee and dependents who are enrolled in the plan. Summary of Benefits and Member Copays Office Visits During regular hours ......................................................No charge Emergency office visit (After regular hours ).......................$ 20.00 Broken appointment (Without 24 hour notice)...................$ 20.00 Diagnostic Comprehensive oral exam..............................................No charge Periodic oral exam...........................................................No charge Oral hygiene instruction..................................................No charge X-rays, complete series...................................................No charge Bitewing X-rays................................................................No charge Preventive Teeth cleaning - adult (1 every 6 months)......................No charge Teeth cleaning - child (1 every 6 months)......................No charge Restorative - Amalgam Restorations Primary teeth Cavities - 1 surface...........................................................No charge Cavities - 2 surfaces.........................................................No charge Cavities - 3, 4 or more surfaces ......................................No charge Amalgam Restorations Permanent teeth Cavities - 1 surface ..........................................................No charge Cavities - 2 surfaces.........................................................No charge Cavities - 3, 4 or more surfaces ......................................No charge Resin Restorations Permanent teeth Composite resin - 1 surface, anterior tooth.........................$ 10.00 Composite resin - 2 or 3 surfaces, anterior tooth...............$ 10.00 Composite resin - 1 surface, posterior tooth......................$ 60.00 Composite resin - 2 surfaces, posterior tooth.....................$ 85.00 Periodontics Gingivectomy/gingivoplasty, per quadrant...................No charge Periodontal scaling/root planing - per quadrant................$ 20.00 Prepaid Dental Plan 1000 Service Area Dental coverage is available throughout these counties: Alameda Contra Costa Fresno Imperial Kern Los Angeles Marin Monterey Napa Orange Riverside Sacramento 5 SanBernardino San Diego San Francisco San Joaquin San Luis Obispo San Mateo Santa Barbara Santa Clara Santa Cruz Sonoma Tulare Ventura Crowns* Crown - porcelain with metal (anterior)...............................$ 70.00 Crown - porcelain with metal (posterior)...........................$ 175.00 Crown - full cast metal...........................................................$ 60.00 Crown - stainless steel (primary or permanent).............No charge Endodontics Single root canal therapy (anterior)......................................$ 40.00 Bi-root canal (bicuspid).........................................................$ 65.00 Molar root canal.....................................................................$ 95.00 Dentures and Partials Complete upper or lower denture (each)............................$ 70.00 Immediate upper or lower denture (each)........................$ 120.00 Partial upper or lower, acrylic base (including conventional clasps and rests) (each)...................................$ 50.00 Oral Surgery (extractions) Single tooth......................................................................No charge Each additional tooth......................................................No charge Surgical removal of erupted tooth.................................No charge Soft tissue impaction.......................................................No charge Partial bony impaction....................................................No charge Orthodontics** Orthodontics - adult full upper and lower banded case...................................$1,950.00 Orthodontics - child (Up to age 19) full upper and lower banded case...................................$1,600.00 *Cost of high noble metal (gold, etc.) may be charged extra when used. Not to exceed actual laboratory cost of metal. ** 24 month treatment And within the following zip codes in these counties: Amador: 95654 Madera: 93637, 93638 Butte: 95914, 95917, 95948 Mariposa: 95338 Colusa: 95950 Mendocino: 95427, 95482 El Dorado: 95630, 95667, 95682 Merced: 95301, 95303, 95312, 95315, 95317, 95333, 95334, 95339, 95340, 95341, 95342, 95343, 95344, 95348, 95365 Humboldt: 95501, 95502, 95521, 95525, 95534, 95536, 95537, 95540, 95547, 95549, 95550, 95551, 95556 Kings: 93230, 93291 Placer: 95603, 95616, 95650, 95661, 95677, 95678, 96145 San Benito: 95023, 95024, 95043, 95045 Shasta: 96001, 96002, 96003, 96007, 96019, 96022, 96033, 96047, 96062, 96073, 96079, 96087, 96089, 96095 Solano: 94510, 94533, 94535, 94585, 94589, 94590, 94591, 95620, 95687, 95688 Stanislaus: 95307, 95319, 95328, 95350, 95352, 95353, 95354, 95355, 95356, 95361, 95367, 95368, 95380, 95381, 95384 Sutter: 95659, 95668, 95674, 95676, 95953, 95957, 95982, 95991 Yolo: 95605, 95616, 95691, 95695 Yuba: 95369, 95692, 95901, 95918, 95919, 95961 Prepaid Dental 3000 and 1000 Exclusions & Limitations Dental Prepaid Plan 3000 and 1000 Exclusions & Limitations ental treatment must be received from the D Member’s participating dental office unless exception is specifically authorized in writing by the Plan. R outine and periodic examinations are limited to once every 6 months per enrolled Member. Prophylaxis procedures are limited to once every 6 months. Bitewing radiographs (x-rays) in conjunction with periodic examinations are limited to one series films in any 12 consecutive month period. Full mouth radiographs (x-rays) in conjunction with periodic examinations are limited to once every 3 years. Panoramic films are limited to once every 3 years. Fluoride treatment is limited to enrolled Members under the age of 18 years once every 6 months. Periodontal scaling and root planing, and/or sub-gingival curettage, and periodontal maintenance procedures are limited to one course of therapy during any 12 month period. The following dental services and procedures are not included in the Prepaid Dental Plan 3000 or 1000: Any procedure not specifically listed as a covered benefit. Dental treatment or expenses incurred in connection with any dental procedures started prior to the Member’s effective date under this Plan or after termination of the Member’s coverage. Example: teeth prepared for crowns, root canal treatment in progress, etc. All treatment of fractures and dislocations. Extraction for orthodontic purposes. Dental procedures and charges incurred as part of implants (placement or removal) and prosthetic devices placed on implants (fixed or removable). Example: bridges, crowns, dentures. Replacement of lost or stolen dentures, crown and bridgework or other dental appliances. Dental treatment or procedures requiring or associated with fixed prosthodontic restorations (other than those for replacement of structure lost due to decay) when part of extensive oral rehabilitation or reconstruction. Diagnosis or treatment by any method of any condition related to the jaw joint, TMJ or associated musculature, nerves or other tissues. A dental treatment plan, which, in the opinion of the Participating Dentist, is not medically necessary, will not produce a beneficial result or has a poor prognosis. Any corrective treatment required as a result of dental services performed by a nonparticipating dentist while this coverage is in effect and any dental services started by a non-participating dentist will not be the responsibility of the participating dental office or the Plan for completion or compensation. This is a summary of Exclusions & Limitations Only. For a complete listing, please see the Evidence of Coverage. 6 Dental EPO 3000 & 3500, PPO 4000 & 5000 Benefit Summaries Dental Plans EPO 3000 & 3500, PPO 4000 & 5000 by Ameritas Group Benefits and Copays This is a summary of benefits for the EPO 3000 & 3500 and PPO 4000 & 5000 underwritten by Ameritas Group, a division of Ameritas Life Insurance Corp. All plans are available to companies with 2 or more eligible employees. EPO 3000 Plan Benefits EPO 3500 In-Network^ Out-of-Network^ In-Network^ Out-of-Network^ Annual Maximum $1,0001 $6001 $1,0001 $1,0001 Annual Deductible $50 (Max 3x/Fam) $100 (Max 3x/Fam) $50 (Max 3x/Fam) $50 (Max 3x/Fam) Ded. waived Ded. waived Ded. waived Ded. applies Preventive 100% 80% 100% 100% Basic 80% 80% 80%/90%/100%* 80% Major** (12 mo. wait period) 50% 50% 50% 50% 50%** 50%** 80%** 50%** In-Network Out-of-Network† In-Network Out-of-Network† Annual Maximum $1,2001 $1,0001 $1,6001 $1,3001 Annual Deductible $25 (Max 3x/Fam) $75 (Max 3x/Fam) $25 (Max 3x/Fam) $75 (Max 3x/Fam) Ded. waived Ded. applies Ded. waived Ded. applies 100% 80% 100% 80% Preventive Care Endo/Perio PPO 4000 Plan Benefits Preventive Care Preventive Basic PPO 5000 80%/90%/100%* 80% 80%/90%/100%* 80% Major** (12 mo. wait period) 50% 50% 50% 50% Endo/Perio 80% 50%** 80%** 50%** EPO 3000 EPO 3500 PPO 4000 PPO 5000 N/A $100*** $100*** $100*** “Fusion” Vision Reimbursement Annual Maximum (EPO 3000 & 3500 – In-network providers available in California only.) ^ † Claims are reimbursed at the EPO Fee Schedule for in-network and out-of-network. Out-of-Network benefits are reimbursed at UCR. *Submit one covered dental claim each year and your Basic procedures will advance to the 90% level the following plan year and to 100% on the third year. **12 month waiting period applies. Waiting period will be waived for Groups with 10+ employees and 12 months continuous uninterrupted dental coverage on previous plan. *** Annual maximum per calendar year to spend at any eye care provider. File claim with Ameritas Group for reimbursement. 1 Annual maximum is a dental/vision combined benefit; you choose how to spend your maximum - it may be used toward dental and/or eye care expenses with a maximum of $100 toward eye care expenses. Please Note: • Employer must contribute at least 50% of the employee premium of the lowest cost dental plan being offered. • Employee participation must equal 100%, if the employer pays 100% of the employee premium. • All groups without comparable dental coverage are subject to the waiting periods for major and ortho. 7 Dental EPO 3000 & 3500, PPO 4000 & 5000 Benefit Summaries (continued) Dental RewardsSM by Ameritas Group Members who visit the dentist and use only a portion of their annual maximum benefit in a year are rewarded with additional benefits for the following year. Based on the plan selected, members can earn additional money toward their next year’s annual maximum benefit – if they use less than half of the annual maximum, they can increase their next year’s coverage by $250 and earn an additional $100 to $150 if they visit a network provider. For more information on Dental RewardsSM, please visit www.ameritasgroup.com. (Dental RewardsSM is a registered service mark of Ameritas Life Insurance Corp. and is used with permission.) EPO 3000 EPO 3500 PPO 4000 PPO 5000 Carry Over Amount N/A $250 $250 $250 PPO Bonus N/A $100 $100 $100 Benefit Threshold N/A $500 $500 $750 Maximum Carry Over Amount N/A $1,000 $1,000 $1,000 Dental Plans EPO 3000, 3500, PPO 4000 & 5000 by Ameritas Group Benefits and Copays - Orthodontia Orthodontia is an optional benefit selected for the entire group by the employer Optional Orthodontia EPO 3000 EPO 3500* In-Network Out-of-Network In-Network Out-of-Network Orthodontia (24 mo. wait period)** Not Covered Not Covered 50% 50% Annual Maximum Not Covered Not Covered none none Lifetime Maximum Not Covered Not Covered $1,000 $1,000 Optional Orthodontia PPO 4000* In-Network PPO 5000* Out-of-Network In-Network Out-of-Network Orthodontia (24 mo. wait period)** 50% 50% 50% 50% Annual Maximum none none none none Lifetime Maximum $1,000 $1,000 $1,000 $1,000 Note: Treatment must begin prior to 19th birthday. * Available to groups of 5 or more eligible employees. ** 24 month waiting period applies. Waiting period will be waived for groups with 10+ employees and 24 months continuous uninterrupted orthodontia coverage on previous plan. 8 Dental EPO 3000 & 3500, PPO 4000 & 5000 Exclusions & Limitations EPO 3000 & 3500, PPO 4000 & 5000 Exclusions & Limitations No benefits will be paid for expenses incurred: For overdentures and associated procedures. For a condition covered under any Workers’ Compensation Act or similar law. For charges in excess of those considered reasonable and customary. That are applied toward satisfying a deductible. For cosmetic procedures. That are generally considered by the dental profession as experimental or investigational. For the replacement of dentures, bridge inlays, onlays or crowns that can be repaired or restored to normal function. For implants and: Replacement of lost or stolen appliances Replacement of retainers Athletic mouthguards Precision or semi-precision attachments Dental duplication or sealants For oral hygiene instructions and: Plaque control Completion of a claim form Acid etch Missed appointments Prescription of take home fluoride Diagnostic photographs For services not completed when insurance ends, except that certain services which began while insured may be covered if completed within 31 days of termination of coverage. For the treatment of cleft palate and anodontia. For services or supplies payable under any medical expense plan. For orthodontia, unless included within Coverage Schedule. Prior to the date the insured is covered under the policy. For the diagnosis or treatment of TMJ. For hospital services. For any child 26 years of age and over. During any waiting period we require, when you voluntarily end your insurance and re-enroll at a later date. Your waiting period is 2 years and begins on the date your coverage first ended. Charges for infection control, sterilization and waste disposal. For procedures that have begun but have not been completed. For services and treatment provided at no charge, with or without insurance coverage. 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. This is a summary of Exclusions & Limitations Only. For a complete listing, please see the Evidence of Coverage. 9 10 866.251.4718 www.hsacalifornia.com HC0320.7.12