Pebp ppo dental plan and summary of benefits for

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PEBP PPO DENTAL PLAN AND SUMMARY OF BENEFITS FOR LIFE AND LONG-TERM DISABILITY INSURANCE MASTER PLAN DOCUMENT PLAN YEAR 2020

(EFFECTIVE JULY 1, 2019 ? June 30, 2020)

Public Employees' Benefits Program 901 S. Stewart Street, Suite 1001 Carson City, Nevada 89701 pebp.state.nv.us (775) 684-7000 (800) 326-5496

Public Employees' Benefits Program

Contents

Master Plan Document PPO Dental Plan, Life and Long-Term Disability

Plan Year 2020

Amendment Log....................................................................................................................................... 4

Welcome PEBP Participant ....................................................................................................................... 5

Introduction............................................................................................................................................. 6

Suggestions for Using this Document ............................................................................................................... 7

Accessing Other Benefit Information: .............................................................................................................. 7

Participant Rights and Responsibilities...................................................................................................... 8

Self-Funded PPO Dental Benefits ............................................................................................................ 10

Eligible Dental Expenses ................................................................................................................................. 10

Non-Eligible Dental Expenses ......................................................................................................................... 10

Out-of-Country Dental Purchases...............................................................................................................10

Deductibles ..................................................................................................................................................... 11

Coinsurance .................................................................................................................................................... 11

Plan Year Maximum Dental Benefits .............................................................................................................. 12

Payment of Dental Benefits ............................................................................................................................ 12

Extension of Dental Coverage.........................................................................................................................12

Dental Pretreatment Estimates ...................................................................................................................... 12

Prescription Drugs Needed for Dental Purposes ............................................................................................ 13

Voluntary PPO Dental Plan Option for Medicare Retirees Enrolled through VIA Benefits ............................ 13

Schedule of Dental Benefits.................................................................................................................... 14

Dental Network ..................................................................................................................................... 18

In-Network Services ........................................................................................................................................ 18

Out-of-Network Services ................................................................................................................................ 18

When Out-of-Network Providers May be Paid as In-Network Providers ....................................................... 19

Exclusions: PPO Dental Plan ................................................................................................................... 19

Self-Funded PPO Dental Claims Administration ....................................................................................... 22

How Dental Benefits are Paid ......................................................................................................................... 22

How to File a Dental Claim..............................................................................................................................23

Where to Send the Claim Form ...................................................................................................................... 24

Dental Appeal Process............................................................................................................................ 24

Written Notice of Denial of Claim...................................................................................................................24

Level 1 Appeal NAC 287.670 ........................................................................................................................... 25

Level 2 Appeal NAC 287.680 ........................................................................................................................... 25

Coordination of Benefits (COB) ............................................................................................................... 26

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Public Employees' Benefits Program

Master Plan Document

PPO Dental Plan, Life and Long-Term Disability

Plan Year 2020

When and How Coordination of Benefits (COB) Applies ................................................................................ 27

Which plan Pays First: Order of Benefit Determination Rules........................................................................28

The Overriding Rules...................................................................................................................................28

Rule 1: Non-Dependent/Dependent...........................................................................................................28

Rule 2: Dependent Child Covered under More Than One plan ................................................................. 29

Rule 3: Active/Laid-Off or Retired Employee..............................................................................................29

Rule 4: Continuation Coverage ................................................................................................................... 30

Rule 5: Longer/Shorter Length of Coverage ............................................................................................... 30

Administration of COB .................................................................................................................................... 30

Coordination with Medicare...........................................................................................................................31

Coverage under Medicare and This Plan When you have End-Stage Renal Disease..................................31

How Much This Plan Pays When It Is Secondary to Medicare....................................................................31

Coordination with Other Government Programs ........................................................................................... 32

Medicaid ..................................................................................................................................................... 32

Tricare ......................................................................................................................................................... 32

Veterans Affairs facility Services ................................................................................................................. 32

Worker's Compensation ................................................................................................................................. 32

Third Party Liability ................................................................................................................................ 33

Subrogation and Rights of Recovery...............................................................................................................33

Basic Life Insurance ................................................................................................................................ 34

Eligibility for Life Insurance.............................................................................................................................34

Coverage ......................................................................................................................................................... 35

Long-Term Disability (LTD) Insurance ...................................................................................................... 35

Premium Payment .......................................................................................................................................... 35

How the LTD Benefit Works............................................................................................................................35

Participant Contact Guide....................................................................................................................... 36

Key Terms and Definitions ...................................................................................................................... 40

BA03282019

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Public Employees' Benefits Program

Amendment Log PPO Dental Plan, Life and Long-Term Disability

Plan Year 2020

Amendment Log

Any amendments, changes or updates to this document will be listed here. The amendment log will include what sections are amended and where the changes can be found.

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Public Employees' Benefits Program

Welcome PEBP Participant

Welcome PEBP Participant PPO Dental Plan, Life and Long-Term Disability

Plan Year 2020

Welcome to the State of Nevada Public Employees' Benefits Program (PEBP). PEBP provides a variety of benefits such as medical, dental, life insurance, long-term disability, flexible spending accounts, and other voluntary insurance benefits for eligible state and local government employees, retirees, and their eligible dependents.

As a PEBP participant, you may enroll in whichever benefit plan offered in your geographical area that best meets your needs, subject to specific eligibility and Plan requirements. These plans include the Consumer Driven Health Plan (CDHP) with a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA), the Premier (EPO) Plan, and Health Plan of Nevada HMO Plan. (In general, Medicare retirees are required to enroll in a medical plan through PEBP's Medicare Exchange vendor). You are also encouraged to research plan provider access and quality of care in your service area.

This document describes PEBP's PPO Dental Plan, Life and Long-Term Disability Benefits. Active employees enrolled in a PEBP-sponsored medical plan (CDHP, Premier Plan or Health Plan of Nevada HMO Plan) receive dental, basic life and long-term disability benefits. Retirees enrolled in a PEBP-sponsored medical plan receive dental coverage and if eligible, basic life insurance coverage. Eligible retirees enrolled in a medical plan through PEBP's Medicare Exchange receive basic life insurance and the choice to enroll in PEBP's voluntary PPO Dental Plan option.

PEBP participants should examine this document to become familiar with the PPO Dental Plan, basic life insurance and life and long-term disability benefits. In addition to examining this document, participants are encouraged to read the Master Plan Documents or Evidence of Coverage Certificates (EOCs), Summary Plan Descriptions, and Summary of Benefits and Coverage applicable to their medical plan. Participants should also examine the PEBP Enrollment and Eligibility, PEBP Health and Welfare Wrap Plan, Section 125, Medicare Exchange HRA Summary Plan Description, and other plan materials relevant to their benefits. These documents and other materials are available at pebp.state.nv.us or to request a particular document by mail, contact PEBP at 775-684-7000 or 800-326-5496 or email member services by selecting the contact us feature in your E-PEBP portal member account.

In addition, helpful material is available from PEBP or any PEBP vendor listed in the Participant Contact Guide.

PEBP encourages you to stay informed of the most up to date information regarding your health care benefits. It is your responsibility to know and follow the plan provisions and other requirements described in PEBP's Master Plan Document and related materials.

Sincerely, Public Employees' Benefits Program

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Public Employees' Benefits Program

Introduction

Introduction PPO Dental Plan, Life and Long-Term Disability

Plan Year 2020

This Master Plan Document describes the PEBP self-funded PPO Dental Plan benefits offered to eligible employees, retirees and their covered dependents. Additional benefits for life and longterm disability are summarized in this document.

This PEBP plan is governed by the State of Nevada.

This document is intended to comply with the Nevada Revised Statutes (NRS) Chapter 287, and the Nevada Administrative Code 287 as amended and certain provisions of NRS 695G and NRS 689B.

The Plan described in this document is effective July 1, 2019, and unless stated differently, replaces all other self-funded Dental Benefit Plan documents and summary plan descriptions previously provided to you.

This document will help you understand and use the benefits provided by the Public Employees' Benefits Program (PEBP). You should review it and also show it to members of your family who are or will be covered by the Plan. It will give you an understanding of the coverage provided, the procedures to follow in submitting claims, and your responsibilities to provide necessary information to the Plan. Be sure to read the Exclusions, and Key Terms and Definitions Sections. Remember, not every expense you incur for health care is covered by the Plan.

All provisions of this document contain important information. If you have any questions about your coverage or your obligations under the terms of the Plan, please contact PEBP at the number listed in the Participant Contact Guide. The Participant Contact Guide provides you with contact information for the various components of the Public Employees' Benefits Program.

PEBP intends to maintain this Plan indefinitely, but reserves the right to terminate, suspend, discontinue or amend the Plan at any time and for any reason. As the Plan is amended from time to time, you will be sent information explaining the changes. If those later notices describe a benefit or procedure that is different from what is described here, you should rely on the later information. Be sure to keep this document, along with notices of any Plan changes, in a safe and convenient place where you and your family can find and refer to them.

The benefits offered with the Consumer Driven Health Plan, Premier Plan, and Health Plan of Nevada include prescription drug benefits, dental coverage, long-term disability, and basic life insurance as applicable. The medical and prescription drug benefits are described in separately in the applicable plan's Master Plan Document or Evidence of Coverage certificate. An independent third-party claims administrator pays the claims for the PPO Dental Plan.

Per NRS 287.0485 no officer, employee, or retiree of the State has any inherent right to benefits provided under the PEBP.

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