Eligibility

Eligible Employee Means
An individual employed by a participating employer who works 20 hours or more per week, and who is considered an employee for Social Security purposes. Partners and Proprietors are also considered to be eligible employees.

Eligible Dependent Means
- An employee's spouse; and

- Each unmarried child, from birth to age 19, who is living with You in a regular parent-child relationship and for whom You can claim an exemption on Your federal income tax.

- Each unmarried child, at least 19 years of age to 23 years of age (or as required by law) who is primarily dependent upon You for support and who is a full-time student. A full-time student is one who is enrolled for at least 12 semester hours for credit in an accredited junior college, college or university.

- Each unmarried child at least 19 years of age: (a) who is primarily dependent upon You for support because he is incapable of self-sustaining employment by reason of mental retardation or physical handicap; (b) who was incapacitated and insured under the Policy on his 19th birthday; and (c) who continues to be incapacitated beyond his 19th birthday.

Ineligible Firms
Bands or orchestras, barber and beauty shops; bar rooms; cocktail lounges; dental offices/labs; optical labs; entertainers; massage parlors; parking lots and garages; real estate sales; taxi companies; groups where there is not employer/employee relationship; and groups where more then half the employees are related by blood or marriage.

This list of ineligible firms is representative only and not all-inclusive. The insurance company reserves the right to reject any firm.

General Information

Premiums, Renewability
Applicable Premium Rates are guaranteed for each Participating Employer Unit for 12 months from date of issue. Thereafter, rates are subject to change in accordance with the Master Policy. Coverage is renewable as long as eligibility criteria are satisfied and premiums are paid when due.

Participation Discount
In the event the final dental employee participation reaches the greater of 3 employees or 50% of the eligible employees, your monthly premium rates charged may be reduced by 10%. Final approval of this discount is to be made by Company.

Effective Date
When a firm joins the Plan, the insurance for its current employees will be effective on the date approved by the insurance company. Future new employees will become insured on the first of the month following the completion of the probationary period selected by the employer. A completed enrollment form must be received within 31 days of new employee eligibility.

An employee who does not enroll when initially eligible is considered a late entrant.  A late entrant is eligible to enroll in the Program as a new employee on the Plan's Anniversary Date or immediately if a qualifying event occurs.

Termination of Coverage
Coverage terminates on the earliest of the following dates: (a) the last day of the month in which You cease to be eligible for coverage; (b) the last day of the month in which Your Dependent is no longer a dependent as defined; (c) subject to the Grace Period, the last day of the month for which a premium has been paid by you or on your behalf; (d) or the date the Master Policy ends.

Coordination of Benefits
This Plan will be coordinated with any other group, blanket or franchise plan under which an individual will receive benefits. This helps keep the cost of the Plan reasonable.

Reasonable and Customary
Reasonable and Customary means the usual, customary and regular charges for the area where such expenses are incurred.

Benefit Provisions, Limitations and Exclusions

Expenses Incurred
An Eligible Dental Expense is considered incurred on the following dates: For full and partial dentures - the date the final impression is taken; for fixed bridges, crowns, inlays and onlays - the date the teeth are first prepared; for root canal therapy - on the date the pulp chamber is opened; for periodontal surgery - on the date surgery is performed; for all other services - the date the service is performed. An Eligible Vision Expense is considered incurred on the date the vision service is performed.

Deductible Amount
The calendar year Deductible, if any, is shown in the Coverage Schedule. The Deductible is an amount of charges You must incur for Yourself or on behalf of Your insured Dependent before We start paying benefits.

Dental Maximum Calendar Year Limit
The maximum limit payable for all Eligible Expenses in any calendar year is shown in the Coverage Schedule. The Maximum Calendar Year Limit, if any, will apply to each person covered under the Policy.

Dental Pretreatment Review
If the Dental Course of Treatment will exceed the amount shown in the Coverage Schedule, We will request prior review. We must be given the Dentist's treatment plan consisting of a description of the planned treatment with estimated charges and diagnostic x-rays. We will determine Eligible Expenses and state how much We will pay for the treatment. Our determination may suggest an alternate less expensive Course of Treatment if it will produce professionally satisfactory results. If You do not request a pretreatment review We will pay for the least expensive method of treatment regardless of the method actually used.

Dental Alternate Benefit
If: 1) We determine that a less expensive alternate procedure, service or Course of Treatment can be performed in place of the proposed treatment to correct a dental condition; and 2) the alternative treatment will produce a professionally satisfactory result; then the maximum We will allow will be the charge for the less expensive treatment.

Missing Tooth
When covered under your plan, benefits are provided for placement of dentures,
fixed bridgework, implants or the addition of teeth to existing dentures only when
the service includes replacement of a natural tooth extracted or lost while covered
under this plan. This limitation ends after the individual receiving care has been
covered under this plan for 36 consecutive months.

Replacement Sales

Credit for Prior Time (CPT)

Credit towards satisfaction of any [benefit year class/waiting period class] may be given for the length of time an employee was covered under the employer’s prior dental insurance plan, provided there is no interruption in coverage between the prior plan and the replacement plan.  The insured applying for CPT must have been covered for the same benefit classes under the prior plan in order to receive credit under the new plan.  In other words, if the employer’s prior plan did not provide Major or Orthodontic class coverage and the new plan provides both, CPT may not be given for the class not previously provided.

CPT is given individually to each person (employee, spouse or child) covered. Any new employee and/or dependents added on or subsequent to the group’s effective date of this coverage, will not receive CPT.

The agent has no authority to grant CPT or to waive the waiting period provision of the Plan.

Dental Expenses NOT Covered

• type="disc"> for overdentures and associated procedures
• for charges in excess of those considered reasonable and customary;
• for cosmetic procedures;
• for the replacement of dentures, bridges, inlays, onlays or crowns that can be repaired or restored to normal function;
• for implants and for replacement of lost or stolen appliances, replacement of retainers, athletic mouthguards, precision or semi-precision attachments, denture duplication;
• for oral hygiene instructions and for plaque control, completion of a claim form, acid etch, broken appointments, prescription or take-home fluoride, or diagnostic photographs;
• for services not completed by the end of the month in which coverage ends unless continuation of coverage has been requested and accepted by Us;
• for procedures that are begun, but not completed;
• for services and treatment provided without charge or for which there would be no charge in the absence of insurance;
• for services in connection with war or any act of war, whether declared or undeclared, or condition contracted or accident occurring while on full-time active duty in the armed forces of any country or combination of countries;
• for a condition covered under any Worker's Compensation Act or similar law; that are applied toward satisfaction of a Deductible, if any; that are generally considered by the dental profession as experimental or investigational;
• for the treatment of cleft palate and anodontia;
• for services or supplies payable under any medical expense plan;
• for orthodontia, unless included within Coverage Schedule;
• for services rendered prior to the date the Insured is covered under the Policy;  
• for the diagnosis or treatment of Temporomandibular Joint Dysfunction (TMJD);
• for hospital services;
• for any unmarried child age 19 years of age and over unless he is dependent upon You for support, while a full-time student. A full-time student is one who is enrolled for 12 semester hours for credit in an accredited junior college, college or university. Any exception for a full-time student will end at age 23;
• during any waiting period We require, when You voluntarily end Your insurance and re-enroll at a later date, Your waiting period is 2 years and begins on the date Your coverage first ended.

DENTAL PLAN DESCRIPTIONS (click to view the plan description)