UNITE HERE HEALTH
Summary Plan Description
Long Beach/Orange County Plan Plan 278
August 2012
This Summary Plan Description supercedes
and replaces all materials previously issued.
2
The Plan Administrator and the agent for service of legal process is the Chief Executive Officer (CEO) of UNITE HERE HEALTH. Service of legal process may also be made on any Plan Trustee.
The CEO’s address and phone number are:
UNITE HERE HEALTH Chief Executive Officer
P. O. Box 6020 Aurora, IL 60598-0020
(630) 236-5100
UNITE HERE HEALTH (the Fund) was created to provide benefits for you and your covered dependents. UNITE HERE HEALTH serves participants working for employers in the hospi- tality industry and is governed by a Board of Trustees composed of an equal number of union and employer trustees. Each employer contributes to UNITE HERE HEALTH accord- ing to a specific contract, called a Collective Bargaining Agreement, between the employ- er and the union.
Your Plan, Plan 278, has been adopted by the Trustees for the payment of Medical and other health and welfare benefits from UNITE HERE HEALTH. This booklet is your Summary Plan Description (SPD). It is a summary of the Plan’s rules and regulations and describes:
■ How you become eligible;
■ When your dependents are covered;
■ What benefits you have;
■ Limitations and exclusions;
■ How to file claims; and
■ How to appeal denied claims.
If information contained in the SPD is inconsistent with those rules and regulations, the rules and regulations will govern. If information contained in the SPD is inconsistent with any insurance contract governing benefits, those insurance contracts will govern.
No contributing employer, employer association, labor organization, or any individual employed by one of these organizations has the authority to answer questions or interpret any provisions of this Summary Plan Description on behalf of UNITE HERE HEALTH.
I NTRODUCTION
4
Who Pays for Your Benefits?
Employers participating in the Plan are required to make contributions for their employees.
These contributions are controlled by the terms of the Collective Bargaining Agreements negotiated by your local union. Depending on the plan of benefits you select and your Collective Bargaining Agreement, you may also be required to contribute towards the cost of Employee Coverage. The Plan is supported by employer contributions and any required contributions you make.
What Benefits Are Provided Through Insurance Companies?
The Plan insures both medical HMO benefit options, underwritten by Kaiser Permanente (Kaiser) and Health Net Medical Group (Health Net).
The Dental Benefit options offered under Coast Dental Group, Dental Health Services/
Universal Care, and United Concordia Dental Plan are fully insured. Vision Coverage is also fully insured through a contract with UnitedHealthcare.
The Plan provides the Alternate Dental Benefit as a self-funded benefit. Self-funded means that this benefit is not funded by insurance contracts. Benefits and associated administra- tive expenses are paid directly from UNITE HERE HEALTH.
The Plan also insures Life Insurance and Accidental Death and Dismemberment Benefits.
These benefits are funded and guaranteed under group contracts underwritten by Dearborn National.
A BOUT P LAN F INANCES
To request enrollment or election forms, report changes in your employment or family status, inquire about claims, self-payments or request additional information,
contact the Garden Grove UNITE HERE HEALTH office:
13252 Garden Grove Boulevard, Suite 200 Garden Grove, California 92843
(855) 844-5262
Visit our website at www.uniteherehealth.org
Set up an account on the UNITE HERE HEALTH website to check eligibility, update address information, add dependent information, and make COBRA payments online.
I MPORTANT P HONE N UMBERS
Kaiser Permanente HMO Option Only www.kp.org
For Benefit Questions and to
Find a Kaiser Permanente Doctor or Hospital (800) 464-4000 After-Hours Kaiser Permanente Advice Nurse
During regular business hours, contact your local Kaiser Permanente
center (888) 576-6225
Health Net HMO Option Only www.healthnet.com
For Benefit Questions and to
Find a Health Net Doctor or Hospital (800) 400-8987
Decision Power (Nurse Line) (800) 893-5597
Coast Plan Group Dental Option Only
For benefit questions and to find a Coast Plan dentist
www.coastdentalgroup.com (714) 995-9700
Dental Health Services/Universal Care Option Only For benefit questions and to find a DHS dentist
www.dentalhealthservices.com (800) 637-6453
(562) 595-6000 United Concordia Dental Option Only
For benefit questions and to find a United Concordia dentist www.ucci.com (866) 357-3304 Alternate Dental Benefit
For benefit questions
www.uniteherehealth.org (855) 844-5262
Vision Care
For benefit questions and to find a UnitedHealthcare Vision provider
www.myuhcvision.com (800) 638-3120
(800) 839-3242 (provider finder)
6
This Table of Contents is designed to help you find specific benefit information easily and quickly.
Look for the question that best describes what you want to know.
Where Does the Money to Pay Benefits Come From?
About Plan Finances . . . .4
Who Pays for Your Benefits? . . . .4
What Benefits Are Provided Through Insurance Companies? . . . .4
What Health and Welfare Benefits Does the Plan Provide?
Summary of Benefits – Medical HMO . . . .10Summary of Benefits – Dental Options . . . .11
Who’s Covered by the Plan?
Who’s Eligible . . . .13Employees . . . .13
Dependents . . . .13
Who Your Dependents Are . . . .13
Enrollment Requirements . . . .14
Choice of Coverage Options . . . .14
Employees . . . .14
Dependents . . . .14
Dependent Documentation . . . .15
How Do I Use Medical HMO Coverage?
Medical Benefits Options . . . .16How Do I Use a Medical HMO? . . . .16
How the Medical HMO Contract Affects Your Benefits . . . .16
What Dental Services Does the Plan Cover?
Dental Benefits Options . . . .18Alternate Dental Benefit . . . .18
What the Plan Pays . . . .18
What You Pay . . . .18
Pre-determination of Benefits . . . .19
Alternate Course of Treatment . . . .19
Medically Necessary Care and Treatment . . . .19
What’s Covered . . . .20
What’s Not Covered . . . .20
Dental Benefits After Eligibility Ends . . . .21
Schedule of Benefits Under the Alternate Dental Benefit . . . .22
T ABLE OF C ONTENTS
TABLE OFCONTENTS
Does the Plan Provide Benefits for Eye Exams and Glasses?
Vision Care Benefits . . . .28
What’s Covered . . . .28
What the Plan Pays . . . .29
What You Pay . . . .29
What’s Not Covered . . . .29
What If I’m Also Covered Under Another Dental Plan?
Coordination of Benefits for the Alternate Dental Benefit . . . .30Which Plan Pays First . . . .31
Order of Payment . . . .31
COB and Precertification . . . .31
Special Rules for Medicare . . . .32
Husband and Wife, or Domestic Partner, Employees Under This Plan . . . .32
When Must Plan Payments Be Returned?
Subrogation . . . .33The Plan’s Right to Recover Payments . . . .33
When Injury Is Caused by Someone Else . . . .33
Statement of Facts and Repayment Agreement . . . .33
What If I Die?
Life and Accidental Death & Dismemberment Insurance Benefit . . . .35Life Insurance . . . .35
Benefit Amount . . . .35
Naming a Beneficiary . . . .35
Continuation If You Become Totally Disabled . . . .36
Converting to Individual Life Insurance Coverage . . . .36
Filing a Claim . . . .36
Accidental Death & Dismemberment Insurance . . . .37
AD&D Exclusions . . . .37
Naming a Beneficiary . . . .37
Filing a Claim . . . .38
Additional Insurance Benefits and Services . . . .38
Accidental Death & Dismemberment Insurance Benefits . . . .38
Life Insurance Benefits . . . .38
How Do I Become Eligible For and Then Continue Coverage?
Eligibility for Coverage . . . .40When Your Coverage Begins . . . .40
When Dependent Coverage Begins . . . .41
Continuing Eligibility . . . .41
Self-payments . . . .42
Self-payments During a Work Place Closing . . . .42
8
TABLE OFCONTENTS
Self-payments During a Strike . . . .42
Vacation Hours . . . .42
Enrollment Periods . . . .42
Open Enrollment Periods . . . .43
Employee Special Enrollment Periods . . . .43
Dependent Special Enrollment Periods . . . .43
Retiree Eligibility . . . .43
When Does Coverage End?
Termination of Coverage . . . .45When Employee Coverage Ends . . . .45
When Dependent Coverage Ends . . . .45
Certificate of Creditable Coverage . . . .46
When Your Employer’s Collective Bargaining Agreement Expires . . . .47
The Effect of Severely Delinquent Employer Contributions . . . .47
Limited Retroactive Terminations of Coverage Allowed . . . .48
Remedies for Fraud . . . .48
What If I Lose Coverage and Then Return to Work?
Re-establishing Eligibility . . . .49Portability . . . .49
Family and Medical Leave Act . . . .49
The Effect of Uniformed Service . . . .50
How Can Coverage Be Continued?
COBRA Continuation Coverage . . . .51Who Can Elect COBRA Coverage? . . . .51
What Is a Qualifying Event? . . . .51
What Coverage Can Be Continued? . . . .52
How Long Can Coverage Be Continued? . . . .52
Termination of COBRA Coverage . . . .53
Notifying UNITE HERE HEALTH When Qualifying Events Occur . . . .53
Election and Payment Deadlines . . . .54
How Do I File a Claim and What Do I Do If It’s Denied?
General Claim Provisions . . . .56Filing a Benefit Claim . . . .56
Deadlines for Filing a Benefit Claim . . . .57
Individuals Who May File a Benefit Claim . . . .57
Who Is an Authorized Representative? . . . .57
Payment of Claims . . . .58
Concurrent Care Decisions . . . .58
Life and Accidental Death & Dismemberment Insurance Benefit Claims . . . .58
Health Care Claims Not Involving Concurrent Care Decisions . . . .59
TABLE OFCONTENTS
If a Benefit Claim Is Denied . . . .59
Appealing the Denial of a Claim . . . .60
Appeals to UNITE HERE HEALTH Involving Urgent Care Claims . . . .60
Appeals Under the Sole Authority of the Plan Administrator . . . .60
Review of Appeals . . . .61
Notice of the Decision on Your Appeal . . . .61
Independent External Review Procedures for the Alternate Dental Benefit . . . .62
What Else Do I Need to Know?
Other Important Information . . . .64Interpretation of Plan Provisions . . . .64
Medical HMO Benefits . . . .64
Dental Benefits through a Dental HMO . . . .64
Vision Benefits . . . .64
Independent Review Organization . . . .64
All Other Authority Rests with the Board of Trustees . . . .64
Amendment or Termination of the Plan . . . .65
Providers . . . .65
Workers’ Compensation . . . .65
Type of Plan . . . .65
Employer and Employee Organizations . . . .66
Plan Administrator . . . .66
Employer Identification Number . . . .66
Plan Number . . . .66
Plan Year . . . .66
Your Rights Under ERISA . . . .67
Receive Information About Your Plan and Benefits . . . .67
Continue Group Health Plan Coverage . . . .67
Creditable Coverage . . . .68
Prudent Actions by Plan Fiduciaries . . . .68
Enforce Your Rights . . . .68
Assistance With Your Questions . . . .69
Board of Trustees . . . .70
Provider Organization Phone Numbers and Addresses . . . .72
10
Description of Services Health Net HMO Kaiser Permanente HMO
Calendar Year Deductible None None
Calendar Year Out-of-Pocket Maximum $1,500 per person
$4,500 per family (3 or more members) $1,500 per person
$3,000 per family (2 or more members)
Annual Maximum Benefit None None
Office Visit – most primary and specialty
care consultations, exams and treatment 100% after $10 copay 100% after $10 copay
Preventive/Wellness Care 100% 100%
Scheduled Prenatal Care 100% after $10 copay 100%
Urgent Care 100% after $15 copay 100% after $10 copay
Emergency Room Visit 100% after $50 copay 100% after $35 copay
Ambulance 100% 100%
Outpatient Surgery 100% $10 copay
Outpatient X-Ray and Lab 100% 100%
Hospitalization – including inpatient surgery 100% after $250 copay 100% after $250 copay Mental Health Treatment
Inpatient 100% after $250 copay 100% after $250 copay
Outpatient 100% after $10 copay 100% after $10 copay (individual visit)
100% after $5 copay (group visit) Substance Abuse Treatment
Inpatient 100% after $250 copay 100% after $250 copay
Outpatient 100% after $10 copay 100% after $10 copay (individual visit)
100% after $5 copay (group visit)
Home Health Care 100% after $10 copay,
limited to 100 visits per year 100% limited to 100 visits per year Skilled Nursing Facility Care 100% after $250 copay,
limited to 100 days per year 100% limited to 100 days per year
Hospice Care 100% 100%
Durable Medical Equipment 100% 100%
Prescription Drugs Retail (up to a 30-day supply) Retail (up to a 30-day supply)
Generic Drugs 100% after $10 copay 100% after $15 copay
Brand Name Drugs 100% after $30 copay 100% after $30 copay
Mail (up to a 90-day supply) Mail (31-day to 100-day supply)
Generic Drugs 100% after $20 copay 100% after $30 copay
Brand Name Drugs 100% after $60 copay 100% after $60 copay
S UMMARY OF B ENEFITS – M EDICAL HMO
The following is a summary of the benefits payable under each medical HMO option. See the Health Net or Kaiser Benefit Summary for details about the coverage paid under each HMO. Benefits payable are governed by the contract between UNITE HERE HEALTH and the medical HMO. If there are any conflicts between this summary and the contract with the HMO, the terms of the contract will govern.
Description of Services Alternate Dental Plan
(Maximum Reimbursement) Coast Dental Group
Dental Health Services
United Concordia
Employee Dependent
Annual Maximum Benefit None $400/person None None None
Routine Oral Exams $4.50 $3.30 100% 100% 100%
X-Rays $1.50 single film
$0.75 each additional film
$1.10 single film
$0.55 each
additional film 100% 100% 100%
Prophylaxis $6.75 $4.95 100% 100% 100%
Topical Application of Fluoride $9.00 $6.00 100% 100% 100%
Space Maintainers $2.50 - $20.00 Not covered 100% 100% 100%
Amalgam Restorations $6.00 - $11.25 $4.40 - $8.25 100% 100% 100%
Crowns $8.50 - $50.00 Not covered 100% after $35
copay
100% after
$35 - $60 copay
100% after
$25 - $75 copay Pulp Capping (excludes final
restoration) $4.50 $3.30 100% 100% 100%
Periodontal Scaling/Root
Planing $9.00 $6.60 100% after
$20 copay (per quadrant)
100% after
$20 copay
(per quadrant) 100%
Complete Maxillary Denture $77.50 Not covered 100% after
$55 copay
100% after
$55 copay
100% after
$100 copay
Rebase Dentures Varies Not covered 100% after
$30 copay
100% after
$30 copay 100%
Removal of Impacted Tooth –
Soft Tissue $12.75 $9.35 100% 100% 100%
Comprehensive Orthodontic
Treatment for Teenagers Not covered Not covered 100% after
$1,800 copay
100% after
$1,800 copay
100% after
$1,500 copay
S UMMARY OF B ENEFITS – D ENTAL O PTIONS
The following is a summary of the benefits payable under each Dental Benefit option. Benefits under Coast Dental Group, Dental Health Services/Universal Care, and United Concordia options are provided through a contract between UNITE HERE HEALTH and the dental HMO. See the certificate of coverage for details about the coverage paid under each HMO.
If there are any conflicts between this summary and the contract with the HMO, the terms of the contract will govern.
12
Employees
You are eligible for coverage if:
■ You work for an employer who is required by a Collective Bargaining Agreement to contribute to UNITE HERE HEALTH on your behalf;
■ The necessary contributions are received by UNITE HERE HEALTH; and
■ You satisfy the Plan’s eligibility rules.
If you are required to make any payment toward the cost of providing coverage for you and your family, you must arrange with your employer to make those payments by pay- roll deduction. If your employer does not permit payroll deductions, you must submit any payment owed to UNITE HERE HEALTH.
Dependents
Your dependents become eligible for coverage on the date you become eligible or on the date you acquire the dependent, whichever happens last.
Who Your Dependents Are
For benefit purposes, your dependents are:
■ Your husband or wife, but only if there is valid documentation (see page 15);
■ Your same-sex or opposite-sex domestic partner, under certain circumstances: con- tact UNITE HERE HEALTH for details;
■ Your children, including: natural children, step-children, adopted children, children placed with you for adoption and for whom you are legally required to provide sup- port until the adoption is finalized, children entitled to coverage because of a Qualified Medical Child Support Order, or children for whom you are awarded legal guardianship or sole custody pursuant to state domestic relations law, who are under age 26.
To be covered on or after their 26th birthday, your unmarried children must be unable to support themselves because of a mental or physical handicap that began before age 19 and while covered by the Plan on the day prior to their 19th birthday.
The information beginning on page 40 will help you figure out when you are eligible for benefits.
If your employer does not permit payroll deductions, send payments to:
UNITE HERE HEALTH P.O.Box 6557 Aurora, IL 60598-0557
Coverage for your dependents can not begin before your coverage begins.
If you enroll a domestic partner, you will have to pay any federal, state, or local taxes owed on the value of the domestic partner benefits to UNITE HERE HEALTH on a quarterly basis. Contact UNITE HERE HEALTH with ques- tions about covering domestic partners.
IN THIS SECTION
13 EMPLOYEES
13 DEPENDENTS
14 ENROLLMENT
REQUIREMENTS
W HO ’ S E LIGIBLE
14
WHO’SELIGIBLE
Enrollment Requirements
Choice of Coverage Options
UNITE HERE HEALTH offers two HMO options for medical benefits and prescription drug coverage, and four options for dental benefits – three dental HMOs and one indemnity plan. Your required monthly payment, if applicable, is the same regardless of which HMO or dental benefit option you choose.
■ Medical Benefits Options:
➤ Kaiser Permanente HMO
➤ Health Net HMO
■ Dental Benefits Options
➤ The Coast Dental Group
➤ United Concordia Plan
➤ Dental Health Services/Universal Care Plan
➤ Alternate Dental Benefit
You may choose either medical HMO option, and any one of the four dental benefits options. Your enrolled dependents will automatically be covered under the same medical and dental benefits options you select. However, if you and your spouse are both employ- ees, you must select the same medical and dental benefits options.
Employees
You need to fill out an election form, whether or not you are required to contribute to the cost of coverage. The form must be completed and submitted to UNITE HERE HEALTH by the enrollment due dates. Plan benefits will not be paid until a completed form is submit- ted.
If you choose not to enroll, you and your dependents will not be covered. You can enroll later. However, your coverage will not begin until UNITE HERE HEALTH receives your com- pleted election form. Contact UNITE HERE HEALTH for more information about late enroll- ment and the effective date of coverage for late enrollment.
You may also be eligible for a special enrollment period. See page 43 for more information.
Dependents
The enrollment form identifies the dependents you want covered and requests: your name, Social Security number, birth date, home address, telephone number, employer’s name and address, and the dependent’s name, sex, birth date, and Social Security number.
The enrollment form must be submitted to UNITE HERE HEALTH within 30 days after the date you become entitled to elect Dependent Coverage.
For more information on termination of Dependent Coverage or on continuing coverage for your children over 26, see page 45.
In some cases, you may be permitted to waive coverage if you have other medical coverage.
Please contact UNITE HERE HEALTH for more information about waiving coverage.
Once you have Dependent Coverage, you must still enroll newly acquired dependents and submit the required proof to the Aurora, Illinois, UNITE HERE HEALTH Office.
Dependent Documentation
In order to verify a person’s dependent status for benefit purposes, in addition to the com- pleted enrollment form, you must also provide, as appropriate, at least one of the following:
■ A certified copy of your marriage certificate;
■ An affidavit of domestic partnership, if you are enrolling a domestic partner;
■ A commemoration of marriage issued by a generally recognized denomination of organized religion;
■ A certified copy of the birth certificate;
■ Baptismal certificate;
■ Hospital birth records;
■ Written proof of adoption or legal guardianship;
■ Copies of court decrees that obligate an employee to provide medical benefits for a dependent child;
■ Notarized copies of a participant’s most recent Federal Income Tax return (Form 1040 or its equivalents);
■ Certificates of Creditable Coverage issued in accordance with the provisions of the Health Insurance Portability and Accountability Act of 1996, as amended;
■ Documentation of dependent status issued and certified by the United States Immigration and Naturalization Service; or
■ Documentation of dependent status issued and certified by a foreign embassy.
If any of the above documents are used to verify the dependent status of a child, they must contain the names of the child’s parents.
Federal law requires UNITE HERE HEALTH to honor Qualified Medical Child Support Orders.
UNITE HERE HEALTH has estab- lished procedures for determining whether a divorce decree or a support order meets federal requirements and for enrollment of any child named in the Qualified Medical Child Support Order. To obtain a copy of these procedures at no cost, or for more information, contact UNITE HERE HEALTH.
English translations for all documents must be provided as required.
WHO’SELIGIBLE
See the Summary of Benefits for a description of the benefits provided under each medical HMO option.
To reach Kaiser Permanente, visit www.kp.org or call
(800) 464-4000
To reach Health Net, visit www.healthnet.com or call (800) 400-8987
If you select Health Net as your medical HMO, except for urgent or emergency care, you can only receive benefits for care provided in the state of California – even if you or a dependent lives outside the state.
16
IN THIS SECTION
16 HOWDOI USE A
MEDICALHMO?
16 HOW THEMEDICAL
HMO CONTRACT
AFFECTSYOURBENEFITS
UNITE HERE HEALTH has contracted with two medical health maintenance organizations (HMOs) – Kaiser Permanente and Health Net – to provide benefits for you and your enrolled dependents. When you become eligible to enroll in UNITE HERE HEALTH, you will receive a welcome packet highlighting the medical HMO benefit options available to you.
In order to enroll, you must complete the forms included in the enrollment packet.
How Do I Use a Medical HMO?
Once you enroll in a medical HMO, you may be required to choose a primary care doctor.
Even if the medical HMO does not require you to pick a primary care doctor, you may choose to do so. You can choose any available primary care doctor in the network. You may choose a pediatrician as a child’s primary care physician.
Your primary care doctor will help you get care. For example, you may need a referral to see most specialists. Your primary care doctor can do this for you. However, if you are female, you do not need prior authorization or a referral to see a contracted health care professional that specializes in obstetrics or gynecology.
Except in emergencies, you will usually be required to use an HMO doctor, HMO hospital, or HMO facility in order to receive benefits.
You can get more information about your medical HMO benefits by calling either Kaiser Permanente or Health Net, whichever medical HMO you select.
How the Medical HMO Contract Affects Your Benefits
The contract between UNITE HERE HEALTH and the applicable medical HMO governs how benefits are paid under either the Kaiser Permanente HMO or the Health Net HMO. If there is any discrepancy between any information described in this book and the contract between the applicable medical HMO and UNITE HERE HEALTH, the contract will govern.
M EDICAL B ENEFITS
O PTIONS
In addition, these contracts govern how medical HMO benefits are paid and administered.
That means that the certificate of coverage you get when you enroll in either HMO option will explain the rules that apply to your benefits. Several sections of this SPD do not apply to the medical HMO benefits you receive through either Kaiser Permanente or Health Net, including:
■ Subrogation;
■ Coordination of Benefits;
■ General Claim Provisions.
The benefit booklet you receive from either Kaiser Permanente or Health Net will give you more information about your medical management programs, your medical and prescrip- tion drug benefits, coordination of benefits, exclusions and limitations, subrogation, and claims provisions, including filing claim appeals.
MEDICALBENEFITSOPTIONS
18
Retirees and their dependents are not eligible for Dental Benefits.
You have your choice of four options:
■ Coast Dental Group;
■ United Concordia Plan;
■ Dental Health Services/Universal Care Plan; or
■ Alternate Dental Benefit.
If you choose the Coast Dental Group, the United Concordia Plan, or the Dental Health Services/Universal Care Plan, see the applicable brochure for more information about your benefits. UNITE HERE HEALTH contracts with each of these dental HMOs to provide ben- efits to employees and their dependents. The contracts govern the Dental Benefits pro- vided through each dental HMO.
Alternate Dental Benefit
What the Plan Pays
If you or a dependent incurs covered dental expenses, the Plan will reimburse you for the dentist’s charge, up to the maximum benefit listed in the Alternate Dental Benefit Schedule of Benefits (beginning on page 22). The Plan will pay this benefit directly to you.
Benefits for dependents are limited to $400 per year. The maximum benefit does not apply to routine exams provided to children under age 19.
Benefits for temporomandibular joint disorder (TMJ) treatment is limited to a lifetime max- imum benefit of $500 per person.
What You Pay
You are responsible for paying any charges the Plan does not pay, including the difference between the dentist’s actual charges and the maximum allowable benefit or services that are not considered a covered dental expense.
See the Summary of Benefits for a description of the benefits provided under each dental HMO option.
IN THISSECTION 18 ALTERNATEDENTAL
BENEFIT
21 DENTALBENEFITSAFTER
ELIGIBILITYENDS
22 SCHEDULE OFBENEFITS
UNDER THEALTERNATE
DENTALBENEFIT
D ENTAL B ENEFITS O PTIONS
DENTALBENEFITS
Pre-determination of Benefits
If a dentist estimates that charges for proposed non-emergency treatment will total more than $300, you or your dentist must submit a request for pre-determination to the Aurora regional office. The request for pre-determination of benefits should include your name, the patient’s name, the dentist’s name, a detailed proposed treatment plan, and an item- ized list of estimated costs. UNITE HERE HEALTH will review the proposed treatment plan and determine what the Fund will pay for the treatment.
If you don’t request a pre-determination of benefits, UNITE HERE HEALTH may limit bene- fits to $300 or to the maximum benefit for the least expensive alternate course of treat- ment. Your claim may also be denied in its entirety.
Alternate Course of Treatment
If your dentist submits a request for pre-determination of benefits, and UNITE HERE HEALTH determines that an alternate method of treatment would be at least as effective, but less costly, Dental Benefits may be paid based on the alternate method provided the alternate treatment is:
■ Commonly used in the treatment of the existing condition, as determined by UNITE HERE HEALTH’s dental consultant; and
■ Recognized by the dental profession to be appropriate in accordance with accepted nation-wide standards of dental practice.
Medically Necessary Care and Treatment
Medically necessary care and treatment means services, supplies, or places where dental treatment is received which:
■ Are consistent with and effective for the injury or sickness being treated;
■ Constitute good dental practice according to professional standards recognized by the organized medical community in the United States; and
■ Are neither experimental, investigational, nor unproven as determined by appropriate governmental agencies, the organized medical community in the United States, or standards or procedures adopted from time-to-time by the Trustees.
The Board of Trustees has the sole authority to determine what constitutes medically necessary care and treatment, and experimental or investigational procedures. In all cases, the Trustees’ determination will be final and binding. However, those determinations are solely for the purpose of establishing what services or courses of treatment are covered by the Plan. All decisions regarding treatment are between you and your dentist and should be based on all appropriate factors, only one of which is the level of benefits available under the Plan.
Submit claims or requests for Pre- determination of Benefits to:
UNITE HERE HEALTH P.O. Box 6557 Aurora, IL 60598-0557
Pre-determination of benefits does not guarantee eligibility for benefits.
An allowable charge is the amount upon which benefits are based for covered treatment, services, or supplies. The Board of Trustees has the sole authority to determine the level of allowable charges the Plan will use, and in all cases, the Trustees’ determina- tion will be final and binding. The Plan will not consider any amount exceeding the allowable charge for a particular service or supply to be a covered expense.
A dentist is a person who is duly licensed to practice dentistry or perform oral surgery in the state in which he or she is practicing, and who is acting within the scope of that license. For the pur- pose of this definition, a doctor will be considered to be a Dentist when performing a covered den- tal service and is operating within the scope of his or her license.
20
Experimental, investigative, or unproven procedures are those which are classified that way by agencies or subdivisions of the federal government such as the Food and Drug Administration (FDA) or the Office of Health Technology Assesment of the Centers for Medicare & Medicaid Services (CMS), or according to CMS’s Medicare Coverage Issues Manual.
What’s Covered
Dental services listed in the Alternate Dental Benefit Schedule of Benefits include treatment necessary for:
■ Preventive care;
■ Treatment of dental disease or defect; or
■ Treatment of accidental injury.
What’s Not Covered
No Dental Benefits are provided for:
■ Charges incurred before coverage begins;
■ With respect to dependents only, charges for:
➤ the initial placement or the replacement of a prosthetic device (including crowns and inlays that form abutments),
➤ For the addition of teeth to a denture or bridgework if the placement, replace- ment or addition is made to replace teeth, all of which were extracted while the covered person was not eligible for the Alternate Dental Benefit, or
➤ Any major dentistry listed as “not covered” in the Alternate Dental Benefit Schedule of Benefits on pages 22-27.
■ Replacement of lost or stolen appliances or devices;
■ Replacement of, or addition of teeth to, a denture or bridgework unless satisfactory evidence is given to UNITE HERE HEALTH that:
➤ the replacement or the addition of teeth is made to replace, for the first time, one or more natural teeth extracted while you were covered under the Alternate Dental Benefit,
➤ the existing denture or bridgework was installed at least five years prior to its replacement and cannot be repaired to meet professionally recognized stan- dards, or
➤ the existing denture is an immediate temporary denture that requires replace- ment by a permanent denture, but only if the replacement is delivered or installed within 12 months after the date the temporary denture was installed;
■ Orthodontic services;
■ For a procedure that is performed mainly to improve the appearance of the covered person;
■ For facing on a crown when the crown is on a tooth behind the second bicuspid;
■ For specialized techniques that involve precision dentures for personalization or characterization;
■ For services rendered by any provider who is a covered person under this Plan, or is the spouse, parent, child, brother or sister of a covered person;
DENTALBENEFITS
DENTALBENEFITS
■ Services:
➤ that are not necessary and/or customary as determined by the standards of generally accepted dental practice,
➤ for which no valid dental need can be demonstrated, or
➤ that are experimental or investigational in nature;
■ Any injury, sickness, or dental or vision treatment which arises out of or in the course of any occupation or employment, or for which a person has received or is entitled to receive benefits under a workers’ compensation or occupational disease law, whether or not application has been made or approved for such benefits;
■ Any treatment, services, or supplies:
➤ for which no charge is made,
➤ for which a person is not required to pay, or
➤ which are furnished by or payable under any plan or law of a federal or state government entity, or provided by a county, parish, or municipal hospital when there is no legal requirement to pay for such treatment, services, or supplies;
■ Any expense or charge for failure to appear for an appointment as scheduled, or charge for completion of claim forms, or finance charges;
■ Any treatment, services, or supplies purchased or provided outside the 50 United States of America, unless for the treatment of a medical emergency. The decision of the Trustees in determining the emergency will be final;
■ Any charges incurred for treatment, services, or supplies as a result of a declared or undeclared war or any act thereof; or any loss, expense or charge incurred while a person is on active duty or in training in the Armed Forces, National Guard, or Reserves of any state or any country;
■ Any injury or sickness resulting from participation in an insurrection or riot, or par- ticipation in the commission of a felonious act or assault;
■ Any expense greater than the Plan’s maximum benefits, or any expense incurred before eligibility for coverage begins or after eligibility terminates, unless specifical- ly provided for under the Plan.
Dental Benefits After Eligibility Ends
If coverage ends because of the loss of eligibility for reasons other than termination of UNITE HERE HEALTH, benefits will only be determined for allowable charges incurred for treatment that is rendered while you are covered under the Alternate Dental Benefit, and is competed within 30 days of the date your coverage under the Alternate Dental Benefit ends.
If coverage ends because the Plan terminates, in whole or in part, no benefits will be avail- able for claims submitted after coverage ends.
22
The $400 calendar year maximum benefit does not apply to routine exams provided to children under age 19.
DENTALBENEFITS
Schedule of Benefits Under the Alternate Dental Benefit
Maximum Allowable Benefit per Procedure
Description of Services Employee Dependent
Calendar year maximum benefit per person n/a $400
Lifetime maximum benefit for TMJ disorder treatment $500 $500 VISITS AND EXAMINATIONS
Examination (initial episode of treatment only) $4.50 $3.30
Office visits for medication, observation and temporary correction of accidental injuries to natural teeth or supporting structures (post-operative visits and visits where a permanent corrective procedure is performed are not covered)
$3.00 $2.20
Professional visit after hours (optional – in lieu of allowances for
services rendered) $7.50 $5.50
Special consultation (allowable for examination by a dental specialist whose advice or opinion is requested by the attending dentist)
$7.50 $5.50
Prophylaxis – adults $6.75 $4.95
Topical application of sodium fluoride – one treatment $9.00 $6.00 Topical application of stannous fluoride including prophylaxis
(limited to one treatment each 12-month period) $10.50 $7.70 Emergency treatment (palliative) – each visit
(limited to two treatments each 12-month period) $3.75 $2.75 ROENTGENOLOGY AND PATHOLOGY
Single film $1.50 $1.10
Additional films (up to a total of 13 films) $0.75 $0.55
Entire denture series consisting of at least 14 films
(including bitewings if indicated) $11.25 $8.25
Intraoral, occlusal view, maxillary, or mandibular – each $3.00 $2.20 Superior or inferior maxillary, extraoral, one film $7.50 $5.50 Superior or inferior maxillary, extraoral, two films $11.25 $8.25
Biopsy of oral tissue $6.00 $4.40
Microscopic examination $11.25 $8.25
EXTRACTIONS
Initial, per visit, uncomplicated (includes routine post-operative visits) $6.00 $4.40 Each additional tooth, same visit, uncomplicated (includes routine
post-operative visits) $4.50 $3.30
DENTALBENEFITS
Maximum Allowable Benefit per Procedure (cont.)
Description of Services Employee Dependent
Surgical removal of erupted teeth $18.75 $13.75
Post-operative visits (including sutures and complications) $2.25 $1.65 IMPACTED TEETH
Removal of tooth – soft tissue $12.75 $9.35
Removal of tooth – partially bony $18.75 $13.75
Removal of tooth – completely bony $30.00 $22.00
RESTORATIVE DENTISTRY Amalgam restorations
Cavities involving one tooth surface $6.00 $4.40
Cavities involving two tooth surfaces $8.25 $6.05
Cavities involving three or more tooth surfaces $11.25 $8.25 Gold restorations and crowns (not serving as bridge abutments)
Gold foil – one surface $26.25 $19.25
Gold foil – two surfaces $30.00 $22.00
Gold foil – three surfaces $37.50 $27.50
Inlay, gold – one surface $26.25 $19.25
Inlay, gold – two surfaces $30.00 $22.00
Inlay, gold – three surfaces $37.50 $27.50
Inlay (per tooth) in addition to above $7.50 $5.50
Silicate, acrylic and plastic restorations silicate cement filling $6.75 $4.95 ENDODONTICS
Acrylic or plastic fillings $8.25 $6.05
Pulp capping $4.50 $3.30
Therapeutic pulpotomy in addition to restoration – each treatment $4.50 $3.30
Vital pulpotomy $9.00 $6.60
Remineralization – each tooth (CaOH temporary restoration) $7.50 $5.50
Root canal – culturing canal $5.25 $3.85
Root canal – single root canal therapy $33.75 $24.75
Bi-rooted tooth canal therapy $45.00 $33.00
Tri-rooted tooth canal therapy $56.25 $41.25
Apicoectomy (including filling of root canal) $37.50 $27.50
Apicoectomy (separate procedure) $26.25 $19.25
24
DENTALBENEFITS
Maximum Allowable Benefit per Procedure (cont.)
Description of Services Employee Dependent
PERIODONTICS
Emergency treatment periodontal abscess, acute periodontitis, etc.
(allowable for initial episode of treatment only) $7.50 $5.50
Subgingival curettage – root planing $9.00 $6.60
Correction of occlusion $9.00 $6.60
Gingivectomy each quadrant (including post-surgical visits) $37.50 $27.50 Gingivectomy, osseous or muco-gingival surgery each quadrant
(including post-surgical visits) $45.00 $33.00
Gingivectomy, treatment each tooth (fewer than 6 teeth) $7.50 $5.50 ALVEOLAR OR GINGIVAL RECONSTRUCTION
Alveolectomy (edentulous) each quadrant $18.75 $13.75
Alveolectomy (in addition to removal of teeth) each quadrant $7.50 $5.50
Alveoplasty with ridge extension, each arch $31.50 $23.10
Removal of palatal torus $26.25 $19.25
Removal of mandibular tori each quadrant $26.25 $19.25
Excision of hyperplastic tissue each arch $24.00 $17.60
CYSTS AND NEOPLASMS
Intraoral incision and drainage of abscess $7.50 $5.50
Extraoral incision and drainage of abscess $11.25 $8.25
Excision pericoronal gingival $7.50 $5.50
Sialolithotomy: removal of salivary calculus, extraorally $75.00 $55.00 Sialolithotomy: removal of salivary calculus, intraorally $24.75 $18.15
Closure of salivary fistula $45.00 $33.00
Dilation of salivary duct $12.75 $9.35
Resection of benign tumor of soft tissue (2.5 cm or larger) $18.75 $13.75
Resection of malignant tumor TBD TBD
Transplantation of tooth or tooth bud $52.50 $38.50
Removal of foreign body from bone – independent procedure TBD TBD Maxillary sinusotomy to remove tooth fragment or foreign body $48.75 $35.75
Closure of oral fistula or maxillary sinus $30.00 $22.00
Excision of cyst, small $18.75 $13.75
Excision of cyst, large (2.5 cm or larger) $56.25 $41.25
Sequestrectomy for osteomyelitis or bone abscess, superficial $15.00 $11.00
Condylectomy of temporomandibular joint $225.00 $165.00
Meniscectomy of temporomandibular joint $187.50 $137.50
Radical resection of bone for tumor with bone graft TBD TBD
DENTALBENEFITS
Maximum Allowable Benefit per Procedure (cont.)
Description of Services Employee Dependent
MISCELLANEOUS
Incision and removal of foreign body from soft tissue $7.50 $5.50
Frenectomy $18.75 $13.75
Suture of soft tissue wound or injury $7.50 $5.50
Crown exposure for orthodontia $11.25 $8.25
Injection of sclerosing agent into temporomandibular joint $22.50 $16.50 Treatment of trigeminal neuralgia by injection into second and third
divisions $25.50 $18.70
Peripheral nerve block, breaches of fifth cranial $4.50 $3.30
Drugs – antibiotic injection $3.75 $2.75
General anesthesia (allowable only if not hospital confined) $11.25 $8.25
GOLD RESTORATION
Allowances shown below are for gold restorations other
than crowns on abutment teeth
One tooth surface $15.00 Not covered
Two tooth surfaces $20.00 Not covered
Three or more tooth surfaces $25.00 Not covered
Onlays, additional – per tooth $5.00 Not covered
CROWNS
No allowance is made for facings on crowns, posterior
to 2nd bicuspids
Acrylic $30.00 Not covered
Acrylic with metal $37.50 Not covered
Porcelain with metal $50.00 Not covered
Porcelain $37.50 Not covered
Gold (full) $32.50 Not covered
3/4 gold $30.00 Not covered
Stainless steel (primary) $8.50 Not covered
Stainless steel (permanent) $10.00 Not covered
Gold dowel pin $5.00 Not covered
PONTICS
Cast gold (sanitary) $20.00 Not covered
Steele’s facing $22.50 Not covered
Tru-pontic type $27.50 Not covered
Porcelain baked to gold $40.00 Not covered
Porcelain processed to gold $27.50 Not covered
26
DENTALBENEFITS
Maximum Allowable Benefit per Procedure (cont.)
Description of Services Employee Dependent
REMOVABLE (UNILATERAL) BRIDGES
One piece casting, chrome cobalt alloy clasp attachment (all types)
– per unit, including pontics $10.00 Not covered
RECEMENTATION
Inlay $2.50 Not covered
Crown $2.50 Not covered
Bridge $5.00 Not covered
REPAIRS, CROWNS & BRIDGES
Fee based on time and laboratory charges TBD Not covered
DENTURES
Dentures, partial dentures and reline fees – including adjustments
for 6-month period following installation $77.50 Not covered
Complete mandibular denture $77.50 Not covered
Partial acrylic upper or lower with gold or chrome cobalt alloy
clasps – base fee $37.50 Not covered
Teeth and clasps – extra, per unit $2.50 Not covered
Partial lower or upper with chrome cobalt alloy lingual or palatal
bar and acrylic saddles – base fee $75.00 Not covered
Teeth and clasps – extra, per unit $2.50 Not covered
Stayplate – base fee $15.00 Not covered
Teeth and clasps – extra, per unit $1.50 Not covered
Immediate splint denture $35.00 Not covered
Denture adjustments $2.00 Not covered
Office reline – cold cure – acrylic $7.50 Not covered
Special tissue conditioning per denture, in addition to reline
maximum $17.50 Not covered
2 per denture $7.50 Not covered
Denture duplication (jump case) per denture $27.50 Not covered
Simple stress breakers – extra $7.00 Not covered
REPAIRS, DENTURES, ACRYLIC
Broken denture, repairing (no teeth involved) $6.00 Not covered Replacing missing or broken teeth, each additional $1.50 Not covered Adding teeth to partial denture to replace extracted natural teeth –
first tooth $12.50 Not covered
First tooth with clasp $15.00 Not covered
Each additional tooth and clasp $2.50 Not covered
Partial denture repairs – based on time and laboratory charges TBD Not covered
DENTALBENEFITS
Maximum Allowable Benefit per Procedure (cont.)
Description of Services Employee Dependent
SPACE MAINTAINERS
Fee includes all adjustments within six months following
installation
Fixed space maintainer (band type) $17.50 Not covered
Removable acrylic space maintainer
With stainless steel round wire rest only $20.00 Not covered Stainless steel clasps and/or activating wires, in addition per
wire or clasp $2.50 Not covered
Office visit for observation, adjustment and activation per visit $2.00 Not covered
Study models $2.50 Not covered
Removable inhibiting appliance to correct thumb sucking $20.00 Not covered Office visit for observation, adjustment and activation per visit $2.00 Not covered Fixed or cemented inhibiting appliance to correct thumb sucking $20.00 Not covered Office visit for observation, adjustment and activation per visit $2.00 Not covered
The maximum allowable benefit per procedure for the services and supplies labelled “TBD” in the table on the previous pages will be determined
based upon the nature and extent of the service performed.
28
Send claims for Vision Care Benefits to:
UnitedHealthcare Vision Claims Department
P. O. Box 30978 Salt Lake City, UT 84130 Customer service number:
(800) 638-3120 fax: (248) 733-6060
IN THISSECTION 28 WHAT’SCOVERED
29 WHAT THEPLANPAYS
29 WHATYOUPAY
29 WHAT’SNOTCOVERED
Retirees and their dependents are not eligible for Vision Care Benefits.
Vision Care Benefits are provided through an insurance contract with UnitedHealthcare. If there are any conflicts between the insurance contract and the plan documents, the con- tract shall govern.
The level of benefits are based on whether you use a network provider or a non-network provider. Generally, the highest level of benefits applies to covered services furnished by UnitedHealthcare network providers.
To locate a network provider near you, contact
UnitedHealthcare Vision
toll free
(800) 638-3120
www.myuhcvision.com
What’s Covered
The following services and supplies are available to you or a covered dependent when fur- nished by a licensed vision professional:
■ A routine eye examination performed by a state-licensed optometrist or ophthal- mologist;
■ Standard lenses, including scratch-resistant coating:
➤ single vision,
➤ bifocal lenses,
➤ trifocal lenses, or
➤ lenticular lenses;
■ Frames, up to a $50 wholesale allowance or a $130 retail allowance; and
■ Elective or medically necessary contact lenses, including fitting and evaluation, and up to two follow-up visits. Elective contact lenses are subject to a maximum $105 allowance for all materials, fittings and evaluations.
V ISION C ARE B ENEFITS
VISIONCAREBENEFITS
What the Plan Pays
For network services, the Plan pays:
■ 100% after a $15 copayment for routine eye examinations, but not more frequently than once during a 24-month period;
■ 100% after a $10 copayment for spectacle lenses during a 24-month period;
■ 100% after a $10 copayment for one set of frames during a 24-month period, subject to a $50 wholesale maximum benefit at a private practice, or a $130 retail maximum benefit at a retail chain provider; or
■ 100% after a $10 copayment for one pair of contact lenses, including evaluation, fitting and up to two follow-up visits during a 24-month period, subject to a $105 maximum benefit for elective contact lenses.
For non-network services, the Plan pays up to the maximum benefit shown below, but not more frequently than once during a 24-month period:
■ $45 for eye examinations;
■ $45 for frames;
■ $40 per pair of single vision lenses;
■ $60 per pair of bifocal lenses;
■ $80 per pair of trifocal lenses;
■ $125 per pair of lenticular lenses;
■ $105 per pair of elective contact lenses; or
■ $210 per pair of medically necessary contact lenses.
What You Pay
You pay the applicable exam or materials copays, plus any amounts in excess of what the Plan pays.
What’s Not Covered
No Vision Care Benefits are provided for:
■ Treatment in progress before coverage begins, but only to the extent charges for such treatment are incurred before coverage begins;
■ Services and supplies not specifically listed as covered;
■ Non-prescription lenses;
■ Medical or surgical treatment of the eyes;
■ Malignancies or congenital malformations;
■ Other than elective contact lenses, services or supplies that are cosmetic;
■ Orthoptics or vision training;
■ Exams or eyewear required for employment;
■ Two pairs of spectacle lenses instead of bifocals; or
■ Replacement of lost or broken lenses or frames before the beginning of a new 24- month benefit period.
30
This section only applies to employees and their dependents who are enrolled in the Alternate Dental Benefit. If you are enrolled in one of the other Dental Benefit choices,
the contract between UNITE HERE HEALTH and the contracted provider will govern.
This section does not apply to any medical, prescription drug, or other services provided under a medical HMO, or to Vision Care Benefits. The contract between UNITE HERE
HEALTH and the contracted provider will govern.
If you or your dependents are covered under the Alternate Dental Benefit and another group health plan providing dental benefits, the two plans will coordinate benefit pay- ments. Coordination of Benefits (COB) means that two or more plans may each pay a por- tion of your allowable expenses. However, the combined benefit payments from all plans will not exceed 100% of allowable expenses.
This Plan coordinates benefits with the following types of plans:
■ Group, blanket, or franchise insurance coverage;
■ Group Blue Cross or Blue Shield coverage;
■ Any other group coverage, including labor-management trusteed plans, employee organization benefit plans, or employer organization benefit plans;
■ Any coverage under governmental programs or provided by any statute, except Medicaid; and
■ Any automobile insurance policies (including “no fault” coverage) containing per- sonal injury protection provisions.
The Plan’s Coordination of Benefits provisions only apply to the Alternate Dental Benefit.
IN THISSECTION
31 WHICHPLANPAYSFIRST
31 COB AND
PRECERTIFICATION
32 SPECIALRULES FOR
MEDICARE
32 HUSBAND ANDWIFE, OR
DOMESTICPARTNER, EMPLOYEESUNDERTHIS
PLAN
