25C - AGMT GROUP INSURANCE - Laserfiche WebLink

Home Browse Search

TABLE OF CONTENTS Section Paae NOTICE FOR RESIDENTS OF CALIFORNIA.................................................................................................... 4 Confidentiality of Dental Records.................................................................................................................... 4 OrganDonation............................................................................................................................................... 4 LanguageAssistance...................................................................................................................................... 4 NOTICE FOR RESIDENTS OF ALL STATES.................................................................................................... 5 Notice Regarding Your Rights and Responsibilities........................................................................................ 5 Rights........................................................................................................................................................... 5 Responsibilities............................................................................................................................................ 5 DENTALBENEFITS............................................................................................................................................6 Dentist -Patient Relationship............................................................................................................................ 6 WhoMay Enroll............................................................................................................................................... 6 SERVICEAREA.................................................................................................................................................. 7 DEPENDENTCOVERAGE................................................................................................................................. 7 WHEN COVERAGE BEGINS............................................................................................................................. 7 Choiceof Dentists............................................................................................................................................7 Facilities........................................................................................................................................................... 7 Changing Your Selected General Dental Office .............................................................................................. 6 ProviderReimbursement................................................................................................................................. 8 Liability of Subscriber or Enrollee for Payment................................................................................................8 PrepaymentFee...........................................................................................................................................8 Co-Payments............................................................................................................................................... 8 Orthodontic Covered Services..................................................................................................................... 9 YearlyMaximums.........................................................................................................................................9 Covered Services After Dental Coverage Ends........................................................................................... 9 Non -Covered Services................................................................................................................................. 9 OtherCharges..............................................................................................................................................9 Reimbursement Provisions.............................................................................................................................. 9 SpecialtyCare Referrals.................................................................................................................................. 9 SecondOpinion............................................................................................................................................. 10 EmergencyDental Care................................................................................................................................ 10 TERMINATION OF BENEFITS......................................................................................................................... 11 Cancellationof Benefits................................................................................................................................. 11 RenewalProvisions....................................................................................................................................... 12 Reinstatement................................................................................................................................................12 Disen rollment................................................................................................................................................. 12 CONTINUITYOF CARE................................................................................................................................... 12 CurrentMembers........................................................................................................................................... 12 NewMembers................................................................................................................................................12 DENTAL BENEFITS: INQUIRIES AND GRIEVANCE PROCEDURES............................................................13 Routine Questions About Dental Benefits..................................................................................................... 13 GrievanceProcedures................................................................................................................................... 13 Arbitration ......... :.................................... ............... ............ ......... ................. ......... .................... .... ............ ...... 14 Coordinationof Benefits................................................................................................................................ 14 ThirdParty Liability .....................................................................................................:.................................. 14 Assignmentof Benefits.................................................................................................................................. 14 INDIVIDUAL CONTINUATION OF DENTAL BENEFITS WITH PAYMENT OF THE PREPAYMENT FEE..... 14 For Mentally Or Physically Handicapped Children........................................................................................ 14 ForFamily And Medical Leave...................................................................................................................... 15 AtThe Organization's Option.........................................................................................................................15 COBRA CONTINUATION FOR DENTAL BENEFITS....................................................................................... 15 Cal -Cobra Continuation For Dental Benefits................................................................................................. 15 Events that Allow Continuation, and Length of Continuation..................................................................... 15 NewDependents........................................................................................................................................16 Termination of Coverage............................................................................................................................16 Notice and Election of Coverage................................................................................................................16 Costof Continued Coverage...................................................................................................................... 17 Payment of the Prepayment Fees..............................................................................................................17 Exceptions..................................................................................................................................................17 GCERT2011-DHMO-EOC 25^-16