Summary of benefits dental care coverage

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Office of Human Resources

SUMMARY OF BENEFITS

DENTAL CARE COVERAGE

Distributed in 2017 Through the University of Minnesota UPlan

Dental Care

Be prepared for the possibility of a dental emergency before the need arises by knowing your clinic's procedure for care needed after regular clinic hours.

Name of your clinic:

Address:

Phone:

Dental Plan Group Numbers:

Delta Dental PPO: Delta Dental Premier: University Choice (Delta Dental) Health Partners Dental: Health Partners Dental Choice:

6100 6090 6113 16000 16000

Benefit Questions

You can reach the Employee Benefits Service Center at 612-624-8647 or 1-800-756-2363, select option 1, or email benefits@umn.edu.

Residents/Fellows

Residents/fellows in job codes 9541, 9548, 9549, 9552, 9553, 9554, 9555, 9556, 9559, 9568, 9582, 9583, and 9569 are not covered in this plan, but are covered in the University of Minnesota Residents/Fellows plan that is available at the following link: .

Introduction

This Summary of Benefits is intended to describe the coverage you have for dental benefits under the University of Minnesota UPlan (the Plan) in Plan Year 2017. This booklet describes the eligibility provisions of the Plan, the events that can cause you to lose coverage, your rights to continue coverage when you or your dependents are no longer eligible to participate in the Plan, and your rights to appeal a coverage decision or claim denial.

You will also find a description of the dental benefits covered under the Plan in this Summary of Benefits, including comprehensive coverage for most conditions requiring dental diagnosis and treatment including many preventive and restorative services such as: periodic examinations, x-rays, cleanings, fillings, restorative crowns, root canals, extractions, bridgework, and orthodontic treatment for children. You will also read about the levels of coverage under the Plan and the deductibles and coinsurance that are your responsibility.

The companies that administer the claims are: Delta Dental of Minnesota and HealthPartners Administrators, Inc.

At Open Enrollment each year, you have the opportunity to select the dental plan option you want to use for the year. Your cost varies depending on which dental plan option and coverage level you select. This booklet explains which events during the year might allow you to add a dependent or otherwise modify your coverage.

For further information about your dental benefits, you may contact the Employee Benefits Service Center or the Administrators at the appropriate address below.

Dental Claims Administrators

Delta Dental of Minnesota 500 Washington Avenue South, Suite 2060 Minneapolis, MN 55415

Phone: 651-406-5916 Toll Free: 1-800-448-3815 TTY: 1-888-853-7570 Website: uofm

HealthPartners Administrators, Inc. 8170 33rd Avenue South Bloomington, MN 55425

Phone: 952-883-5000 Toll Free: 1-800-883-2177 TTY: 952-883-5127 Website: uofm

Summary of Benefits ? Dental Care Coverage

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Specific Information About the Plan

Employer: University of Minnesota

Name of the Plan: The Plan shall be known as the University of Minnesota UPlan Dental Program that provides dental benefits to certain eligible participants and their dependents.

Address of the Plan: University of Minnesota Employee Benefits 200 Donhowe Building 319 15th Ave. SE Minneapolis, MN 55455-0103

Plan Year: The Plan Year begins on January 1 and ends on December 31. A Plan Year is 12 months in duration.

Plan Sponsor: Board of Regents 600 McNamara Alumni Center 200 Oak Street SE Minneapolis, MN 55455-2020

Funding: Claims under the Plan are paid from the assets of the University of Minnesota UPlan Dental Program.

Dental Claims Administrators: Delta Dental of Minnesota 500 Washington Avenue South, Suite 2060

Minneapolis, MN 55415 HealthPartners Administrators, Inc. 8170 33rd Avenue South Bloomington, MN 55425

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Summary of Benefits ? Dental Care Coverage

Table of Contents

Plan Availability.....................................................................................................................................................................................5 Plan Comparison..................................................................................................................................................................................6

I.

Introduction to Your Dental Coverage

A. Claims Administrators..................................................................................................................................................................8 B. Rate Structure..................................................................................................................................................................................8 C. Summary of Benefits.....................................................................................................................................................................8 D. Plan Amendments..........................................................................................................................................................................9 E. Your Identification Card...............................................................................................................................................................9 F. Provider Directory..........................................................................................................................................................................9 G. Conflict with Existing Law..........................................................................................................................................................9 H. Records...............................................................................................................................................................................................9 I. Clerical Error......................................................................................................................................................................................9 J. How to use the Plan.....................................................................................................................................................................10

II.

Coverage Eligibility and Enrollment

A. Eligibility..........................................................................................................................................................................................10 B. Effective Date of Coverage.....................................................................................................................................................15 C. Initial Enrollment.........................................................................................................................................................................15 D. Open Enrollment.........................................................................................................................................................................15 E. Midyear Enrollment Due to Status Change......................................................................................................................15 F. Midyear Change Due to Dental Plan Selection....................................................................................................... 16 G. Adding New Dependents............................................................................................................................................... 16 H. ACA Special Enrollment...........................................................................................................................................................17 I. Waive Coverage.............................................................................................................................................................................17 J. Re-Elect Coverage after Waiving Coverage......................................................................................................................17 K. Termination of Coverage..........................................................................................................................................................17 L. Misuse of Plan...............................................................................................................................................................................19 M. Continuation.................................................................................................................................................................................19 N. Choosing a Dental Plan.............................................................................................................................................................22 O. Employees Whose Permanent Work Location is Outside of Minnesota.............................................................22. P. Retirement......................................................................................................................................................................................22 Q. Long-Term Disability...................................................................................................................................................................22

III.

Plan Descriptions

A. Delta Dental PPO........................................................................................................................................................................23 B. Delta Dental Premier.................................................................................................................................................................23 C. University Choice........................................................................................................................................................................24. D. UPlan HealthPartners Dental..................................................................................................................................................24 E. UPlan HealthPartners Dental Choice..................................................................................................................................24

IV.

Benefit Features

A. Benefits............................................................................................................................................................................................25 B. Pretreatment Estimate..............................................................................................................................................................25 C. Claim Payments ..........................................................................................................................................................................26 D. Plan Maximums.............................................................................................................................................................................27. E. Emergency Services....................................................................................................................................................................27 F. Preventive Care............................................................................................................................................................................28.

Summary of Benefits ? Dental Care Coverage

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Table of Contents

G. Basic Restorative Care..............................................................................................................................................................30 H. Major Restorative Care............................................................................................................................................................. 37 I. Orthodontics................................................................................................................................................................................... 39

V. Exclusions and General Limitations.......................................................................................................................... 41

VI. Definitions......................................................................................................................................................................................44

VII.

Coordination of Benefits

A. Definitions...................................................................................................................................................................................... 47 B. Order of Benefits Rule.............................................................................................................................................................. 47 C. Effect on Benefits of This Plan .............................................................................................................................................48 D. Right to Receive and Release Needed Information....................................................................................................... 49 E. Facility of Payment...................................................................................................................................................................... 49 F. Right of Recovery......................................................................................................................................................................... 49

VIII. Disputing Determination Concerning Eligibility, Enrollment, Other Administrative Issue, or Pretreatment Estimate of Benefits

A1. Dental Claims Administrator Review and Appeal Process.......................................................................................50 A2. Employee Benefits Service Center Coverage Review Process..............................................................................50 B. Employee Benefits Review Committee .............................................................................................................................50 C. Employee Benefits Director Final Review.......................................................................................................................... 51

IX.

Disputing a Payment Denial

A. Dental Claims Administrator Review and Appeal Process.......................................................................................... 51 B. Employee Benefits Review Committee............................................................................................................................... 51 C. Employee Benefits Director Final Review.......................................................................................................................... 51

X. Notice of Privacy Practices

A. University of Minnesota-Sponsored Health Plans and Organizations Covered by this Notice.......................................................................................................................................................... 52 B. Your Protected Health Information.................................................................................................................................. 52 C. How the Group Health Plan Uses and Discloses Your PHI..................................................................................... 52 D. Your Rights Concerning Your PHI..................................................................................................................................... 54 E. Complaints................................................................................................................................................................................. 55 F. The Group Health Plan's Duties Concerning Your PHI............................................................................................ 55 G. Contact Information .............................................................................................................................................................. 55

XI.

COBRA Notice

A. Continuation of Coverage....................................................................................................................................................... 56 B. Qualifying Events Determine Length of Coverage.........................................................................................................57 C. End of COBRA Continuation Coverage............................................................................................................................ 59 D. Cost of Continuation Coverage............................................................................................................................................ 59 E. Keep Your Plan Informed of Address Changes............................................................................................................... 59 F. Questions About Billing.............................................................................................................................................................60 G. Questions About Coverage....................................................................................................................................................60

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Summary of Benefits ? Dental Care Coverage

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